SUA Resource Library: 

Program Monitoring Materials 
Foreword 

In 2012, the Administration for Community Living (ACL), an operating division of the US 

Department of Health and Human Services, began a comprehensive evaluation of its National 

Family Caregiver Support Program (NFCSP). This was the first comprehensive federal evaluation 

of the NFCSP, which serves over 800,000 family caregivers annually. The NFCSP evaluation has 

three broad goals to benefit policy and program decision-making: 

1. Collect and analyze information on program processes and site operations; 

2. Evaluate program efficiency and cost issues for approaches best suited to specific 

contexts; and

3. Evaluate effectiveness of the program’s contribution to family caregivers in terms of 

maintaining their health and well-being, improving their caregiving skills, and 

avoiding or delaying institutional care of the care recipient.

As part of the evaluation survey, State Units on Aging (SUAs) were asked to submit relevant 

documents if they answered ‘yes’ to any of the following five questions: 

 Do you have a statewide task force, commission or coalition specifically to examine 

family caregiver issues?

 Have community needs assessments for caregiver support services been conducted?

 Does your state have a standardized caregiver assessment?

 Does your SUA conduct routine programmatic monitoring of the NFCSP program?

 Do you use a uniform caregiver satisfaction survey across all AAAs?

ACL received assessment tools and grouped them into the following categories:

1. Community Assessment Materials

2. General Customer Satisfaction Survey Materials

3. Grandparent Assessment Materials

4. High-Level Administrative Materials

5. Program Monitoring Materials

6. State Caregiver Assessments

7. State Care Recipient Assessments

8. Task Force Materials

9. Uniform Satisfaction Materials

10. Other Materials

While ACL does not specifically endorse these tools, we are sharing them because they may be 

helpful to other programs. For more information on the NFCSP please go to: 

http://www.aoa.acl.gov/. For more information on the evaluation of the NFCSP please go to: 

http://www.aoa.acl.gov/Program_Results/Program_Evaluation.aspx
Program Monitoring Materials 

Colorado Programmatic Monitoring Tool ..................................................................................................... 3 

Idaho Monitoring Report .............................................................................................................................. 8 

Idaho AAA National Family Caregiver Support Worksheet ........................................................................ 40

Ohio Monitoring Results ............................................................................................................................. 41

Oregon Program Monitoring Assessment Tool 2014 ................................................................................. 44

South Carolina Report Codes ...................................................................................................................... 48

South Carolina Cumulative Quarterly and Annual Reports ........................................................................ 49

South Carolina Service Definitions .............................................................................................................. 51

Utah Caregiver Monitoring Tool Template ................................................................................................. 60

Vermont AAA Dementia Respite Grant with Monitoring Information ....................................................... 70

2
1

CAREGIVING SERVICES ON-SITE EVALUATION TOOL SFY15 

Agency Name Region __________ 

 

Date _______________ Services Provided 

Attendees Name 1. Todd Swanson Title 1. Monitoring and Compliance Agency 1. SUA 

Name 1. Title 1. Agency 1. 

Name 1. Title 1. Agency 1. 

Name 1. Title 1. Agency 1. 

Overview Issue to 

be 

resolved

?

Relevant 

Referen

ce

Comments Requirement Complia

nce

Yes 

No

Please give me an overview of 

your program. 

What challenges do you face?

What are your strengths? What 

do you do exceptionally well?

What assistive technology is 

available for visually impaired 

and deaf or hard of hearing 

clients?

What processes do you currently 

have in place or plan to put in 

place to increase efficiencies in 

services and service delivery?

Colorado Programmatic Monitoring Tool 3
2O

verview

Issue to 

be 

reso

lved

?

Relevant Referen

ce

CommentsRequirementCompli

a

nce Yes 

No

I. TARGET POPULATIONS A. Describe how the agency 

ensures 

targeting participants of 

greatest social need, economic 

need

, low

-income 

minority 

consumers, and consumers residing in rural areas.

1.W

hat type of media is used to

 co

mplete outreach?

2.How is effectiveness measured?

3.W

hat are the outcomes?

10

.13

0

303.0 ASU

#05-14

Examples Requirement in RFP and 

contrac

t

Outcomes Evaluate at

minimum 

annual Included in 4

-

year plan

How do actual participants map to targeted populations? How are persons defined as “frail –

3 or

more ADLs” targeted?

I

I. PR

OVIDER/SUBCONTRACTOR 

M

O

NITORING EVALUATION

W

hen was the last ti

m

e your agency 

received an on-si

te evaluation from 

the AAA? What is the process followed for an 

on-si

te evaluation? 

10

.240.9 

C

10

.26

0

A

SU

#05-16

N

ew

–w

ithin 

90 calendar 

da

ys of

prov

iding 

serv

ices

A

nnually after

Colorado Programmatic Monitoring Tool 4
3O

verview

Issue to 

be 

reso

lved

?

Relevant Referen

ce

CommentsRequirementCompli

a

nce Yes 

No

III. FISCAL OPERATIONS Is your agency a For Profit Agency? If yes, was your contract approved 

by SUA?

S

UA Approval

W

hat are the procedures of the AAA 

rei

mbursements to your agency?

Uni

t Reimbursement 

Docu

mentation

(employee time sheets)

10

.31

9

How do you collect program income? Describe how often Program Income is expended. What opportunities do you provide to receive program income? Have any programs received no or marginal program income? If so, why?

Con

tract

Example of Procedure in Place

D. How is approp

riate handling of 

cash donations ensured and monitored? Please provide MONTH 

A

udit

10

.260 C Full Price

Colorado Programmatic Monitoring Tool 5
4O

verview

Issue to 

be 

reso

lved

?

Relevant Referen

ce

CommentsRequirementCompli

a

nce Yes 

No

documentation of donations What is the suggested contribution for a unit of service? How do you maintain 

con

fidentiality of those who 

con

tribute and those who do not?

10.320.1 C

424.0

Does your program stay on budget? IV. PROGRAM DEVELOPMENT/COORDINATION What key community partners do you work with to deliver your 

pro

grams?

Does your agency have a wait list, if yes how is it monitored? V. POLICIES A. How do you assess consumer 

needs? D. Background Check Reports 10

.240.1

1 

A

8

304.0 SUA

#05-15

A

ll

employees, volunteers & Contractors who have 

direc

t contact 

w

ith elderly 

Colorado Programmatic Monitoring Tool 6
5O

verview

Issue to 

be 

reso

lved

?

Relevant Referen

ce

CommentsRequirementCompli

a

nce Yes 

No

consumer

E. Emergency Response Plans Including Telephone Reassurance VI. CONSUMER SATISFACTION What type of media is used to 

determine Consumer Satisfaction? Include Examples. Satisfaction Surveys Telephone Interviews and Visits

Con

tract 

Exh

ibit 

A

Page 

5 Paragra

ph

8

Example of Procedure in Place Outcomes

Please give us an example of a recent consumer complaint and your procedure for handling it. Review Forms and Complaint Log

10

.260 

G

,

I

A

udit

10

.260.3 

B1

Example of Procedure in Place

W

here are the unserved area for 

you

r program?

A

re there things that you would like 

to chan

ge in order to operate your 

pro

gram more efficiently or 

e

ffectively? What? When are you planning to implement these?

A

DDITIONAL NOTES 

Colorado Programmatic Monitoring Tool 7
SECTION I. Elderly Clients and Caregivers

A. Elderly Client Counts

State ID: ID Fiscal Year: 2014 

Total

 18,155

 42,081

 55,974

1. Unduplicated Count of Persons Served For

 Registered Services Supported by the OAA

 Title III

(Number does not include caregivers served)

2. Estimated* Unduplicated Count of Persons

 Served For Unregistered Services Supported

 by the OAA Title III

(Number does not include caregivers served)

3. Total Estimated Unduplicated Count of

 Persons Served Through Services Supported

 by the OAA Title III

(Number does not include caregivers served)

* There is no prescribed method for developing this estimate.

Reported by: ID Idaho Commission on Aging IA Page 3

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 8
SECTION I. Elderly Clients

B. General Characteristics of Elderly Clients Receiving Registered Services and Those Receiving Cluster 2 Registered Services

State ID: ID Fiscal Year: 2014 

X Total Registered Clients

(Cluster 1 and Cluster 2)

Congregate Meals Nutrition Counseling Assisted Transportation

Age of Client

85+

Age of Client

75-84

Age of Client

60-74

With Income

Below Poverty

Total

Total Clients

Total with Age Reported

Age Missing

Female

Male

Gender Missing

Rural Clients

Rural Missing

Poverty Missing

Live Alone

Live Alone Missing

Clients by Ethnicity

Hispanic / Latino

Not Hispanic or Latino

Ethnicity Missing

Clients by Race or Ethnicity

White (Alone) - Non-Hispanic

Total Minorities

White (Alone) - Hispanic

American Indian or Alaskan Native (Alone)

Asian (Alone)

Black / African American (Alone)

Native Hawaiian or Other Pacific Islander (Alone)

Persons Reporting Some Other Race

Persons Reporting 2 or More Races

Race Missing

Clients Receiving Registered Services

 18,155 3,811

 18,112 3,807 7,080 6,245 4,424

 43 4

 11,214 2,539 4,277 3,856 2,840

 6,857 1,266 2,753 2,369 1,573

 84 6 50 20 11

 9,014 1,923 3,696 3,117 1,978

 218 1 141 51 19

 566 322 135 93

 6,826 2,061 2,240 2,340 2,159

 1,601 245 827 489 251

 422 127 186 147 74

 17,279 3,664 6,624 5,988 4,292

 454 20 270 110 58

 16,526 3,442 6,292 5,734 4,140

 393 136 177 137 68

 210 77 89 76 38

 78 21 27 26 22

 25 9 11 7 4

 38 6 22 12 3

 74 16 38 20 14

 75 27 24 30 21

 736 77 400 203 114

Reported by: ID Idaho Commission on Aging IB Page 4 (Total)

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 9
SECTION I. Elderly Clients

B. General Characteristics of Elderly Clients Receiving Registered Services and Those Receiving Cluster 2 Registered Services

State ID: ID Fiscal Year: 2014 

Total Registered Clients

(Cluster 1 and Cluster 2)

X Congregate Meals Nutrition Counseling Assisted Transportation

Age of Client

85+

Age of Client

75-84

Age of Client

60-74

With Income

Below Poverty

Total

Total Clients

Total with Age Reported

Age Missing

Female

Male

Gender Missing

Rural Clients

Rural Missing

Poverty Missing

Live Alone

Live Alone Missing

Clients by Ethnicity

Hispanic / Latino

Not Hispanic or Latino

Ethnicity Missing

Clients by Race or Ethnicity

White (Alone) - Non-Hispanic

Total Minorities

White (Alone) - Hispanic

American Indian or Alaskan Native (Alone)

Asian (Alone)

Black / African American (Alone)

Native Hawaiian or Other Pacific Islander (Alone)

Persons Reporting Some Other Race

Persons Reporting 2 or More Races

Race Missing

Clients Receiving Registered Services

 14,039 2,545

 14,000 2,541 5,905 4,893 2,874

 39 4

 8,541 1,669 3,547 2,966 1,807

 5,427 871 2,310 1,913 1,060

 71 5 48 14 7

 7,533 1,411 3,291 2,582 1,450

 214 1 141 48 18

 483 306 108 54

 4,537 1,253 1,528 1,642 1,287

 1,585 245 825 482 245

 307 86 148 102 42

 13,343 2,452 5,503 4,702 2,799

 389 7 254 89 33

 12,753 2,285 5,238 4,492 2,699

 279 91 137 92 39

 174 58 72 67 29

 63 14 23 22 15

 14 4 4 4 3

 36 5 21 12 2

 62 14 35 16 9

 49 16 15 25 9

 609 58 360 163 69

Reported by: ID Idaho Commission on Aging IB Page 4 (CM)

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 10
SECTION I. Elderly Clients

B. General Characteristics of Elderly Clients Receiving Registered Services and Those Receiving Cluster 2 Registered Services

State ID: ID Fiscal Year: 2014 

Total Registered Clients

(Cluster 1 and Cluster 2)

Congregate Meals X Nutrition Counseling Assisted Transportation

Age of Client

85+

Age of Client

75-84

Age of Client

60-74

With Income

Below Poverty

Total

Total Clients

Total with Age Reported

Age Missing

Female

Male

Gender Missing

Rural Clients

Rural Missing

Poverty Missing

Live Alone

Live Alone Missing

Clients by Ethnicity

Hispanic / Latino

Not Hispanic or Latino

Ethnicity Missing

Clients by Race or Ethnicity

White (Alone) - Non-Hispanic

Total Minorities

White (Alone) - Hispanic

American Indian or Alaskan Native (Alone)

Asian (Alone)

Black / African American (Alone)

Native Hawaiian or Other Pacific Islander (Alone)

Persons Reporting Some Other Race

Persons Reporting 2 or More Races

Race Missing

Clients Receiving Registered Services

Reported by: ID Idaho Commission on Aging IB Page 4 (NC)

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 11
SECTION I. Elderly Clients

B. General Characteristics of Elderly Clients Receiving Registered Services and Those Receiving Cluster 2 Registered Services

State ID: ID Fiscal Year: 2014 

Total Registered Clients

(Cluster 1 and Cluster 2)

Congregate Meals Nutrition Counseling X Assisted Transportation

Age of Client

85+

Age of Client

75-84

Age of Client

60-74

With Income

Below Poverty

Total

Total Clients

Total with Age Reported

Age Missing

Female

Male

Gender Missing

Rural Clients

Rural Missing

Poverty Missing

Live Alone

Live Alone Missing

Clients by Ethnicity

Hispanic / Latino

Not Hispanic or Latino

Ethnicity Missing

Clients by Race or Ethnicity

White (Alone) - Non-Hispanic

Total Minorities

White (Alone) - Hispanic

American Indian or Alaskan Native (Alone)

Asian (Alone)

Black / African American (Alone)

Native Hawaiian or Other Pacific Islander (Alone)

Persons Reporting Some Other Race

Persons Reporting 2 or More Races

Race Missing

Clients Receiving Registered Services

Reported by: ID Idaho Commission on Aging IB Page 4 (AT)

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 12
SECTION I. Elderly Clients

C. Detailed ADL Characteristics of Elderly Clients Receiving Cluster 1 Services

(Report information for all Cluster 1 services combined and each service separately.)

State ID: ID Fiscal Year: 2014 

X Total Cluster 1 Clients Personal Care Homemaker

Chore

Case Management

Home Delivered Meals Adult Day Care/Health

Age

75-84

1

ADL

All 

Ages

2

ADL

All 

Ages

0

ADL

All 

Ages

Total

Age 

60-74 

Total

All 

Ages

1

ADL

All 

Ages

3+

ADL

Age 

60-74 

0

ADL

Age 

60-74 

1

ADL

Age 

60-74 

3+

ADL

Age

75-84

Total

Age

75-84

2

ADL

Age

75-84

3+

ADL

Age 

60-74 

2

ADL

Age

75-84

0

ADL

Age

85+

Total

Age

85+

0

ADL

Age

85+

1

ADL

Age

85+

2

ADL

Age

85+

3+

ADL

Total Clients

Clients with Age Data

Age Missing

ADLs Missing

Female

Male

Gender Missing

Rural

Rural Missing

Income below Poverty Level

Poverty Missing

Live Alone

Live Alone Missing

Hispanic / Latino

Not Hispanic or Latino

Ethnicity Missing

Clients by Race or Ethnicity

White (Alone) - Non-Hispanic

Total Minorities

Clients by Ethnicity

White (Alone) - Hispanic

American Indian or Alaskan

Native (Alone)

Asian (Alone)

Black / African American

(Alone)

Native Hawaiian or Pacific 

Islander (Alone)

Persons Reporting Some Other

Race

Persons Reporting 2 or More

Races

Race Missing

 4,483 381 356 593 3,127

 4,479 381 356 593 3,125 1,254 112 100 173 864 1,479 127 115 191 1,036 1,710 132 135 224 1,210

 4 0 0 0 2

 26 5 10 9

 2,927 198 200 400 2,117 779 59 54 110 554 972 66 66 133 701 1,155 70 79 154 848

 1,542 182 156 193 1,000 473 53 46 63 308 500 60 49 58 330 551 62 56 70 359

 14 1 0 0 10 2 0 0 0 2 7 1 0 0 5 4 0 0 0 3

 1,699 166 160 206 1,162 454 49 42 52 310 614 56 57 76 424 617 56 59 76 424

 4 1 0 0 3 0 0 0 0 0 3 1 0 0 2 1 0 0 0 1

 1,382 129 109 195 947 509 38 41 76 353 395 32 36 52 275 456 54 28 63 310

 85 1 4 8 59 16 0 1 4 10 27 0 1 1 19 41 1 2 3 30

 2,531 142 212 355 1,813 766 42 63 104 555 769 37 68 105 557 988 61 81 145 696

 16 0 0 1 5 2 0 0 0 1 7 0 0 0 2 6 0 0 1 2

 123 8 13 17 84 40 2 1 5 32 48 2 8 7 30 35 4 4 5 22

 4,294 372 340 569 3,003 1,198 110 97 166 822 1,409 125 107 183 992 1,650 127 131 215 1,172

 66 1 3 7 40 16 0 2 2 10 22 0 0 1 14 25 1 0 4 16

 4,127 356 328 550 2,881 1,129 104 93 162 766 1,364 119 103 175 963 1,597 123 127 208 1,135

 122 6 14 18 84 42 2 2 5 33 48 2 7 9 30 32 2 5 4 21

 37 5 4 4 24 17 2 1 2 12 10 1 1 2 6 9 2 1 0 6

 16 2 1 5 8 4 0 0 1 3 5 2 1 1 1 7 0 0 3 4

 11 1 0 1 9 7 0 0 1 6 3 1 0 0 2 1 0 0 0 1

 2 1 0 1 0 1 1 0 0 0 0 0 0 0 0 1 0 0 1 0

 12 2 0 0 10 3 1 0 0 2 4 0 0 0 4 5 1 0 0 4

 28 4 2 5 17 11 0 1 2 8 5 2 0 0 3 12 2 1 3 6

 128 4 7 9 94 40 2 3 0 34 40 0 3 4 27 46 2 1 5 33

ADL SUMMARY FOR

Reported by: ID Idaho Commission on Aging IC Page 5 (Total)

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 13
SECTION I. Elderly Clients

C. Detailed ADL Characteristics of Elderly Clients Receiving Cluster 1 Services

(Report information for all Cluster 1 services combined and each service separately.)

State ID: ID Fiscal Year: 2014 

Total Cluster 1 Clients Personal Care Homemaker

Chore

Case Management

Home Delivered Meals Adult Day Care/Health

X

Age

75-84

1

ADL

All 

Ages

2

ADL

All 

Ages

0

ADL

All 

Ages

Total

Age 

60-74 

Total

All 

Ages

1

ADL

All 

Ages

3+

ADL

Age 

60-74 

0

ADL

Age 

60-74 

1

ADL

Age 

60-74 

3+

ADL

Age

75-84

Total

Age

75-84

2

ADL

Age

75-84

3+

ADL

Age 

60-74 

2

ADL

Age

75-84

0

ADL

Age

85+

Total

Age

85+

0

ADL

Age

85+

1

ADL

Age

85+

2

ADL

Age

85+

3+

ADL

Total Clients

Clients with Age Data

Age Missing

ADLs Missing

Female

Male

Gender Missing

Rural

Rural Missing

Income below Poverty Level

Poverty Missing

Live Alone

Live Alone Missing

Hispanic / Latino

Not Hispanic or Latino

Ethnicity Missing

Clients by Race or Ethnicity

White (Alone) - Non-Hispanic

Total Minorities

Clients by Ethnicity

White (Alone) - Hispanic

American Indian or Alaskan

Native (Alone)

Asian (Alone)

Black / African American

(Alone)

Native Hawaiian or Pacific 

Islander (Alone)

Persons Reporting Some Other

Race

Persons Reporting 2 or More

Races

Race Missing

ADL SUMMARY FOR

Reported by: ID Idaho Commission on Aging IC Page 5 (PC)

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 14
SECTION I. Elderly Clients

C. Detailed ADL Characteristics of Elderly Clients Receiving Cluster 1 Services

(Report information for all Cluster 1 services combined and each service separately.)

State ID: ID Fiscal Year: 2014 

Total Cluster 1 Clients Personal Care Homemaker

Chore

Case Management

Home Delivered Meals Adult Day Care/Health

X

Age

75-84

1

ADL

All 

Ages

2

ADL

All 

Ages

0

ADL

All 

Ages

Total

Age 

60-74 

Total

All 

Ages

1

ADL

All 

Ages

3+

ADL

Age 

60-74 

0

ADL

Age 

60-74 

1

ADL

Age 

60-74 

3+

ADL

Age

75-84

Total

Age

75-84

2

ADL

Age

75-84

3+

ADL

Age 

60-74 

2

ADL

Age

75-84

0

ADL

Age

85+

Total

Age

85+

0

ADL

Age

85+

1

ADL

Age

85+

2

ADL

Age

85+

3+

ADL

Total Clients

Clients with Age Data

Age Missing

ADLs Missing

Female

Male

Gender Missing

Rural

Rural Missing

Income below Poverty Level

Poverty Missing

Live Alone

Live Alone Missing

Hispanic / Latino

Not Hispanic or Latino

Ethnicity Missing

Clients by Race or Ethnicity

White (Alone) - Non-Hispanic

Total Minorities

Clients by Ethnicity

White (Alone) - Hispanic

American Indian or Alaskan

Native (Alone)

Asian (Alone)

Black / African American

(Alone)

Native Hawaiian or Pacific 

Islander (Alone)

Persons Reporting Some Other

Race

Persons Reporting 2 or More

Races

Race Missing

 1,075 24 42 100 907

 1,074 24 42 100 907 361 9 23 36 293 345 7 7 30 301 358 8 12 32 305

 1 0 0 0 0

 2 0 0 1

 826 18 26 75 706 267 6 14 25 222 265 4 7 20 234 285 8 5 28 243

 245 6 16 25 198 93 3 9 11 70 78 3 0 10 65 73 0 7 4 62

 4 0 0 0 3 1 0 0 0 1 2 0 0 0 2 0 0 0 0 0

 396 8 20 34 334 130 4 12 9 105 144 2 5 12 125 119 2 3 13 101

 1 0 0 0 1 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0

 438 14 21 47 356 180 4 16 20 140 112 4 1 10 97 139 6 4 16 113

 7 0 0 0 6 1 0 0 0 1 2 0 0 0 2 4 0 0 0 3

 825 14 29 82 700 284 4 18 30 232 269 5 6 23 235 269 5 5 28 231

 2 0 0 0 1 0 0 0 0 0 1 0 0 0 1 1 0 0 0 0

 19 1 0 2 16 7 0 0 0 7 9 1 0 1 7 3 0 0 1 2

 1,049 23 42 98 886 353 9 23 36 285 332 6 7 29 290 354 8 12 31 303

 7 0 0 0 5 1 0 0 0 1 4 0 0 0 4 1 0 0 0 0

 1,002 20 38 96 848 327 7 21 35 264 324 5 6 28 285 341 8 11 31 291

 21 1 1 2 17 10 0 0 0 10 9 1 0 2 6 2 0 1 0 1

 11 2 1 0 8 5 1 1 0 3 2 1 0 0 1 4 0 0 0 4

 6 0 1 0 5 3 0 0 0 3 2 0 1 0 1 1 0 0 0 1

 3 0 0 0 3 1 0 0 0 1 2 0 0 0 2 0 0 0 0 0

 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

 3 1 0 0 2 1 1 0 0 0 0 0 0 0 0 2 0 0 0 2

 7 0 1 1 5 7 0 1 1 5 0 0 0 0 0 0 0 0 0 0

 22 0 0 1 19 7 0 0 0 7 6 0 0 0 6 8 0 0 1 6

ADL SUMMARY FOR

Reported by: ID Idaho Commission on Aging IC Page 5 (Homemaker)

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 15
SECTION I. Elderly Clients

C. Detailed ADL Characteristics of Elderly Clients Receiving Cluster 1 Services

(Report information for all Cluster 1 services combined and each service separately.)

State ID: ID Fiscal Year: 2014 

Total Cluster 1 Clients Personal Care Homemaker

Chore

Case Management

X Home Delivered Meals Adult Day Care/Health

Age

75-84

1

ADL

All 

Ages

2

ADL

All 

Ages

0

ADL

All 

Ages

Total

Age 

60-74 

Total

All 

Ages

1

ADL

All 

Ages

3+

ADL

Age 

60-74 

0

ADL

Age 

60-74 

1

ADL

Age 

60-74 

3+

ADL

Age

75-84

Total

Age

75-84

2

ADL

Age

75-84

3+

ADL

Age 

60-74 

2

ADL

Age

75-84

0

ADL

Age

85+

Total

Age

85+

0

ADL

Age

85+

1

ADL

Age

85+

2

ADL

Age

85+

3+

ADL

Total Clients

Clients with Age Data

Age Missing

ADLs Missing

Female

Male

Gender Missing

Rural

Rural Missing

Income below Poverty Level

Poverty Missing

Live Alone

Live Alone Missing

Hispanic / Latino

Not Hispanic or Latino

Ethnicity Missing

Clients by Race or Ethnicity

White (Alone) - Non-Hispanic

Total Minorities

Clients by Ethnicity

White (Alone) - Hispanic

American Indian or Alaskan

Native (Alone)

Asian (Alone)

Black / African American

(Alone)

Native Hawaiian or Pacific 

Islander (Alone)

Persons Reporting Some Other

Race

Persons Reporting 2 or More

Races

Race Missing

 38 0 1 1 36

 38 0 1 1 36 9 0 0 1 8 15 0 0 0 15 14 0 1 0 13

 0 0 0 0 0

 0 0 0 0

 31 0 0 1 30 6 0 0 1 5 13 0 0 0 13 12 0 0 0 12

 7 0 1 0 6 3 0 0 0 3 2 0 0 0 2 2 0 1 0 1

 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

 18 0 0 1 17 5 0 0 1 4 6 0 0 0 6 7 0 0 0 7

 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

 8 0 0 1 7 3 0 0 1 2 3 0 0 0 3 2 0 0 0 2

 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

 31 0 0 0 31 8 0 0 0 8 11 0 0 0 11 12 0 0 0 12

 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

 38 0 1 1 36 9 0 0 1 8 15 0 0 0 15 14 0 1 0 13

 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

 37 0 1 1 35 8 0 0 1 7 15 0 0 0 15 14 0 1 0 13

 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

 1 0 0 0 1 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0

 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

ADL SUMMARY FOR

Reported by: ID Idaho Commission on Aging IC Page 5 (Chore)

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 16
SECTION I. Elderly Clients

C. Detailed ADL Characteristics of Elderly Clients Receiving Cluster 1 Services

(Report information for all Cluster 1 services combined and each service separately.)

State ID: ID Fiscal Year: 2014 

Total Cluster 1 Clients Personal Care Homemaker

Chore

Case Management

X Home Delivered Meals Adult Day Care/Health

Age

75-84

1

ADL

All 

Ages

2

ADL

All 

Ages

0

ADL

All 

Ages

Total

Age 

60-74 

Total

All 

Ages

1

ADL

All 

Ages

3+

ADL

Age 

60-74 

0

ADL

Age 

60-74 

1

ADL

Age 

60-74 

3+

ADL

Age

75-84

Total

Age

75-84

2

ADL

Age

75-84

3+

ADL

Age 

60-74 

2

ADL

Age

75-84

0

ADL

Age

85+

Total

Age

85+

0

ADL

Age

85+

1

ADL

Age

85+

2

ADL

Age

85+

3+

ADL

Total Clients

Clients with Age Data

Age Missing

ADLs Missing

Female

Male

Gender Missing

Rural

Rural Missing

Income below Poverty Level

Poverty Missing

Live Alone

Live Alone Missing

Hispanic / Latino

Not Hispanic or Latino

Ethnicity Missing

Clients by Race or Ethnicity

White (Alone) - Non-Hispanic

Total Minorities

Clients by Ethnicity

White (Alone) - Hispanic

American Indian or Alaskan

Native (Alone)

Asian (Alone)

Black / African American

(Alone)

Native Hawaiian or Pacific 

Islander (Alone)

Persons Reporting Some Other

Race

Persons Reporting 2 or More

Races

Race Missing

 3,563 318 307 492 2,425

 3,561 318 307 492 2,423 972 86 83 137 661 1,174 110 102 156 797 1,396 115 118 197 959

 2 0 0 0 2

 21 5 9 7

 2,258 158 171 328 1,591 583 44 42 85 410 744 54 58 109 518 922 58 70 134 657

 1,294 160 136 164 825 387 42 41 52 249 425 56 44 47 275 470 57 48 63 299

 11 0 0 0 9 2 0 0 0 2 5 0 0 0 4 4 0 0 0 3

 1,336 137 139 168 889 348 38 36 42 231 483 49 49 62 322 499 47 53 63 335

 3 1 0 0 2 0 0 0 0 0 2 1 0 0 1 1 0 0 0 1

 1,040 108 93 154 683 366 30 34 56 245 309 28 33 43 205 356 47 24 53 231

 75 1 4 8 53 14 0 1 4 8 24 0 1 1 17 37 1 2 3 28

 1,956 115 182 288 1,363 582 33 51 79 417 584 30 61 84 407 785 50 70 125 536

 11 0 0 1 3 2 0 0 0 1 5 0 0 0 1 4 0 0 1 1

 105 6 13 16 69 35 2 1 5 27 41 1 8 7 24 29 3 4 4 18

 3,402 311 291 469 2,322 923 84 80 130 626 1,115 109 94 148 762 1,344 111 114 189 926

 56 1 3 7 34 14 0 2 2 8 18 0 0 1 11 23 1 0 4 15

 3,271 298 282 454 2,226 869 80 76 127 582 1,079 103 91 143 739 1,302 108 111 182 897

 103 4 13 17 69 36 2 2 5 27 40 1 7 8 24 27 1 4 4 18

 27 4 3 2 18 15 2 1 2 10 7 1 1 0 5 5 1 1 0 3

 12 2 0 4 6 2 0 0 1 1 4 2 0 1 1 6 0 0 2 4

 9 1 0 1 7 7 0 0 1 6 1 1 0 0 0 1 0 0 0 1

 2 1 0 1 0 1 1 0 0 0 0 0 0 0 0 1 0 0 1 0

 9 1 0 0 8 2 0 0 0 2 4 0 0 0 4 3 1 0 0 2

 22 4 2 4 12 6 0 1 1 4 5 2 0 0 3 11 2 1 3 5

 108 3 7 9 79 34 1 3 0 29 34 0 3 4 21 40 2 1 5 29

ADL SUMMARY FOR

Reported by: ID Idaho Commission on Aging IC Page 5 (HDM)

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 17
SECTION I. Elderly Clients

C. Detailed ADL Characteristics of Elderly Clients Receiving Cluster 1 Services

(Report information for all Cluster 1 services combined and each service separately.)

State ID: ID Fiscal Year: 2014 

Total Cluster 1 Clients Personal Care Homemaker

Chore

Case Management

Home Delivered Meals X Adult Day Care/Health

Age

75-84

1

ADL

All 

Ages

2

ADL

All 

Ages

0

ADL

All 

Ages

Total

Age 

60-74 

Total

All 

Ages

1

ADL

All 

Ages

3+

ADL

Age 

60-74 

0

ADL

Age 

60-74 

1

ADL

Age 

60-74 

3+

ADL

Age

75-84

Total

Age

75-84

2

ADL

Age

75-84

3+

ADL

Age 

60-74 

2

ADL

Age

75-84

0

ADL

Age

85+

Total

Age

85+

0

ADL

Age

85+

1

ADL

Age

85+

2

ADL

Age

85+

3+

ADL

Total Clients

Clients with Age Data

Age Missing

ADLs Missing

Female

Male

Gender Missing

Rural

Rural Missing

Income below Poverty Level

Poverty Missing

Live Alone

Live Alone Missing

Hispanic / Latino

Not Hispanic or Latino

Ethnicity Missing

Clients by Race or Ethnicity

White (Alone) - Non-Hispanic

Total Minorities

Clients by Ethnicity

White (Alone) - Hispanic

American Indian or Alaskan

Native (Alone)

Asian (Alone)

Black / African American

(Alone)

Native Hawaiian or Pacific 

Islander (Alone)

Persons Reporting Some Other

Race

Persons Reporting 2 or More

Races

Race Missing

ADL SUMMARY FOR

Reported by: ID Idaho Commission on Aging IC Page 5 (ADC/H)

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 18
SECTION I. Elderly Clients

C. Detailed ADL Characteristics of Elderly Clients Receiving Cluster 1 Services

(Report information for all Cluster 1 services combined and each service separately.)

State ID: ID Fiscal Year: 2014 

Total Cluster 1 Clients Personal Care Homemaker

Chore

Case Management

Home Delivered Meals Adult Day Care/Health

X

Age

75-84

1

ADL

All 

Ages

2

ADL

All 

Ages

0

ADL

All 

Ages

Total

Age 

60-74 

Total

All 

Ages

1

ADL

All 

Ages

3+

ADL

Age 

60-74 

0

ADL

Age 

60-74 

1

ADL

Age 

60-74 

3+

ADL

Age

75-84

Total

Age

75-84

2

ADL

Age

75-84

3+

ADL

Age 

60-74 

2

ADL

Age

75-84

0

ADL

Age

85+

Total

Age

85+

0

ADL

Age

85+

1

ADL

Age

85+

2

ADL

Age

85+

3+

ADL

Total Clients

Clients with Age Data

Age Missing

ADLs Missing

Female

Male

Gender Missing

Rural

Rural Missing

Income below Poverty Level

Poverty Missing

Live Alone

Live Alone Missing

Hispanic / Latino

Not Hispanic or Latino

Ethnicity Missing

Clients by Race or Ethnicity

White (Alone) - Non-Hispanic

Total Minorities

Clients by Ethnicity

White (Alone) - Hispanic

American Indian or Alaskan

Native (Alone)

Asian (Alone)

Black / African American

(Alone)

Native Hawaiian or Pacific 

Islander (Alone)

Persons Reporting Some Other

Race

Persons Reporting 2 or More

Races

Race Missing

 1,050 96 85 144 722

 1,049 96 85 144 722 288 34 25 41 188 328 28 29 51 219 413 31 28 49 304

 1 0 0 0 0

 3 0 1 1

 688 60 53 102 472 179 21 16 30 112 216 17 19 35 144 278 21 17 34 206

 361 35 32 42 250 109 13 9 11 76 111 10 10 16 75 135 10 11 15 98

 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0

 410 39 44 57 268 113 14 15 16 68 139 12 17 20 90 151 11 11 20 108

 2 0 0 0 2 0 0 0 0 0 1 0 0 0 1 1 0 0 0 1

 350 30 30 53 237 133 12 16 19 86 90 5 9 14 62 114 11 3 18 82

 10 0 0 0 7 1 0 0 0 1 4 0 0 0 3 4 0 0 0 3

 545 41 54 85 364 168 14 21 27 106 151 9 16 26 100 223 18 17 31 156

 3 0 0 0 1 0 0 0 0 0 1 0 0 0 0 1 0 0 0 1

 26 3 1 2 20 10 1 0 1 8 7 1 1 0 5 9 1 0 1 7

 1,019 93 84 142 699 277 33 25 40 179 319 27 28 51 213 403 30 28 48 296

 5 0 0 0 3 1 0 0 0 1 2 0 0 0 1 1 0 0 0 1

 995 89 81 139 685 270 31 25 40 174 311 26 26 49 209 395 29 28 47 291

 27 3 1 2 21 9 1 0 1 7 8 1 1 0 6 10 1 0 1 8

 10 1 1 2 6 3 0 0 0 3 4 0 0 2 2 2 1 0 0 1

 7 1 1 1 4 2 0 0 0 2 2 1 1 0 0 3 0 0 1 2

 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

 2 1 0 0 1 1 1 0 0 0 1 0 0 0 1 0 0 0 0 0

 3 0 0 0 3 1 0 0 0 1 1 0 0 0 1 1 0 0 0 1

 6 1 1 0 2 2 1 0 0 1 1 0 1 0 0 2 0 0 0 1

ADL SUMMARY FOR

Reported by: ID Idaho Commission on Aging IC Page 5 (CM)

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 19
SECTION I. Elderly Clients

D. Detailed IADL Characteristics of Elderly Clients Receiving Cluster 1 Services

(Report information for all Cluster 1 services combined and each service separately.)

State ID: ID Fiscal Year: 2014 

X Total Cluster 1 Clients Personal Care Homemaker

Chore

Case Management

Home Delivered Meals Adult Day Care/Health

IADL SUMMARY FOR Age

75-84

1

ADL

All 

Ages

2

ADL

All 

Ages

0

ADL

All 

Ages

Total

Age 

60-74 

Total

All 

Ages

1

ADL

All 

Ages

3+

ADL

Age 

60-74 

0

ADL

Age 

60-74 

1

ADL

Age 

60-74 

3+

ADL

Age

75-84

Total

Age

75-84

2

ADL

Age

75-84

3+

ADL

Age 

60-74 

2

ADL

Age

75-84

0

ADL

Age

85+

Total

Age

85+

0

ADL

Age

85+

1

ADL

Age

85+

2

ADL

Age

85+

3+

ADL

Total Clients

Clients with Age Data

Age Missing

IADLs Missing

Female

Male

Gender Missing

Rural

Rural Missing

Income below Poverty Level

Poverty Missing

Live Alone

Live Alone Missing

Hispanic / Latino

Not Hispanic or Latino

Ethnicity Missing

Clients by Race or Ethnicity

White (Alone) - Non-Hispanic

Total Minorities

Clients by Ethnicity

White (Alone) - Hispanic

American Indian or Alaskan

Native (Alone)

Asian (Alone)

Black / African American

(Alone)

Native Hawaiian or Pacific 

Islander (Alone)

Persons Reporting Some Other

Race

Persons Reporting 2 or More

Races

Race Missing

 4,483

 4,479

 4

 29

 2,927

 1,542

 14

 1,699

 4

 1,382

 85

 2,531

 16

 123

 4,294

 66

 4,127

 122

 37

 16

 11

 2

 12

 28

 128

 166

 166

 0

 94

 72

 0

 76

 0

 65

 0

 54

 0

 4

 161

 1

 160

 2

 0

 0

 0

 0

 1

 2

 1

 51

 51

 0

 26

 25

 0

 23

 0

 13

 0

 14

 0

 0

 51

 0

 49

 0

 0

 1

 0

 0

 0

 0

 1

 6 11 10

 86

 86

 0

 52

 34

 0

 37

 0

 32

 1

 44

 0

 1

 84

 1

 80

 1

 0

 0

 0

 0

 1

 1

 3

 4,151

 4,149

 2

 2,741

 1,399

 11

 1,557

 4

 1,270

 70

 2,409

 6

 117

 3,986

 48

 3,826

 119

 37

 15

 11

 2

 9

 25

 107

 1,254

 779

 473

 2

 454

 0

 509

 16

 766

 2

 40

 1,198

 16

 1,129

 42

 17

 4

 7

 1

 3

 11

 40

 47

 26

 21

 0

 21

 0

 11

 0

 15

 0

 0

 47

 0

 45

 0

 0

 0

 0

 0

 1

 0

 1

 22

 14

 8

 0

 9

 0

 7

 0

 7

 0

 0

 22

 0

 21

 0

 0

 0

 0

 0

 0

 0

 1

 31

 24

 7

 0

 14

 0

 12

 0

 14

 0

 1

 29

 1

 28

 0

 0

 0

 0

 0

 0

 1

 2

 1,148

 713

 433

 2

 409

 0

 478

 15

 727

 1

 39

 1,096

 13

 1,031

 42

 17

 4

 7

 1

 2

 10

 34

 1,479

 972

 500

 7

 614

 3

 395

 27

 769

 7

 48

 1,409

 22

 1,364

 48

 10

 5

 3

 0

 4

 5

 40

 47

 30

 17

 0

 17

 0

 15

 0

 13

 0

 0

 47

 0

 46

 0

 0

 0

 0

 0

 0

 1

 0

 20

 9

 11

 0

 9

 0

 4

 0

 5

 0

 20

 0

 0

 0

 19

 0

 1

 0

 0

 0

 0

 0

 29

 15

 14

 0

 14

 0

 13

 0

 16

 0

 0

 29

 0

 27

 1

 0

 0

 0

 0

 0

 0

 1

 1,372

 911

 455

 6

 572

 3

 363

 21

 733

 2

 47

 1,310

 15

 1,268

 47

 10

 4

 3

 0

 4

 4

 32

 1,710

 1,155

 551

 4

 617

 1

 456

 41

 988

 6

 35

 1,650

 25

 1,597

 32

 9

 7

 1

 1

 5

 12

 46

 63

 35

 28

 0

 34

 0

 34

 0

 24

 0

 4

 58

 1

 60

 2

 0

 0

 0

 0

 0

 1

 0

 9

 3

 6

 0

 5

 0

 2

 0

 2

 0

 0

 9

 0

 9

 0

 0

 0

 0

 0

 0

 0

 0

 26

 13

 13

 0

 9

 0

 7

 1

 14

 0

 0

 26

 0

 25

 0

 0

 0

 0

 0

 1

 0

 0

 1,602

 1,099

 500

 3

 567

 1

 412

 34

 943

 3

 31

 1,552

 19

 1,499

 30

 9

 7

 1

 1

 3

 11

 41

Reported by: ID Idaho Commission on Aging ID Page 6 (Total)

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 20
SECTION I. Elderly Clients

D. Detailed IADL Characteristics of Elderly Clients Receiving Cluster 1 Services

(Report information for all Cluster 1 services combined and each service separately.)

State ID: ID Fiscal Year: 2014 

Total Cluster 1 Clients Personal Care Homemaker

Chore

Case Management

Home Delivered Meals Adult Day Care/Health

X

IADL SUMMARY FOR Age

75-84

1

ADL

All 

Ages

2

ADL

All 

Ages

0

ADL

All 

Ages

Total

Age 

60-74 

Total

All 

Ages

1

ADL

All 

Ages

3+

ADL

Age 

60-74 

0

ADL

Age 

60-74 

1

ADL

Age 

60-74 

3+

ADL

Age

75-84

Total

Age

75-84

2

ADL

Age

75-84

3+

ADL

Age 

60-74 

2

ADL

Age

75-84

0

ADL

Age

85+

Total

Age

85+

0

ADL

Age

85+

1

ADL

Age

85+

2

ADL

Age

85+

3+

ADL

Total Clients

Clients with Age Data

Age Missing

IADLs Missing

Female

Male

Gender Missing

Rural

Rural Missing

Income below Poverty Level

Poverty Missing

Live Alone

Live Alone Missing

Hispanic / Latino

Not Hispanic or Latino

Ethnicity Missing

Clients by Race or Ethnicity

White (Alone) - Non-Hispanic

Total Minorities

Clients by Ethnicity

White (Alone) - Hispanic

American Indian or Alaskan

Native (Alone)

Asian (Alone)

Black / African American

(Alone)

Native Hawaiian or Pacific 

Islander (Alone)

Persons Reporting Some Other

Race

Persons Reporting 2 or More

Races

Race Missing

Reported by: ID Idaho Commission on Aging ID Page 6 (PC)

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 21
SECTION I. Elderly Clients

D. Detailed IADL Characteristics of Elderly Clients Receiving Cluster 1 Services

(Report information for all Cluster 1 services combined and each service separately.)

State ID: ID Fiscal Year: 2014 

Total Cluster 1 Clients Personal Care Homemaker

Chore

Case Management

Home Delivered Meals Adult Day Care/Health

X

IADL SUMMARY FOR Age

75-84

1

ADL

All 

Ages

2

ADL

All 

Ages

0

ADL

All 

Ages

Total

Age 

60-74 

Total

All 

Ages

1

ADL

All 

Ages

3+

ADL

Age 

60-74 

0

ADL

Age 

60-74 

1

ADL

Age 

60-74 

3+

ADL

Age

75-84

Total

Age

75-84

2

ADL

Age

75-84

3+

ADL

Age 

60-74 

2

ADL

Age

75-84

0

ADL

Age

85+

Total

Age

85+

0

ADL

Age

85+

1

ADL

Age

85+

2

ADL

Age

85+

3+

ADL

Total Clients

Clients with Age Data

Age Missing

IADLs Missing

Female

Male

Gender Missing

Rural

Rural Missing

Income below Poverty Level

Poverty Missing

Live Alone

Live Alone Missing

Hispanic / Latino

Not Hispanic or Latino

Ethnicity Missing

Clients by Race or Ethnicity

White (Alone) - Non-Hispanic

Total Minorities

Clients by Ethnicity

White (Alone) - Hispanic

American Indian or Alaskan

Native (Alone)

Asian (Alone)

Black / African American

(Alone)

Native Hawaiian or Pacific 

Islander (Alone)

Persons Reporting Some Other

Race

Persons Reporting 2 or More

Races

Race Missing

 1,075

 1,074

 1

 2

 826

 245

 4

 396

 1

 438

 7

 825

 2

 19

 1,049

 7

 1,002

 21

 11

 6

 3

 0

 3

 7

 22

 5

 5

 0

 4

 1

 0

 0

 0

 4

 0

 3

 0

 0

 5

 0

 4

 0

 0

 0

 0

 0

 1

 0

 0

 8

 8

 0

 7

 1

 0

 1

 0

 3

 0

 4

 0

 0

 8

 0

 8

 0

 0

 0

 0

 0

 0

 0

 0

 0 0 1

 11

 11

 0

 8

 3

 0

 5

 0

 4

 0

 8

 0

 0

 11

 0

 10

 0

 0

 0

 0

 0

 0

 1

 0

 1,049

 1,049

 0

 806

 240

 3

 390

 1

 427

 6

 810

 1

 19

 1,025

 5

 980

 21

 11

 6

 3

 0

 2

 6

 20

 361

 267

 93

 1

 130

 0

 180

 1

 284

 0

 7

 353

 1

 327

 10

 5

 3

 1

 0

 1

 7

 7

 3

 2

 1

 0

 0

 0

 2

 0

 2

 0

 0

 3

 0

 2

 0

 0

 0

 0

 0

 1

 0

 0

 3

 3

 0

 0

 1

 0

 3

 0

 3

 0

 0

 3

 0

 3

 0

 0

 0

 0

 0

 0

 0

 0

 5

 4

 1

 0

 3

 0

 2

 0

 2

 0

 0

 5

 0

 4

 0

 0

 0

 0

 0

 0

 1

 0

 350

 258

 91

 1

 126

 0

 173

 1

 277

 0

 7

 342

 1

 318

 10

 5

 3

 1

 0

 0

 6

 7

 345

 265

 78

 2

 144

 1

 112

 2

 269

 1

 9

 332

 4

 324

 9

 2

 2

 2

 0

 0

 0

 6

 1

 1

 0

 0

 0

 0

 1

 0

 1

 0

 0

 1

 0

 1

 0

 0

 0

 0

 0

 0

 0

 0

 5

 4

 1

 0

 0

 0

 0

 0

 1

 0

 5

 0

 0

 0

 5

 0

 0

 0

 0

 0

 0

 0

 3

 3

 0

 0

 2

 0

 1

 0

 3

 0

 0

 3

 0

 3

 0

 0

 0

 0

 0

 0

 0

 0

 336

 257

 77

 2

 142

 1

 110

 2

 264

 1

 9

 323

 4

 315

 9

 2

 2

 2

 0

 0

 0

 6

 358

 285

 73

 0

 119

 0

 139

 4

 269

 1

 3

 354

 1

 341

 2

 4

 1

 0

 0

 2

 0

 8

 1

 1

 0

 0

 0

 0

 1

 0

 0

 0

 0

 1

 0

 1

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 3

 1

 2

 0

 0

 0

 1

 0

 3

 0

 0

 3

 0

 3

 0

 0

 0

 0

 0

 0

 0

 0

 353

 282

 71

 0

 119

 0

 137

 3

 266

 0

 3

 350

 0

 337

 2

 4

 1

 0

 0

 2

 0

 7

Reported by: ID Idaho Commission on Aging ID Page 6 (Homemaker)

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 22
SECTION I. Elderly Clients

D. Detailed IADL Characteristics of Elderly Clients Receiving Cluster 1 Services

(Report information for all Cluster 1 services combined and each service separately.)

State ID: ID Fiscal Year: 2014 

Total Cluster 1 Clients Personal Care Homemaker

Chore

Case Management

X Home Delivered Meals Adult Day Care/Health

IADL SUMMARY FOR Age

75-84

1

ADL

All 

Ages

2

ADL

All 

Ages

0

ADL

All 

Ages

Total

Age 

60-74 

Total

All 

Ages

1

ADL

All 

Ages

3+

ADL

Age 

60-74 

0

ADL

Age 

60-74 

1

ADL

Age 

60-74 

3+

ADL

Age

75-84

Total

Age

75-84

2

ADL

Age

75-84

3+

ADL

Age 

60-74 

2

ADL

Age

75-84

0

ADL

Age

85+

Total

Age

85+

0

ADL

Age

85+

1

ADL

Age

85+

2

ADL

Age

85+

3+

ADL

Total Clients

Clients with Age Data

Age Missing

IADLs Missing

Female

Male

Gender Missing

Rural

Rural Missing

Income below Poverty Level

Poverty Missing

Live Alone

Live Alone Missing

Hispanic / Latino

Not Hispanic or Latino

Ethnicity Missing

Clients by Race or Ethnicity

White (Alone) - Non-Hispanic

Total Minorities

Clients by Ethnicity

White (Alone) - Hispanic

American Indian or Alaskan

Native (Alone)

Asian (Alone)

Black / African American

(Alone)

Native Hawaiian or Pacific 

Islander (Alone)

Persons Reporting Some Other

Race

Persons Reporting 2 or More

Races

Race Missing

 38

 38

 0

 0

 31

 7

 0

 18

 0

 8

 0

 31

 0

 0

 38

 0

 37

 0

 1

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0 0 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 38

 38

 0

 31

 7

 0

 18

 0

 8

 0

 31

 0

 0

 38

 0

 37

 0

 1

 0

 0

 0

 0

 0

 0

 9

 6

 3

 0

 5

 0

 3

 0

 8

 0

 0

 9

 0

 8

 0

 1

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 9

 6

 3

 0

 5

 0

 3

 0

 8

 0

 0

 9

 0

 8

 0

 1

 0

 0

 0

 0

 0

 0

 15

 13

 2

 0

 6

 0

 3

 0

 11

 0

 0

 15

 0

 15

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 15

 13

 2

 0

 6

 0

 3

 0

 11

 0

 0

 15

 0

 15

 0

 0

 0

 0

 0

 0

 0

 0

 14

 12

 2

 0

 7

 0

 2

 0

 12

 0

 0

 14

 0

 14

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 0

 14

 12

 2

 0

 7

 0

 2

 0

 12

 0

 0

 14

 0

 14

 0

 0

 0

 0

 0

 0

 0

 0

Reported by: ID Idaho Commission on Aging ID Page 6 (Chore)

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 23
SECTION I. Elderly Clients

D. Detailed IADL Characteristics of Elderly Clients Receiving Cluster 1 Services

(Report information for all Cluster 1 services combined and each service separately.)

State ID: ID Fiscal Year: 2014 

Total Cluster 1 Clients Personal Care Homemaker

Chore

Case Management

X Home Delivered Meals Adult Day Care/Health

IADL SUMMARY FOR Age

75-84

1

ADL

All 

Ages

2

ADL

All 

Ages

0

ADL

All 

Ages

Total

Age 

60-74 

Total

All 

Ages

1

ADL

All 

Ages

3+

ADL

Age 

60-74 

0

ADL

Age 

60-74 

1

ADL

Age 

60-74 

3+

ADL

Age

75-84

Total

Age

75-84

2

ADL

Age

75-84

3+

ADL

Age 

60-74 

2

ADL

Age

75-84

0

ADL

Age

85+

Total

Age

85+

0

ADL

Age

85+

1

ADL

Age

85+

2

ADL

Age

85+

3+

ADL

Total Clients

Clients with Age Data

Age Missing

IADLs Missing

Female

Male

Gender Missing

Rural

Rural Missing

Income below Poverty Level

Poverty Missing

Live Alone

Live Alone Missing

Hispanic / Latino

Not Hispanic or Latino

Ethnicity Missing

Clients by Race or Ethnicity

White (Alone) - Non-Hispanic

Total Minorities

Clients by Ethnicity

White (Alone) - Hispanic

American Indian or Alaskan

Native (Alone)

Asian (Alone)

Black / African American

(Alone)

Native Hawaiian or Pacific 

Islander (Alone)

Persons Reporting Some Other

Race

Persons Reporting 2 or More

Races

Race Missing

 3,563

 3,561

 2

 24

 2,258

 1,294

 11

 1,336

 3

 1,040

 75

 1,956

 11

 105

 3,402

 56

 3,271

 103

 27

 12

 9

 2

 9

 22

 108

 136

 136

 0

 75

 61

 0

 63

 0

 53

 0

 43

 0

 3

 132

 1

 133

 1

 0

 0

 0

 0

 0

 2

 0

 41

 41

 0

 19

 22

 0

 19

 0

 11

 0

 9

 0

 0

 41

 0

 39

 0

 0

 1

 0

 0

 0

 0

 1

 6 10 8

 71

 71

 0

 40

 31

 0

 31

 0

 26

 1

 34

 0

 1

 69

 1

 66

 1

 0

 0

 0

 0

 1

 0

 3

 3,291

 3,289

 2

 2,112

 1,170

 9

 1,219

 3

 948

 64

 1,861

 4

 100

 3,149

 42

 3,022

 101

 27

 11

 9

 2

 7

 20

 92

 972

 583

 387

 2

 348

 0

 366

 14

 582

 2

 35

 923

 14

 869

 36

 15

 2

 7

 1

 2

 6

 34

 32

 17

 15

 0

 15

 0

 6

 0

 9

 0

 0

 32

 0

 32

 0

 0

 0

 0

 0

 0

 0

 0

 16

 10

 6

 0

 6

 0

 5

 0

 3

 0

 0

 16

 0

 15

 0

 0

 0

 0

 0

 0

 0

 1

 23

 18

 5

 0

 10

 0

 9

 0

 10

 0

 1

 21

 1

 21

 0

 0

 0

 0

 0

 0

 0

 2

 895

 536

 357

 2

 316

 0

 345

 13

 557

 1

 34

 850

 11

 797

 36

 15

 2

 7

 1

 2

 6

 29

 1,174

 744

 425

 5

 483

 2

 309

 24

 584

 5

 41

 1,115

 18

 1,079

 40

 7

 4

 1

 0

 4

 5

 34

 40

 25

 15

 0

 15

 0

 13

 0

 12

 0

 0

 40

 0

 39

 0

 0

 0

 0

 0

 0

 1

 0

 16

 6

 10

 0

 8

 0

 4

 0

 4

 0

 16

 0

 0

 0

 15

 0

 1

 0

 0

 0

 0

 0

 24

 10

 14

 0

 12

 0

 11

 0

 12

 0

 0

 24

 0

 22

 1

 0

 0

 0

 0

 0

 0

 1

 1,084

 697

 383

 4

 446

 2

 281

 19

 554

 1

 40

 1,032

 12

 1,000

 39

 7

 3

 1

 0

 4

 4

 26

 1,396

 922

 470

 4

 499

 1

 356

 37

 785

 4

 29

 1,344

 23

 1,302

 27

 5

 6

 1

 1

 3

 11

 40

 57

 31

 26

 0

 30

 0

 30

 0

 20

 0

 3

 53

 1

 55

 1

 0

 0

 0

 0

 0

 1

 0

 9

 3

 6

 0

 5

 0

 2

 0

 2

 0

 0

 9

 0

 9

 0

 0

 0

 0

 0

 0

 0

 0

 24

 12

 12

 0

 9

 0

 6

 1

 12

 0

 0

 24

 0

 23

 0

 0

 0

 0

 0

 1

 0

 0

 1,298

 872

 423

 3

 454

 1

 317

 32

 747

 2

 26

 1,254

 18

 1,211

 26

 5

 6

 1

 1

 1

 10

 37

Reported by: ID Idaho Commission on Aging ID Page 6 (HDM)

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 24
SECTION I. Elderly Clients

D. Detailed IADL Characteristics of Elderly Clients Receiving Cluster 1 Services

(Report information for all Cluster 1 services combined and each service separately.)

State ID: ID Fiscal Year: 2014 

Total Cluster 1 Clients Personal Care Homemaker

Chore

Case Management

Home Delivered Meals X Adult Day Care/Health

IADL SUMMARY FOR Age

75-84

1

ADL

All 

Ages

2

ADL

All 

Ages

0

ADL

All 

Ages

Total

Age 

60-74 

Total

All 

Ages

1

ADL

All 

Ages

3+

ADL

Age 

60-74 

0

ADL

Age 

60-74 

1

ADL

Age 

60-74 

3+

ADL

Age

75-84

Total

Age

75-84

2

ADL

Age

75-84

3+

ADL

Age 

60-74 

2

ADL

Age

75-84

0

ADL

Age

85+

Total

Age

85+

0

ADL

Age

85+

1

ADL

Age

85+

2

ADL

Age

85+

3+

ADL

Total Clients

Clients with Age Data

Age Missing

IADLs Missing

Female

Male

Gender Missing

Rural

Rural Missing

Income below Poverty Level

Poverty Missing

Live Alone

Live Alone Missing

Hispanic / Latino

Not Hispanic or Latino

Ethnicity Missing

Clients by Race or Ethnicity

White (Alone) - Non-Hispanic

Total Minorities

Clients by Ethnicity

White (Alone) - Hispanic

American Indian or Alaskan

Native (Alone)

Asian (Alone)

Black / African American

(Alone)

Native Hawaiian or Pacific 

Islander (Alone)

Persons Reporting Some Other

Race

Persons Reporting 2 or More

Races

Race Missing

Reported by: ID Idaho Commission on Aging ID Page 6 (ADC/H)

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 25
SECTION I. Elderly Clients

D. Detailed IADL Characteristics of Elderly Clients Receiving Cluster 1 Services

(Report information for all Cluster 1 services combined and each service separately.)

State ID: ID Fiscal Year: 2014 

Total Cluster 1 Clients Personal Care Homemaker

Chore

Case Management

Home Delivered Meals Adult Day Care/Health

X

IADL SUMMARY FOR Age

75-84

1

ADL

All 

Ages

2

ADL

All 

Ages

0

ADL

All 

Ages

Total

Age 

60-74 

Total

All 

Ages

1

ADL

All 

Ages

3+

ADL

Age 

60-74 

0

ADL

Age 

60-74 

1

ADL

Age 

60-74 

3+

ADL

Age

75-84

Total

Age

75-84

2

ADL

Age

75-84

3+

ADL

Age 

60-74 

2

ADL

Age

75-84

0

ADL

Age

85+

Total

Age

85+

0

ADL

Age

85+

1

ADL

Age

85+

2

ADL

Age

85+

3+

ADL

Total Clients

Clients with Age Data

Age Missing

IADLs Missing

Female

Male

Gender Missing

Rural

Rural Missing

Income below Poverty Level

Poverty Missing

Live Alone

Live Alone Missing

Hispanic / Latino

Not Hispanic or Latino

Ethnicity Missing

Clients by Race or Ethnicity

White (Alone) - Non-Hispanic

Total Minorities

Clients by Ethnicity

White (Alone) - Hispanic

American Indian or Alaskan

Native (Alone)

Asian (Alone)

Black / African American

(Alone)

Native Hawaiian or Pacific 

Islander (Alone)

Persons Reporting Some Other

Race

Persons Reporting 2 or More

Races

Race Missing

 1,050

 1,049

 1

 3

 688

 361

 1

 410

 2

 350

 10

 545

 3

 26

 1,019

 5

 995

 27

 10

 7

 0

 0

 2

 3

 6

 32

 32

 0

 19

 13

 0

 15

 0

 12

 0

 11

 0

 1

 31

 0

 29

 1

 0

 0

 0

 0

 1

 0

 1

 11

 11

 0

 7

 4

 0

 5

 0

 2

 0

 5

 0

 0

 11

 0

 11

 0

 0

 0

 0

 0

 0

 0

 0

 0 1 1

 17

 17

 0

 11

 6

 0

 4

 0

 8

 0

 11

 0

 0

 17

 0

 17

 0

 0

 0

 0

 0

 0

 0

 0

 987

 987

 0

 650

 336

 1

 384

 2

 328

 7

 517

 1

 25

 959

 3

 937

 26

 10

 7

 0

 0

 1

 3

 3

 288

 179

 109

 0

 113

 0

 133

 1

 168

 0

 10

 277

 1

 270

 9

 3

 2

 0

 0

 1

 1

 2

 14

 8

 6

 0

 7

 0

 3

 0

 6

 0

 0

 14

 0

 12

 0

 0

 0

 0

 0

 1

 0

 1

 7

 5

 2

 0

 4

 0

 2

 0

 4

 0

 0

 7

 0

 7

 0

 0

 0

 0

 0

 0

 0

 0

 7

 5

 2

 0

 2

 0

 5

 0

 5

 0

 0

 7

 0

 7

 0

 0

 0

 0

 0

 0

 0

 0

 260

 161

 99

 0

 100

 0

 123

 1

 153

 0

 10

 249

 1

 244

 9

 3

 2

 0

 0

 0

 1

 1

 328

 216

 111

 1

 139

 1

 90

 4

 151

 1

 7

 319

 2

 311

 8

 4

 2

 0

 0

 1

 1

 1

 7

 4

 3

 0

 2

 0

 2

 0

 1

 0

 0

 7

 0

 7

 0

 0

 0

 0

 0

 0

 0

 0

 3

 2

 1

 0

 1

 0

 0

 0

 1

 0

 3

 0

 0

 0

 3

 0

 0

 0

 0

 0

 0

 0

 5

 3

 2

 0

 1

 0

 2

 0

 3

 0

 0

 5

 0

 5

 0

 0

 0

 0

 0

 0

 0

 0

 312

 206

 105

 1

 135

 1

 86

 3

 146

 0

 7

 304

 1

 295

 8

 4

 2

 0

 0

 1

 1

 1

 413

 278

 135

 0

 151

 1

 114

 4

 223

 1

 9

 403

 1

 395

 10

 2

 3

 0

 0

 0

 1

 2

 9

 6

 3

 0

 5

 0

 6

 0

 4

 0

 1

 8

 0

 8

 1

 0

 0

 0

 0

 0

 0

 0

 1

 0

 1

 0

 0

 0

 0

 0

 0

 0

 0

 1

 0

 1

 0

 0

 0

 0

 0

 0

 0

 0

 5

 3

 2

 0

 1

 0

 1

 0

 3

 0

 0

 5

 0

 5

 0

 0

 0

 0

 0

 0

 0

 0

 397

 269

 128

 0

 144

 1

 107

 3

 215

 1

 8

 388

 1

 381

 9

 2

 3

 0

 0

 0

 1

 1

Reported by: ID Idaho Commission on Aging ID Page 6 (CM)

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 26
SECTION I. Caregivers

E. Summary Characteristics of Caregivers Serving Elderly Individuals (National Family Caregiver Support Program - Title III-E)*

Note: Data is for Title III-E Group 1 Services only - See Section II-B for specifics.

State ID: ID Fiscal Year: 2014 

Total Caregivers

Caregivers with Age Data

Age Missing

Female

Male

Gender Missing

Rural

Rural Missing

Caregivers by Ethnicity

Hispanic / Latino

Not Hispanic or Latino

Ethnicity Missing

Caregivers by Race or Ethnicity

White (Alone) - Non-Hispanic

Total Minorities

White (Alone) - Hispanic

Am. Ind./Alaska Native (Alone)

Asian (Alone)

Black / African American (Alone)

Native Hawaiian or Other Pacific Islander (Alone)

Persons Reporting Some Other Race

Persons Reporting 2 or More Races

Race Missing

All Caregivers Age of the

Caregiver

Age 60-74

Age of the

Caregiver

Age 75-84

Age of the

Caregiver

Age 85+

Age of the

Caregiver

Under 60

Caregiver Characteristics

Caregivers by Relationship

Husband

Wife

Son/Son-in-Law

Daughter/Daughter-in-Law

Other Relative

Non-Relative

Relationship Missing

 610

 608 79 205 191 133

 2

 338 49 140 99 48

 271 30 65 91 85

 1 0 0 1 0

 212 19 67 71 55

 0 0 0 0 0

 11 2 5 2 2

 586 76 196 184 129

 13 1 4 5 2

 558 70 190 175 123

 13 3 3 2 5

 1 0 1 0 0

 2 1 1 0 0

 1 0 0 0 0

 1 0 1 0 0

 2 0 2 0 0

 2 0 1 1 0

 30 5 6 13 5

 143 4 36 62 41

 162 7 59 67 29

 30 20 7 1 2

 61 27 33 1 0

 6 2 4 0 0

 9 2 4 1 2

 335 38 114 106 75

Reported by: ID Idaho Commission on Aging IE Page 7

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 27
SECTION I. Caregivers

F. Summary Characteristics of Grandparents and Other Elderly Caregivers Serving Children* (National Family Caregiver Support Program - Title III-E)

Note: Data is for Title III-E Group 1 Services only - See Section II-C for specifics.

State ID: ID Fiscal Year: 2014 

Total Caregivers

Caregivers with Age

Age Missing

Female

Male

Gender Missing

Rural

Rural Missing

Caregivers by Ethnicity

Hispanic / Latino

Not Hispanic or Latino

Ethnicity Missing

Caregivers by Race or Ethnicity

White (Alone) - Non-Hispanic

Total Minorities

White (Alone) - Hispanic

American Indian/Alaska Native (Alone)

Asian (Alone)

Black or African American (Alone)

Native Hawaiian or Other Pacific Islander (Alone)

Persons Reporting Some Other Race

Persons Reporting 2 or More Races

Race Missing

All Caregivers Age of the

Caregiver

55-74

Age of the

Caregiver

75-84

Age of the

Caregiver

Age 85+

Grandparent/Relative Caregiver

Characteristics

Caregivers by Relationship

Grandparents

Other Elderly Relative

Other Elderly Non-Relative

Relationship Missing

Total Children 18 or younger receiving care

 1

 1 0 0 1

 0

 1 0 0 1

 0 0 0 0

 0 0 0 0

 0 0 0 0

 0 0 0 0

 0 0 0 0

 1 0 0 1

 0 0 0 0

 1 0 0 1

 0 0 0 0

 0 0 0 0

 0 0 0 0

 0 0 0 0

 0 0 0 0

 0 0 0 0

 0 0 0 0

 0 0 0 0

 0 0 0 0

 0

 0 0 0 0

 1 0 0 1

 0 0 0 0

Total persons with disabilities

19 - 59 years old receiving care

 1

Reported by: ID Idaho Commission on Aging IF Page 8

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 28
SECTION II. Utilization and Expenditure Profiles

A. Title III Utilization, Expenditure Profile (Except Title III-E)

State ID: ID Fiscal Year: 2014 

A. Title III Utilization, Expenditure, and Program Income Received Profile (Except Title III-E)

$0.00 $0.00 $0.00 $0.00 $0.00 17. Self-Directed Care 0 $0.00 $0.00

$0.00 $0.00 $0.00 $51,635.64 16. Health Promotion 21 17 56 $51,635.64 $51,635.64 $0.00

and Disease Control

$3,326,945.85 $8,416,045.53 $2,809,165.07 $1,051,315.00 $1,339,148.72 $884,846.49 $51,635.64

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

Cluster 1: Registered Services - Requiring Detailed Client Profile

Cluster 3: Non-Registered Services - No Client Profile Required

Cluster 2: Registered Services - Requiring Summary Client Profile

 171 42 4,955

$1.00 $1.00 $0.00 $1.00

$1,562.27 $1,562.27 $0.00 $1,562.27 24 3 18,853.00

$747,353.85 $747,353.85 $0.00 $747,353.85 8 5 29,489.75

$1.00 $1.00 $0.00 $0.00 $1.00 $0.00 52 13 2,798.00

$75,614.02 $75,614.02 $0.00 $75,614.02 7 2 1,321.99

$176,481.26 $395,776.02 $86,342.76 $176,481.26 32 5 88,664.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 0 0 0 0 0.00

 481,078.00

$1,339,147.72 $3,289,610.44 $1,751,194.15 $1,339,147.72 83 16 14,039 2,475 482,061.00

$0.00 $0.00 $0.00 $0.00 0 0 0 0.00

$0.00 $317,393.28 $0.00 $0.00 9 7 1,050 2,067.44

$0.00 $0.00 $0.00 $0.00 0 0 0 0.00

 477,961.00

$884,846.49 $2,653,055.66 $929,636.56 $884,846.49 72 14 3,563 2,642 451,273.00

$3,257.63 $5,861.29 $15.50 $3,257.63 3 1 38 197.25

$47,044.97 $878,181.06 $41,976.10 $47,044.97 49 16 1,075 58,020.10

$0.00 $0.00 $0.00 $0.00 0 0 0 0.00

Total (Unduplicated)

15. Other Services

14. Outreach

13. Information and

 Assistance

12. Nutrition Education

11. Legal Assistance

10. Transportation

9. Nutrition Counseling

 8a. NSIP Congregate

 Meals

8. Congregate Meals

OAA

Title III

Expenditures

($)

Part D

OAA

Title III

Expenditures

($)

Part C2

OAA

Title III

Expenditures 

($)

Part C1

Program

Income

Received

Total Service 

Expenditure

Title III

Expenditure

7. Assisted

 Transportation

6. Case Management

5. Adult Day

 Care/Health

 4a. NSIP Home

 Delivered Meals

4. Home Delivered

 Meals

3. Chore

2. Homemaker

1. Personal Care

Service

Units

# Persons

Served at

High 

Nutrition

Risk

Unduplicated

Persons

Served

# of

AAAs

Direct

Services

Provision

For

Selected Services

Number

of

Providers

OAA

Title III

Expenditures

($)

Part B

Reported by: ID Idaho Commission on Aging IIA Page 9

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 29
SECTION II. Utilization and Expenditure Profiles

B. Title III-E Utilization, Expenditure, and Program Income Received Profile for Caregivers Serving Elderly Individuals

State ID: ID Fiscal Year: 2014 

Title III-E

Expenditures

(Federal $)

Caregiver Support Categories: Total Service

Expenditures

(All Sources)

Program

Income

Received

# Caregivers Served Units of Service # of Providers

(unduplicated)

Group 1

1. Counseling/Support Groups/

 Caregiver Training

2. Respite Care

3. Supplemental Services

Group 2

5. Access Assistance

6. Information Services

Totals (unduplicated)

Unduplicated number of

caregivers:

Estimated unduplicated

number of caregivers:

Estimated Audience Size: # Activities:

$28,367.50 $28,367.50 71 397.00 3

$201,061.97 $426,760.94 $163.20 291 31,890.35 59

$135,353.60 $143,848.26 $8,494.67 287 27,835.70 30

$185,091.38 $185,091.38 1,886 4,276.25 7

$36,697.18 $36,697.18 3,725 539.00 3

$586,571.63 $820,765.26 $8,657.87 92

4. Self-Directed Care

Caregiver Support Categories: Title III-E

Expenditures

(Federal $)

Total Service

Expenditures

(All Sources)

Program

Income

Received

# Caregivers Served Units of Service # of Providers

(unduplicated)

Caregiver Support Categories: Title III-E

Expenditures

(Federal $)

Total Service

Expenditures

(All Sources)

Program

Income

Received

# Caregivers Served Units of Service # of Providers

(unduplicated)

Reported by: ID Idaho Commission on Aging IIB Page 10

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 30
SECTION II. Utilization and Expenditure Profiles

C. Title III-E Utilization, Expenditure, and Program Income Received Profile for Grandparents and Other Elderly Caregivers Serving Children

State ID: ID Fiscal Year: 2014 

Group 1

1. Counseling/Support Groups/

 Caregiver Training

2. Respite Care

3. Supplemental Services

Group 2

5. Access Assistance

6. Information Services

Totals (unduplicated)

Unduplicated number of

caregivers:

Estimated unduplicated

number of caregivers:

Estimated Audience Size: # Activities:

$9,774.00 $9,774.00 1 245.00 1

$2,103.94 $2,103.94 4 16.50 2

$11,877.94 $11,877.94 3

4. Self-Directed Care

# of Providers

(unduplicated)

Program # Caregivers Served Units of Service

Income

Received

Total Service

Expenditures

(All Sources)

Title III-E

Expenditures

(Federal $)

Caregiver Support Categories:

Caregiver Support Categories: # of Providers

(unduplicated)

Program # Caregivers Served Units of Service

Income

Received

Total Service

Expenditures

(All Sources)

Title III-E

Expenditures

(Federal $)

Caregiver Support Categories: # of Providers

(unduplicated)

Program # Caregivers Served Units of Service

Income

Received

Total Service

Expenditures

(All Sources)

Title III-E

Expenditures

(Federal $)

Reported by: ID Idaho Commission on Aging IIC Page 11

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 31
SECTION II. Utilization and Expenditure Profiles

D. Title VII Expenditures by Chapter

State ID: ID Fiscal Year: 2014 

C. Title VII Expenditure By Chapter Title VII Expenditure Total Service Expenditure

Chapter 3: Elder Abuse Prevention

Chapter 4: Legal Assistance Development

$35,901.00 $35,901.00

Reported by: ID Idaho Commission on Aging IID Page 12

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 32
SECTION II. Utilization and Expenditure Profiles

E. Other Services Profile

State ID: ID Fiscal Year: 2014 

Estimated

Service Units

Estimated

Unduplicated

Persons

Served

Total Service

Expenditure

Amount

OAA

Service

Expenditure

Amount

Mission/

Purpose

Category

Service Unit Name

(Up to 15 Characters)

Service Name

(Up to 50 Characters)

Activity F. Services which 

support other 

goals/outcomes

Public Information $1.00 $1.00 1,698 76.00

Reported by: ID Idaho Commission on Aging IIE Page 13

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 33
SECTION III. Network Profiles

A. State Unit on Aging Staffing Profile

State ID: ID Fiscal Year: 2014 

SUA Personnel Categories Total FTEs Minority FTEs

1. Agency Executive / Management Staff

2. Other Paid Professional Staff

 (By Functional Responsibility)

 A. Planning

 B. Development

 C. Administration

 D. Service Delivery

 E. Access / Care Coordination

 F. Other

3. Clerical / Support Staff

4. Total SUA Staff

 3.00000 1.00000

 1.00000 0.00000

 5.00000 1.00000

 3.00000 0.00000

 0.00000 0.00000

 0.00000 0.00000

 0.00000 0.00000

 1.00000 1.00000

 13.00000 3.00000

Reported by: ID Idaho Commission on Aging IIIA Page 14

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 34
SECTION III. Network Profiles

B. Area Agency on Aging Staffing Profile

State ID: ID Fiscal Year: 2014 Total # of AAA's: 6

AAA Personnel Categories Total FTEs Minority FTEs

1. Agency Executive / Management Staff

2. Other Paid Professional Staff

 (By Functional Responsibility)

 A. Planning

 B. Development

 C. Administration

 D. Service Delivery

 E. Access / Care Coordination

 F. Other

3. Clerical / Support Staff

4. Volunteers

5. Total AAA Staff

 5.00000 0.00000

 1.83000 0.00000

 2.75000 0.00000

 8.00000 0.00000

 13.00000 1.00000

 22.45000 2.00000

 1.00000 0.00000

 1.70000 0.00000

 82.00000 0.00000

 137.73000 3.00000

Reported by: ID Idaho Commission on Aging IIIB Page 15

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 35
SECTION III. Network Profiles

C. Provider Profile (Excluding Area Agencies on Aging providing direct services)

State ID: ID Fiscal Year: 2014 

Total # of Providers

Total

Minority

Rural

 185

 29

 68

Reported by: ID Idaho Commission on Aging IIIC Page 16

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 36
SECTION III. Network Profiles

D. Profile of Community Focal Points and Senior Centers

State ID: ID Fiscal Year: 2014 

Number

1. Total Number of Focal Points Designated Under Section

 306(a)(3) of the Act in Operation in the Past Year.

2. Total Number of Focal Points in Item 1., the Number

 That Were Senior Centers.

3. Total Number of Senior Centers in the State in the Past

 Fiscal Year.

4. Total Number of Senior Centers in Item 3. That Received

 OAA Funds During the Past Fiscal Year.

 0

 0

 110

 98

Reported by: ID Idaho Commission on Aging IIID Page 17

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 37
SECTION IV. DEVELOPMENTAL ACCOMPLISHMENTS

a. FOR HOME AND COMMUNITY BASED PROGRAMS*

State ID: ID Fiscal Year: 2014 

Identification of Three Top Accomplishments

1. Area I has continued to develop and fine tune the Area s strategic marketing plan that focuses on providing outreach; focusing on identifying seniors who have the greatest 

economic and/or social need; paying attention to low-income minority or those seniors living in rural communities who are severely disabled. Area I has also been able to 

increase the number of community presentations about the agency to promote our services with an area of focus on Adult Protection Services.

Type of Development: 1. Public Education/Awareness,2. Resource Development

2. Area IV, in collaboration with the Magic Valley Health Education Forum, presented an Alzheimer s Conference to an audience of over 290 individuals at the College of 

Southern Idaho in March 2014 with Boise State University providing the keynote speaker. Area IV began working with ICOA on the Medicare Improvements for Patients and 

Providers Act and Senior Medicare Patrol grants this year. The Ombudsman program has added and trained a volunteer ombudsman coordinator to assist with monitoring the 

volunteers and data. Volunteer Ombudsman hours have increased 371% this year.

Type of Development: 2. Resource Development,3. Training/Education

3. Area VI now offers transportation services to seniors for the first time since 2008. Transportation services were provided to seniors age 60 and older, free of charge, by the 

South Fremont, Mackay, Salmon Senior Center, Lost River Senior Centers and the Targhee Regional Public Transit Authority. Also, Area VI increased the number of Home 

Delivered Meals served in by 14.4% from 2013 to 2014.

Type of Development: 2. Resource Development

Reported by: ID Idaho Commission on Aging IVA Page 18

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 38
SECTION IV. DEVELOPMENTAL ACCOMPLISHMENTS

B. FOR A SYSTEM OF ELDER RIGHTS

State ID: ID Fiscal Year: 2014 

Identification of Three Top Accomplishments

1. Area I has been able to increase the number of community presentations about the agency to promote our services with an area of focus on Adult Protection Services. 

Incoming calls to Information and Assistance has increased by 13% and Adult Protection Services calls have increased by 8%.

Type of Development: 2. Resource Development,3. Training/Education

2. Area II's Volunteer Ombudsman Corps is over 33 members strong with volunteers contributing 2,292 hours of service in regional nursing homes and assisted living 

facilities, an in-kind value of $45,652.00.

Type of Development: 2. Resource Development

3. AAA V coordinated with the Fort Hall Reservation to sponsor an Elder Abuse Conference; educating over 200 attendees.

Type of Development: 3. Training/Education

Reported by: ID Idaho Commission on Aging IVB Page 19

From Date: 10/01/2013 To Date: 09/30/2014 Print Date: 01/26/2015

Idaho Monitoring Report 39
Review 

Section

 Information Required to Submit to ICOA ICOA Staff Requirement Reference

15-NF-01 Provide an example of written information that is 

provided to caregivers describing caregiver support 

services (1.information, 2. assistance gaining access 

to services, 3. individual counseling, support groups 

or caregiver training, 4. respite, and 5. supplemental 

services) 

 OAA Title III, Part E, Section. 

373. (b) (1)

15-NF-02 Provide the procedure that the AAA uses to 

prioritize family caregivers who provide care for 

older individuals with Alzheimer's disease and 

related disorders with neurological and organic brain 

dysfunction.

OAA Title III, Part E, Section. 

372., (b) (1)

15-NF-03 Provide the procedure that the AAA uses to 

prioritize for grandparents or older individuals who 

are relative caregivers for children with severe 

disabilities. 

OAA Title III, Part E, Section. 

372., (b) (2) and Section. 373. 

(c) (2) (B)

Idaho AAA National Family Caregiver Support Worksheet

Idaho AAA National Family Caregiver Support Worksheet 40
Ohio Monitoring Results 41
Ohio Monitoring Results 42
Ohio Monitoring Results 43
1

Oregon State Unit on Aging 

OAA Family Caregiver Support Program Assessment Tool 2014 

Due 5/23/2014. Please submit only to SUA.Email@dhsoha.state.or.us.

AAA: Date of Assessment: 

Contact person for assessment questions: Contact phone number: 

Part 1: Desk Audit on Program Condition 

Family Caregiver Support Program Standards

YesNo

Comments or Required 

Description

1. The AAA provides which of the following core services to individuals who 

meet the eligibility program of the FCGSP: (check all that apply)

a. Information Services

b. One-on-one family caregiver information

c. Counseling

d. Training

e. Support Groups

f. Respite Care

g. Supplemental Services

2. Units of service are accounted for in Oregon ACCESS according to the 

matrices outlined in the DHS “Service Units and Definitions for Older 

American’s Act and Oregon Project Independence Programs” (Group 1 and 

Group 2 for Caregiver Services)

3. The FCGSP provides access to caregiver training (e.g. Powerful Tools for 

Caregivers, or other evidenced based caregiver training).

Please specify which training 

programs: 

4. Staff and/or partners have been trained to provide caregiver trainings 

listed in Question 3.

Please who conducts the 

trainings.

Oregon Program Monitoring Assessment Tool 2014 44
2

Family Caregiver Support Program Standards

YesNo

Comments or Required 

Description

5. The FCGSP partners with other agencies (private or public programs, 

businesses, faith organizations, health agencies) either on formal or 

informal basis to provide services or information that benefits caregivers. 

Please provide a brief 

description of your FCSGP 

partnerships: 

6. There is a process (i.e. satisfaction surveys) in place that demonstrates 

that services provided help family caregivers successfully meet challenges 

of caregiving that allow the care receiver to remain in their home longer.

Please describe your FCGSP 

process: 

7. Please describe how your AAA ensures that clients meet eligibility criteria for FCGSP services which includes 

• Caregiver to a person age 60 or older 

• Caregiver to a person with dementia of any age 

• Grandparent/relative caregiver age 55 or older to a child age 18 years or younger 

• Grandparent/relative caregiver age 55 or older of an adult child (18 years or older) with disabilities. 

RESPONSE: 

8. Please describe the process for assessing the caregiver’s need for support and offering services that can be of benefit to 

them: (Please include a copy of the assessment or evaluation tool that you use.) 

RESPONSE: 

9. Please describe how services are provided to “at risk” family caregivers (“At risk groups” include people who speak limited 

English, specific ethnic groups, Tribes, caregivers at risk of institutionalization, non-traditional family caregivers, relatives 

raising children): RESPONSE: 

10.Please describe how the program identifies and provide services to caregivers who are: 

(a) older individuals with the greatest social and economic need; and 

(b) older individuals providing care to individuals (including children) with severe disabilities, 

-- Per OAA Title III Part E, Section373 (2) (A) (B) (Please include or reference any tools that you may use to determine 

this.)

RESPONSE: 

Oregon Program Monitoring Assessment Tool 2014 45
3

Part 2: Cause, Effect & Recommendations 

In the Five Findings model described in the AAA Monitoring Instructions, CAUSE explains the difference between program 

standards (criteria) and what is actually happening (your program’s condition). EFFECT is the impact of that difference. 

Cause should detail what is preventing your AAA from fully meeting the standards, or is enabling the AAA to exceed the standards. 

An example for cause would be where Question # 1 asks about the core services that the AAA provides. If you reported the AAA 

does not provide all core services and would like to provide more, what additional services would you like to provide? What are the 

barriers? If the AAA is able to provide all or most core services, discuss the strategies that your agency has used to ensure that 

these services are provided. 

Effect should detail the result of not fully meeting, or of exceeding, program standards. Effect can be either positive or negative. 

An example of effect would be where Questions #3 & 4 asks about caregiver training. If the AAA is not able to provide these 

trainings, the effect may be caregivers who may feel less empowered in their caregiver role. Conversely if the AAA does provide 

these trainings, the effect may be caregivers who are more capable in supporting their loved one. 

Please identify items from the checklist above where your AAA is either not fully meeting, or is exceeding, the standards. Explain 

the cause, effect and recommendation for each in the table below. 

Issue from the monitoring 

checklist above where the 

AAA is not meeting, or is 

exceeding, standards.

Cause Effect Recommendation to continue 

success or remedy lack of 

compliance

Goal date 

for

completion

A.

B.

C.

D.

Oregon Program Monitoring Assessment Tool 2014 46
4

Issue from the monitoring 

checklist above where the 

AAA is not meeting, or is 

exceeding, standards.

Cause Effect Recommendation to continue 

success or remedy lack of 

compliance

Goal date 

for

completion

E.

F.

G.

H.

I.

J.

K.

L.

M.

N.

O.

P.

Due 5/23/2014. Please submit only to SUA.Email@dhsoha.state.or.us.

Oregon Program Monitoring Assessment Tool 2014 47
South Carolina Report Codes 48
South Carolina Cumulative Quarterly and Annual Reports 49
South Carolina Cumulative Quarterly and Annual Reports 50
South Carolina Service Definitions 
South Carolina Service Definitions 
South Carolina Service Definitions 
South Carolina Service Definitions 
South Carolina Service Definitions 
South Carolina Service Definitions 
South Carolina Service Definitions 
South Carolina Service Definitions 
South Carolina Service Definitions 
DHS STANDARD MONITORING TOOL 

UTAH CAREGIVER SUPPORT PROGRAM 

UTAH ADMINISTRATIVE CODE 510-401 

UCA 62A-3-104

 Monitor should review all of the following areas annually. 

 Compliance ratings: Y=Yes; N=No; N/ A=Not Applicable. 

 When AAA is not in compliance, the following ratings will apply to actions taken to bring issue into compliance: 

Verbal Warning; Written Warning; Corrective Action DHS Procedure. 

Rule Reference 

510-401 Monitoring Issue/Area

Compliance

Rating & Action Comments

Contractor/AAA: Date:

Contract Number: 

1 | Page 

4. Eligibility for 

Services - 4(1)

1

Services listed in R510-401-5 (a-e) are

available to caregivers, grandparents and 

older individuals who are relative 

caregivers

Eligibility for 

Services - 4(2)

Services are provided to:

4. Eligibility for 

Services - 4(2)(a)

2

Caregivers who are older individuals 

with greatest social need, and older 

individuals with greatest economic need 

(with particular attention to low income 

older individuals)

4. Eligibility for 

Services - 4(2)(b)

3

Family caregivers who provide care for 

individuals with Alzheimer's disease and 

related disorders with neurological and 

organic brain dysfunction

4. Eligibility for 

Services - 4(2)(c)

4

Older individuals providing care to 

individuals with severe disabilities, 

including children with severe 

disabilities; and

4. Eligibility for 

Services - 4(2)(d)

5

Grandparents or older individuals who 

are relative caregivers who provide care 

for children with severe disabilities

4. Eligibility for 

Services - 4(3)

Respite care and Supplemental Services 

are available to caregivers who are:

4. Eligibility for 

Services - 4(3)(a)

6

 Caregivers of adults 60 years of age or 

older

4. Eligibility for 

Services - 4(3)(b)

7

 Adult family members (age 18 years or 

older) or other adult informal 

caregivers providing care to 

individuals of any age with 

Alzheimer's disease and related 

disorder

4. Eligibility for  Caregivers 60 years of age or older 

Utah Caregiver Monitoring Tool Template 60
DHS STANDARD MONITORING TOOL 

UTAH CAREGIVER SUPPORT PROGRAM 

UTAH ADMINISTRATIVE CODE 510-401 

UCA 62A-3-104

 Monitor should review all of the following areas annually. 

 Compliance ratings: Y=Yes; N=No; N/ A=Not Applicable. 

 When AAA is not in compliance, the following ratings will apply to actions taken to bring issue into compliance: 

Verbal Warning; Written Warning; Corrective Action DHS Procedure. 

Rule Reference 

510-401 Monitoring Issue/Area

Compliance

Rating & Action Comments

Contractor/AAA: Date:

Contract Number: 

2 | Page 

Services - 4(3)(c)

8

caring for persons with mental 

retardation or related developmental

disabilities

4. Eligibility for 

Services - 4(3)(d)

9

 Grandparents or older individual (not 

biological or adoptive parents) 55 

years of age and older who are relative 

caregivers of a child not more than 18 

years of age

4. Eligibility for 

Services - 4(3)(e)

10

 Grandparents and other relatives (not 

biological or adoptive parents) 55 

years of age and older providing care 

to adults, age 18-59 years, with 

disabilities.

4. Eligibility for 

Services - 4(4)

To provide Respite and Supplemental 

Services to eligible caregivers the care 

receiver must be:

4. Eligibility for 

Services - 4(4)( a)

11

 Functionally impaired because the 

individual is unable to perform at least 

two activities of daily living without 

substantial human assistance, 

including verbal reminding, physical 

cueing or supervision;

4. Eligibility for 

Services - 4(4)(b)

12

 Due to a cognitive or other mental 

impairment, requires substantial 

supervision because the individual 

behaves in a manner that poses a 

serious health or safety hazard to the 

individual or to another individual

4. Eligibility for 

Services - 4(4)(c)

13

 A child physically or mentally 

impaired because the individual is 

unable to perform at least two areas of 

major life activity.

4. Eligibility for 

Services - 4(4)(d)

The caregiver:

 must demonstrate a medium-to high 

risk score according to the DAASUtah Caregiver Monitoring Tool Template 61
DHS STANDARD MONITORING TOOL 

UTAH CAREGIVER SUPPORT PROGRAM 

UTAH ADMINISTRATIVE CODE 510-401 

UCA 62A-3-104

 Monitor should review all of the following areas annually. 

 Compliance ratings: Y=Yes; N=No; N/ A=Not Applicable. 

 When AAA is not in compliance, the following ratings will apply to actions taken to bring issue into compliance: 

Verbal Warning; Written Warning; Corrective Action DHS Procedure. 

Rule Reference 

510-401 Monitoring Issue/Area

Compliance

Rating & Action Comments

Contractor/AAA: Date:

Contract Number: 

3 | Page 

14

Approved Demographic Intake and 

Screening tool

15

 must complete the DAAS-Approved 

Assessment

16

 must complete DAAS- Approved 

Caregiver Strain Index

4. Eligibility for 

Services - 4(5)

17

In the event that there is insufficient 

funds to bring an individual on the 

program and Agency shall maintain a list 

of potential applicants. All potential 

applicants will be served in turn by using 

the DAAS-approved Demographic Intake 

and Risk Screening tool, and a Caregiver 

Burden score to determine eligibility for 

services.

5. Responsibilities 

of the Division -

5(1)(d)

18

Pursuant to DCA 62A-3-104, the 

Division shall: define minimal 

documentation and client assessment 

standards to include:

 Authorization for release of 

confidential information

 Nutritional Score on Caregiver and 

Care Receiver

 Client rights and responsibilities

 Client notification of grievance 

procedure

 Client notification of right to appeal

6. Program 

Content - 6 (2)

19

The Area Agency on Aging shall use the 

DAAS approved Demographic Intake 

and Risk Screening form and assessment 

tool to determine eligibility for respite 

and supplemental services and said tools 

shall be kept in the client file.

6. Program Prior to receiving respite or supplemental 

Utah Caregiver Monitoring Tool Template 62
DHS STANDARD MONITORING TOOL 

UTAH CAREGIVER SUPPORT PROGRAM 

UTAH ADMINISTRATIVE CODE 510-401 

UCA 62A-3-104

 Monitor should review all of the following areas annually. 

 Compliance ratings: Y=Yes; N=No; N/ A=Not Applicable. 

 When AAA is not in compliance, the following ratings will apply to actions taken to bring issue into compliance: 

Verbal Warning; Written Warning; Corrective Action DHS Procedure. 

Rule Reference 

510-401 Monitoring Issue/Area

Compliance

Rating & Action Comments

Contractor/AAA: Date:

Contract Number: 

4 | Page 

Content - 6(3)

20

services the Area Agency on Aging shall 

develop a written service plan including 

goals and objectives for the caregiver, 

which shall be kept in the client file.

6. Program 

Content - 6(4)

21

The Area Agency on Aging shall ensure 

the provision of the full range of 

caregiver support services in the 

community by coordinating its activities 

with the activities of other community 

agencies and voluntary organizations 

providing supportive services to family 

caregivers and grandparents or older 

individuals who are relative caregivers of 

children.

Older Americans Act information and 

services shall be provided to family 

caregivers in a direct and helpful manner. 

In cases where caregiver support 

programs already exist within the 

community, coordination of these 

programs and the UCSP is essential to 

maximize the dollars available for family 

caregivers and avoid duplication of 

services.

6. Program 

Content - 6(6)

To assure coordination of caregiver 

services in the planning and service area, 

the Area Agency on Aging shall convene 

a minimum of one joint planning meeting 

annually with other local providers who 

currently provide support services to 

family caregivers. As practical, the Area 

Agency on Aging shall coordinate the 

activities under this program with other 

community agencies and voluntary 

organizations providing services to 

Utah Caregiver Monitoring Tool Template 63
DHS STANDARD MONITORING TOOL 

UTAH CAREGIVER SUPPORT PROGRAM 

UTAH ADMINISTRATIVE CODE 510-401 

UCA 62A-3-104

 Monitor should review all of the following areas annually. 

 Compliance ratings: Y=Yes; N=No; N/ A=Not Applicable. 

 When AAA is not in compliance, the following ratings will apply to actions taken to bring issue into compliance: 

Verbal Warning; Written Warning; Corrective Action DHS Procedure. 

Rule Reference 

510-401 Monitoring Issue/Area

Compliance

Rating & Action Comments

Contractor/AAA: Date:

Contract Number: 

5 | Page 

23 caregivers.

6. Program 

Content - 6 (7)

Funds allocated on an annual basis under 

the UCSP for services provided by and 

Area Agency on Aging shall be 

expended as follows:

6. Program 

Content – 6 (7)(a)

24

 Information to caregiver about 

available services

6. Program 

Content – 6 (7)(b)

25

 Assistance to caregivers in gaining 

access to the services

6. Program 

Content – 6 (7)(c)

26

 Individual counseling, organization of 

support groups, and caregiver training 

to caregivers to assist the caregivers in 

the areas of health, nutrition and

financial literacy and in making 

decisions and solving problems 

relating to their caregiving roles.

6. Program 

Content – 6 (7)(d)

27

 Respite care to enable caregivers to be 

temporarily relieved from their 

caregiving responsibilities.

6. Program 

Content – 6 (7)(e)

28

 Supplemental services, on a limited 

basis, to complement the care provided 

by caregivers.

6. Program 

Content – 6 (7)(f)

29

The Area Agency on Aging shall spend 

no more than ten percent of funds on 

services provided to grandparents and

other individuals who are relative 

caregivers of a child not more than 18 

years of age.

6. Program 

Content – 6 (8)

If a client discontinues Respite and/or 

Supplemental Services before the end of 

the twelve-month period and before the 

Utah Caregiver Monitoring Tool Template 64
DHS STANDARD MONITORING TOOL 

UTAH CAREGIVER SUPPORT PROGRAM 

UTAH ADMINISTRATIVE CODE 510-401 

UCA 62A-3-104

 Monitor should review all of the following areas annually. 

 Compliance ratings: Y=Yes; N=No; N/ A=Not Applicable. 

 When AAA is not in compliance, the following ratings will apply to actions taken to bring issue into compliance: 

Verbal Warning; Written Warning; Corrective Action DHS Procedure. 

Rule Reference 

510-401 Monitoring Issue/Area

Compliance

Rating & Action Comments

Contractor/AAA: Date:

Contract Number: 

6 | Page 

30

annual established service expenditure 

limit per client is reached, the case shall 

be closed.

6. Program 

Content – 6 (8)(a)

31

If funds are available, the caregiver may 

be readmitted to the program subsequent 

to the case closing but shall do so within 

twelve months from the original date of 

enrollment.

6. Program 

Content – (8)(b)

32

If no funds are available, the person will 

be placed at the top of the list to be the 

first person to be admitted to the program 

if the person still has time left on the 

program.

6. Program 

Content – 6 (8)(c)

33

If funds become available, but there is 

not time remaining based on the original 

admission, then the caregiver needs to 

reapply and be considered for admission 

to the program with all other applicants.

6. Program 

Content – 6(9)

34

The Area Agency on Aging shall make 

use of trained volunteers to expand the 

provision of available resources and, if 

possible, work in coordination with 

organizations that have experience in 

providing training, placement, and 

stipends for volunteers or participants 

(such as organizations carrying out 

Federal service programs administered 

by the Corporation for National and 

Community Service), in community 

settings.

7. Caregiver 

Advisory Council 

- 7(1)

35

The Area Agency on Aging shall develop 

and maintain a Caregiver Advisory 

Council

7. Caregiver 

Advisory Council 

The Caregiver Advisory Council may be 

a subgroup of the Area Agency on Aging 

Utah Caregiver Monitoring Tool Template 65
DHS STANDARD MONITORING TOOL 

UTAH CAREGIVER SUPPORT PROGRAM 

UTAH ADMINISTRATIVE CODE 510-401 

UCA 62A-3-104

 Monitor should review all of the following areas annually. 

 Compliance ratings: Y=Yes; N=No; N/ A=Not Applicable. 

 When AAA is not in compliance, the following ratings will apply to actions taken to bring issue into compliance: 

Verbal Warning; Written Warning; Corrective Action DHS Procedure. 

Rule Reference 

510-401 Monitoring Issue/Area

Compliance

Rating & Action Comments

Contractor/AAA: Date:

Contract Number: 

7 | Page 

- 7(2)

36

Advisory Council providing they meet 

the requirements set forth in the rule.

7. Caregiver 

Advisory Council7(2)(a) 

37

The Caregiver Advisory Council may be 

comprised of no less than five members, 

some of who shall be caregivers.

7. Caregiver 

Advisory Council 

- 7(3)

38

The Caregiver Advisory Council shall 

meet no less than semiannually, and 

meetings shall be scheduled by each 

Area Agency on Aging.

7. Caregiver 

Advisory Council 

- 7(4)

39

The primary duty of the Caregiver 

Advisory Council shall include but not 

be limited to conducting an annual 

caregiver satisfaction survey for the 

caregiver program.

7. Caregiver 

Advisory Council 

- 7(5)

40

The Caregiver Advisory Council shall 

advise the Area Agency on Aging in 

determining service needs and 

developing action plans. When there is a 

concern over the use of limited resources 

for Respite Care and Supplemental 

Services, the Area Agencies on Aging, in 

consultation with their Caregiver 

Advisory Council, may further limit the 

amount of services provided to an 

individual caregiver. This local policy

decision shall be in writing and shall be 

uniform for all caregivers for the current 

fiscal year.

8. Voluntary

Contributions - 

8(1)

41

Individuals receiving services from this 

program may be encouraged to 

participate in voluntary contributions for

services, provided that the method or 

solicitation is non-coercive.

8. Voluntary Voluntary contributions shall in no way 

Utah Caregiver Monitoring Tool Template 66
DHS STANDARD MONITORING TOOL 

UTAH CAREGIVER SUPPORT PROGRAM 

UTAH ADMINISTRATIVE CODE 510-401 

UCA 62A-3-104

 Monitor should review all of the following areas annually. 

 Compliance ratings: Y=Yes; N=No; N/ A=Not Applicable. 

 When AAA is not in compliance, the following ratings will apply to actions taken to bring issue into compliance: 

Verbal Warning; Written Warning; Corrective Action DHS Procedure. 

Rule Reference 

510-401 Monitoring Issue/Area

Compliance

Rating & Action Comments

Contractor/AAA: Date:

Contract Number: 

8 | Page 

Contributions - 

8(2)

42

be based on a means test of an individual 

client’s income.

8. Voluntary

Contributions - 

8(3)

Each Area Agency on Aging shall 

implement procedures for voluntary 

contributions in the UCSP, and shall 

comply, at a minimum, with the 

following:

8. Voluntary 

Contributions -

8(3)(a)

43

 Provide each recipient with an 

opportunity to voluntarily contribute to

the cost of the services.

8. Voluntary

Contributions -

8(3)(b)

44

 Clearly inform each recipient that 

there is no obligation to contribute and 

that the contribution is purely 

voluntary.

8. Voluntary

Contributions 8 -

(3)(c)

45

 Protect the privacy and 

confidentiality of each recipient with 

respect to the recipient’s contribution 

or lack of contribution

8. Voluntary 

Contributions -

8(3)(d)

46

 Establish appropriate procedures to 

safeguard and account for voluntary 

contributions.

8. Voluntary

Contributions -

8(4)

47

Use all collected voluntary contributions 

to expand the service for which such 

contributions were given.

8. Voluntary

Contributions -

8(5)

48

In no instance shall services be denied if 

individuals do not participate in 

voluntary contributions.

8. Voluntary 

Contributions - 

8(6)

Area Agencies on Aging will consult 

with relevant service providers and older 

individuals in their planning and service 

Utah Caregiver Monitoring Tool Template 67
DHS STANDARD MONITORING TOOL 

UTAH CAREGIVER SUPPORT PROGRAM 

UTAH ADMINISTRATIVE CODE 510-401 

UCA 62A-3-104

 Monitor should review all of the following areas annually. 

 Compliance ratings: Y=Yes; N=No; N/ A=Not Applicable. 

 When AAA is not in compliance, the following ratings will apply to actions taken to bring issue into compliance: 

Verbal Warning; Written Warning; Corrective Action DHS Procedure. 

Rule Reference 

510-401 Monitoring Issue/Area

Compliance

Rating & Action Comments

Contractor/AAA: Date:

Contract Number: 

9 | Page 

49

area to determine the best method for 

accepting voluntary contributions.

9. Reporting - 9(1)

50

The Area Agency on Aging shall collect 

data and maintain records relating to the 

UCSP in the format specified by the 

Division

9. Reporting - 9(2)

51

The Area Agency on Aging shall furnish 

the records to the DAAS as specified.

9. Reporting - 9(3)

52

The Area Agency on Aging shall report 

to DAAS, as specified, the activities and 

determinations of the Caregiver Advisory 

Council.

9. Reporting - 9(4)

53

The Area Agency on Aging shall report 

to DAAS any mechanisms used with 

caregivers regarding information about 

and access to various services so that the 

persons can better carry out their 

caregiver responsibilities.

10. Waiver

Requests for 

Respite and 

Supplemental 

Services - 10(1)

54

An Area Agency on Aging may request 

in writing a waiver for Respite and 

Supplemental Services in order to enable 

the caregiver to carry out their duties in 

assisting the care receiver. In requesting 

a waiver, the Area Agency on Aging 

must demonstrate that effort has been 

made to access other sources of services 

or funds. The Agency Director, or 

designee, may grant a waiver for 

Supplemental Services or Respite on a 

case-by-case basis provided that such 

waiver is consistent with the law. A copy 

of the approved waiver request must be

placed in the client file and a copy sent in 

writing to the Division.

Utah Caregiver Monitoring Tool Template 68
DHS STANDARD MONITORING TOOL 

UTAH CAREGIVER SUPPORT PROGRAM 

UTAH ADMINISTRATIVE CODE 510-401 

UCA 62A-3-104

 Monitor should review all of the following areas annually. 

 Compliance ratings: Y=Yes; N=No; N/ A=Not Applicable. 

 When AAA is not in compliance, the following ratings will apply to actions taken to bring issue into compliance: 

Verbal Warning; Written Warning; Corrective Action DHS Procedure. 

Rule Reference 

510-401 Monitoring Issue/Area

Compliance

Rating & Action Comments

Contractor/AAA: Date:

Contract Number: 

10 | Page 

Make note if race and ethnicity are 

tracked at intake/assessment.

SUMMARY: 

Utah Caregiver Monitoring Tool Template 69
STATE OF VERMONT Grant #«Grant_» 

GRANT AGREEMENT Page 1 of 31 

1. Parties: This is a Grant Agreement for services between the State of Vermont, Department 

of Disabilities, Aging, and Independent Living (DAIL), (hereinafter called “State”) and 

Central Vermont Council on Aging, Inc. (CVCOA), with a principal place of business in 

Barre, VT (hereinafter called “Grantee”). It is the Grantee’s responsibility to contact the 

Vermont Department of Taxes to determine if, by law, the Grantee is required to have a 

Vermont Department of Taxes Business Account Number. 

2. Subject Matter: The subject matter of this Grant Agreement is to provide supportive 

services for individuals with Alzheimer’s disease and related disorders and for their families 

and caregivers. Detailed services to be provided by the Grantee are described in Attachment 

A.

3. Maximum Amount: In consideration of the services to be performed by Grantee, the State 

agrees to pay Grantee, in accordance with the payment provisions specified in Attachment 

B, a sum not to exceed $46,094. The State program code for this Grant is 43500. 

4. Grant Term: The period of Grantee’s performance shall begin on July 1, 2014 and end on 

June 30, 2015. 

5. Relationship: The State does not consider the Grantee a subrecipient per OMB Circular A133 for the purposes of this Grant.

6. Prior Approval: Approval by the Attorney General’s Office is required.

7. Contact persons for this award:

Grantee’s contact person for this award: Elizabeth Stern 

Telephone#: (802) 479-0531 E-mail Address: bstern@cvcoa.org 

State’s contact person for this award: 

Name & Dept./Division: Will Rowe, DAIL 

Telephone#: (802) 871-3207 E-mail: will.rowe@state.vt.us 

8. Amendment: No changes, modifications, or amendments in the terms and conditions of 

this Grant shall be effective unless reduced to writing, numbered, and signed by the duly 

authorized representative of the State and Grantee. 

9. Cancellation: This Grant Agreement may be suspended or cancelled by either party by 

giving written notice at least thirty (30) days in advance. 

10. Attachments: This Grant consists of thirty-one (31) pages including the following 

attachments which are incorporated herein: 

Attachment A - Specifications of Work to be Performed 

Attachment B - Payment Provisions 

Attachment C - Customary Provisions for Contracts and Grants 

Attachment D - Modifications of Insurance – Does Not Apply 

Attachment E - Business Associate Agreement 

Attachment F - AHS Customary Grant Provisions 

Attachment G – Dementia Respite Program Report 

Attachment H – Dementia Respite Quarterly Grand Expenditure Report 

Vermont AAA Dementia Respite Grant with Monitoring Information 70
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 2 of 31 

Attachment I – Dementia Respite Quarterly Service Report 

Attachment J – Dementia Respite Caregiver Survey 

Attachment K – Caregiver Survey Results 

The order of precedence of these documents shall be as follows: 

This document 

Attachment D – Does Not Apply 

Attachment C

Attachment A 

Attachment B 

Attachment E 

Attachment F 

 Attachment G 

 Attachment H 

 Attachment I 

 Attachment J 

 Attachment K 

WE, THE UNDERSIGNED PARTIES, AGREE TO BE BOUND BY THIS GRANT. 

APPROVED AS TO FORM GRANTEE 

Signature: ___________________________ Signature: _____________________ 

Attorney General’s Office 

Date: _______________________________ Date: _________________________ 

 Name: Elizabeth Stern 

BY THE STATE OF VERMONT 

 

Signature: ___________________________ Title: ________________________ 

Susan Wehry, MD, Commissioner 

Department of Disabilities, Aging, and 

Independent Living 

 Mailing Address: 

Date: ___________________________ 59 North Main St, Suite 200 

 Barre, VT 05641 

Vermont AAA Dementia Respite Grant with Monitoring Information 71
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 3 of 31 

ATTACHMENT A

SPECIFICATIONS OF WORK TO BE PERFORMED 

A. PROGRAM DESCRIPTION: 

The Grantee will operate a dementia respite program in the project service areas they 

serve in the counties of Lamoille, Orange and Washington. Grantee will provide respite 

grants and Information and Support to eligible program participants. Respite grants are 

intended to strengthen family and community capacity to care for the individual with 

dementia and support the unpaid family caregiver. Information and Support are intended 

to help caregivers understand and utilize a variety of caregiver supports and promote the 

development and implementation of Self-Care Plans by and for caregivers. Program 

funds may be used for services and activities that promote caregiver well-being and 

health or provide periods of respite from caregiving including in-home and out-of-home 

respite services (e.g. respite in residential care homes or nursing homes), attendance of 

the care recipient at adult day centers, home care personal services, chore and companion 

services, and other services that provide caregivers with a break from the responsibilities 

and stress associated with caregiving. Individuals eligible for the dementia respite 

program may receive up to $2,000.00 per year in reimbursement for respite services, such 

amount to be determined by the Grantee. Grantee may, under certain circumstances, be 

granted a waiver to increase the total amount of funding available to an individual by 

obtaining written approval from the State dementia program director. 

B. SERVICE DESCRIPTION 

1. Service Description: Grantee will administer the Dementia Respite program funds 

and provide program management services including all of the following:

a. Outreach and public information activities to ensure that the public, 

potential applicants for assistance, community organizations, health care 

service providers and others are aware of the Dementia Respite program;

b. Assistance to respite program applicants, including determination of their 

financial and programmatic eligibility, informing them of eligibility status, 

granting respite funding assistance and providing referral to other 

programs and services;

c. Completion of an Independent Living Assessment (ILA) for each 

applicant including Section 0 (A-D); Section 1(1.A.1-1.H.1 inclusive) 

which shall be entered in the Social Assistance Management System 

(SAMS) using the service code for Dementia Respite;

d. Interviews with primary caregivers to assess the need for support, 

education, assistance, case management, information, assistance and 

referrals as needed;

Vermont AAA Dementia Respite Grant with Monitoring Information 72
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 4 of 31 

e. Collaboration with the Aging and Disabilities Resource Connection 

(ADRC), the Alzheimer’s Association, and other community 

organizations providing other services to the individuals with Alzheimer’s 

disease and related disorders (ADRD) and their caregivers, to ensure 

integration of services across the system of care;

f. Participation of key staff (Dementia Respite Grant Manager, National 

Family Caregiver Support Program Coordinator, case management staff, 

etc.) in State sponsored training related to community-based dementia 

caregiver services;

g. Participation by the Dementia Respite Grant Manager in quarterly 

statewide meetings, to share information, ideas and strategies that promote 

effective management of dementia respite care funding and to conduct 

RBA reviews of Program;

h. Referral of respite grant recipients/caregivers to ADRD education and /or 

support group programs and other services appropriate to applicant and 

household needs;

i. Collection and maintenance of demographic data required for the annual 

Dementia Respite Program Report (Attachment G) due July 31, 2015;

j. Tracking and quarterly reporting of expenditures and services using the 

Dementia Respite Program Quarterly Expenditure Report (Attachment H) 

and the Dementia Respite Program Quarterly Service Report (Attachment 

I);

k. By September 30, 2014, Grantee will collaboratively develop with DAIL 

and all Dementia Respite Coordinators a “Caregiver Self-help Plan”

template to be utilized with participating caregivers;

l. By September 30, 2014, Grantee will develop or enhance a Dementia 

Resource document that lists relevant national, state, and local dementia 

care and caregiver support resources; and

m. The Grantee must spend at least 85% of the Grant funds for 

reimbursement to families for respite services. The Grantee may use up to 

15% of expended Grant funds for administration.

2. Target Population and Eligibility Criteria 

Eligible applicants: 

a. Have annual incomes no greater that 300% of the federal poverty level 

(FPL) per calendar year for an individual or couple ($35,010 for a single 

person and $47,190 of the FPL for a married or civil union couple). 

Vermont AAA Dementia Respite Grant with Monitoring Information 73
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 5 of 31 

Individuals with incomes above 300% of FPL, while ineligible for a 

dementia respite grant, may utilize other service components such as 

Information and Referral, caregiver education, supportive services from 

the respite grant manager, case management and other Area Agency on 

Aging and community services for which they may be eligible; 

b. Have a physician’s diagnosis of Alzheimer’s disease or a related disorder; 

c. Are permanent residents of Vermont; and 

d. Are not receiving services comparable in scope and intent to the dementia 

respite program through the Choices for Care Medicaid Waiver Program 

(CFC); the Attendant Services Program (ASP), respite services provided 

under the National Family Caregiver Support Program (NFCSP) or 

Veterans Independence Program (VIP). This restriction does not apply to 

other non-respite NFCSP services. 

The Grantee may, under certain circumstances, be granted a waiver to 

eligibility restrictions listed in Section 2(d) by obtaining written approval from 

the State Dementia Respite Program Director. In the event that a waiver is 

granted the dementia respite funds are used to pay for services pending 

eligibility for programs identified in Section 2(d), the Grantee will make every 

effort to recover those funds from the providers. 

3. Geographic Area

The area served is the same as the service area served by the Grantee Area 

Agency on Aging. 

4. Length of Time 

a. July 1, 2014 through June 30, 2015. 

C. SERVICE OUTCOMES, PROGRAM PERFORMANCE 

1. Program Performance Measures 

Grantee will track each of the following Results Based Accountability 

(RBA) Performance Measures utilizing RBA report questions in 

Attachment G and Attachment I and review at quarterly, statewide 

program meetings as described in B(1)(g) above: 

a. How much has been done? 

i. Number of caregivers receiving grants. 

ii. Number of caregivers who receive other services including 

information, referral, and support. 

iii. Number of persons with dementia receiving care services. 

Vermont AAA Dementia Respite Grant with Monitoring Information 74
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 6 of 31 

b. How well has the work been done?

i. Percentage of caregivers who receive follow-up check-in 

contact. 

ii. Percentage of caregivers utilizing service supports like 

Powerful Tools, Dementia Café, Alzheimer’s Association 

Caregiver Supports, or other supports. 

iii. Percentage Dementia Respite Grant staff participation in 

Alzheimer’s Disease and other dementia training. 

iv. Percentage of caregivers who develop and implement SelfCare Plans. 

v. Percentage of grant funds expended for respite grants. 

c. How are caregivers better off? 

i. Percentage of Caregiver participants that indicate they agree or 

strongly agree that the Dementia Respite program helped by: a) 

giving them a break from caregiving responsibilities; b) helped 

them maintain their physical health; c) helped them maintain 

their emotional well-being; d) helped them care for their family 

member; e) gave them flexibility to select the respite support 

most helpful to them. 

ii. Percentage of participating caregivers that develop and 

implement Self-Care Plans. 

Vermont AAA Dementia Respite Grant with Monitoring Information 75
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 7 of 31 

ATTACHMENT B

PAYMENT PROVISIONS

The maximum dollar amount payable under this Grant is not intended as any form of a 

guaranteed amount. The Grantee will be paid for products or services specified in 

Attachment A, or services actually performed, up to the maximum allowable amount 

specified in this Grant. The payment schedule for delivered products, or rates for services 

performed, and any additional reimbursements, are included in this attachment. The 

following provisions specifying payments are: 

1. For its part, in consideration of the services delivered by Grantee pursuant to this Grant, 

the State agrees to make payments as follows: 

 The State will pay the Grantee in four payments: 

 The first payment of $11,523.50 will be paid upon execution of this Grant 

agreement. 

 A second payment of $11,523.50 will be made upon receipt and approval of the 

first quarter reports (Attachment H, I) due on or before October 31, 2014. 

 A third payment of $11,523.50 will be made upon receipt and approval of the 2nd

quarter reports (Attachment H, I) due on or before January 31, 2015. 

 The final payment of $11,523.50 will be made upon receipt and approval of the 

3

rd quarter reports (Attachment H, I, and J) due on or before April 30, 2015. 

2. The total amount of carry forward from SFY 14 in combination with SFY 15 award must 

be spent down to at least 5% or greater of the SFY 15 award. No more than 5% of SFY 

15 award shall be carried forward for SFY 15. 

Reports shall be mailed to 

Will Rowe 

Department of Disabilities, Aging and Independent Living 

103 South Main Street, 

Waterbury, VT 05671-1601 

Vermont AAA Dementia Respite Grant with Monitoring Information 76
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 8 of 31 

ATTACHMENT C 

CUSTOMARY PROVISIONS FOR CONTRACTS AND GRANTS 

1. Entire Agreement. This Agreement, whether in the form of a Contract, State Funded Grant, 

or Federally Funded Grant, represents the entire agreement between the parties on the subject 

matter. All prior agreements, representations, statements, negotiations, and understandings 

shall have no effect. 

2. Applicable Law. This Agreement will be governed by the laws of the State of Vermont. 

3. Definitions: For purposes of this Attachment, “Party” shall mean the Contractor, Grantee or 

Subrecipient, with whom the State of Vermont is executing this Agreement and consistent 

with the form of the Agreement. 

4. Appropriations: If appropriations are insufficient to support this Agreement, the State may 

cancel on a date agreed to by the parties or upon the expiration or reduction of existing 

appropriation authority. In the case that this Agreement is funded in whole or in part by 

federal or other non-State funds, and in the event those funds become unavailable or reduced, 

the State may suspend or cancel this Agreement immediately, and the State shall have no 

obligation to fund this Agreement from State revenues. 

5. No Employee Benefits For Party: The Party understands that the State will not provide any 

individual retirement benefits, group life insurance, group health and dental insurance, 

vacation or sick leave, workers compensation or other benefits or services available to State 

employees, nor will the state withhold any state or federal taxes except as required under 

applicable tax laws, which shall be determined in advance of execution of the Agreement. 

The Party understands that all tax returns required by the Internal Revenue Code and the 

State of Vermont, including but not limited to income, withholding, sales and use, and rooms 

and meals, must be filed by the Party, and information as to Agreement income will be 

provided by the State of Vermont to the Internal Revenue Service and the Vermont 

Department of Taxes. 

6. Independence, Liability: The Party will act in an independent capacity and not as officers or 

employees of the State. 

The Party shall defend the State and its officers and employees against all claims or suits 

arising in whole or in part from any act or omission of the Party or of any agent of the Party. 

The State shall notify the Party in the event of any such claim or suit, and the Party shall 

immediately retain counsel and otherwise provide a complete defense against the entire claim 

or suit. The Party shall notify its insurance company and the State within 10 days of 

receiving any claim for damages, notice of claims, pre-claims, or service of judgments or 

claims, for any act or omissions in the performance of this Agreement. 

After a final judgment or settlement the Party may request recoupment of specific defense 

costs and may file suit in Washington Superior Court requesting recoupment. The Party shall 

be entitled to recoup costs only upon a showing that such costs were entirely unrelated to the 

defense of any claim arising from an act or omission of the Party. 

The Party shall indemnify the State and its officers and employees in the event that the State, 

its officers or employees become legally obligated to pay any damages or losses arising from 

any act or omission of the Party. 

Vermont AAA Dementia Respite Grant with Monitoring Information 77
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 9 of 31 

7. Insurance: Before commencing work on this Agreement the Party must provide certificates 

of insurance to show that the following minimum coverage is in effect. It is the responsibility 

of the Party to maintain current certificates of insurance on file with the state through the 

term of the Agreement. No warranty is made that the coverage and limits listed herein are 

adequate to cover and protect the interests of the Party for the Party’s operations. These are 

solely minimums that have been established to protect the interests of the State.

Workers Compensation: With respect to all operations performed, the Party shall carry 

workers’ compensation insurance in accordance with the laws of the State of Vermont. 

General Liability and Property Damage: With respect to all operations performed under 

the Agreement, the Party shall carry general liability insurance having all major divisions 

of coverage including, but not limited to: 

Premises - Operations 

Products and Completed Operations 

Personal Injury Liability 

Contractual Liability 

The policy shall be on an occurrence form and limits shall not be less than: 

$1,000,000 Per Occurrence 

$1,000,000 General Aggregate 

$1,000,000 Products/Completed Operations Aggregate 

$ 50,000 Fire/ Legal/Liability 

Party shall name the State of Vermont and its officers and employees as additional insureds 

for liability arising out of this Agreement. 

Automotive Liability: The Party shall carry automotive liability insurance covering all 

motor vehicles, including hired and non-owned coverage, used in connection with the 

Agreement. Limits of coverage shall not be less than: $1,000,000 combined single limit. 

Party shall name the State of Vermont and its officers and employees as additional insureds 

for liability arising out of this Agreement. 

Professional Liability: Before commencing work on this Agreement and throughout the 

term of this Agreement, the Party shall procure and maintain professional liability 

insurance for any and all services performed under this Agreement, with minimum 

coverage of $ __na__ per occurrence, and $ __na__ aggregate. 

8. Reliance by the State on Representations: All payments by the State under this Agreement 

will be made in reliance upon the accuracy of all prior representations by the Party, including 

but not limited to bills, invoices, progress reports and other proofs of work. 

Vermont AAA Dementia Respite Grant with Monitoring Information 78
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 10 of 31 

9. Requirement to Have a Single Audit: In the case that this Agreement is a Grant that is 

funded in whole or in part by federal funds, the Subrecipient will complete the Subrecipient 

Annual Report annually within 45 days after its fiscal year end, informing the State of 

Vermont whether or not a single audit is required for the prior fiscal year. If a single audit is 

required, the Subrecipient will submit a copy of the audit report to the granting Party within 9 

months. If a single audit is not required, only the Subrecipient Annual Report is required. 

For fiscal years ending before December 25, 2015, a Single Audit is required if the 

subrecipient expends $500,000 or more in federal assistance during its fiscal year and must 

be conducted in accordance with OMB Circular A-133. For fiscal years ending on or after 

December 25, 2015, a Single Audit is required if the subrecipient expends $750,000 or more 

in federal assistance during its fiscal year and must be conducted in accordance with 2 CFR 

Chapter I, Chapter II, Part 200, Subpart F. The Subrecipient Annual Report is required to be 

submitted within 45 days, whether or not a Single Audit is required. 

 

10. Records Available for Audit: The Party will maintain all books, documents, payroll papers, 

accounting records and other evidence pertaining to costs incurred under this agreement and 

make them available at reasonable times during the period of the Agreement and for three 

years thereafter for inspection by any authorized representatives of the State or Federal 

Government. If any litigation, claim, or audit is started before the expiration of the three year 

period, the records shall be retained until all litigation, claims or audit findings involving the 

records have been resolved. The State, by any authorized representative, shall have the right 

at all reasonable times to inspect or otherwise evaluate the work performed or being 

performed under this Agreement. 

11. Fair Employment Practices and Americans with Disabilities Act: Party agrees to comply 

with the requirement of Title 21V.S.A. Chapter 5, Subchapter 6, relating to fair employment 

practices, to the full extent applicable. Party shall also ensure, to the full extent required by 

the Americans with Disabilities Act of 1990, as amended, that qualified individuals with 

disabilities receive equitable access to the services, programs, and activities provided by the 

Party under this Agreement. Party further agrees to include this provision in all subcontracts. 

12. Set Off: The State may set off any sums which the Party owes the State against any sums due 

the Party under this Agreement; provided, however, that any set off of amounts due the State 

of Vermont as taxes shall be in accordance with the procedures more specifically provided 

hereinafter. 

13. Taxes Due to the State: 

a. Party understands and acknowledges responsibility, if applicable, for compliance with 

State tax laws, including income tax withholding for employees performing services 

within the State, payment of use tax on property used within the State, corporate 

and/or personal income tax on income earned within the State. 

b. Party certifies under the pains and penalties of perjury that, as of the date the 

Agreement is signed, the Party is in good standing with respect to, or in full 

compliance with, a plan to pay any and all taxes due the State of Vermont. 

c. Party understands that final payment under this Agreement may be withheld if the 

Commissioner of Taxes determines that the Party is not in good standing with respect 

Vermont AAA Dementia Respite Grant with Monitoring Information 79
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 11 of 31 

to or in full compliance with a plan to pay any and all taxes due to the State of 

Vermont. 

d. Party also understands the State may set off taxes (and related penalties, interest and 

fees) due to the State of Vermont, but only if the Party has failed to make an appeal 

within the time allowed by law, or an appeal has been taken and finally determined 

and the Party has no further legal recourse to contest the amounts due. 

14. Child Support: (Applicable if the Party is a natural person, not a corporation or partnership.) 

Party states that, as of the date the Agreement is signed, he/she: 

a. is not under any obligation to pay child support; or 

b. is under such an obligation and is in good standing with respect to that obligation; or 

c. has agreed to a payment plan with the Vermont Office of Child Support Services and 

is in full compliance with that plan. 

Party makes this statement with regard to support owed to any and all children residing in 

Vermont. In addition, if the Party is a resident of Vermont, Party makes this statement with 

regard to support owed to any and all children residing in any other state or territory of the 

United States. 

15. Sub-Agreements: Party shall not assign, subcontract or subgrant the performance of his 

Agreement or any portion thereof to any other Party without the prior written approval of the 

State. Party also agrees to include in subcontract or subgrant agreements a tax certification in 

accordance with paragraph 13 above. 

Notwithstanding the foregoing, the State agrees that the Party may assign this agreement, 

including all of the Party's rights and obligations hereunder, to any successor in interest to the 

Party arising out of the sale of or reorganization of the Party. 

16. No Gifts or Gratuities: Party shall not give title or possession of anything of substantial 

value (including property, currency, travel and/or education programs) to any officer or 

employee of the State during the term of this Agreement. 

17. Copies: All written reports prepared under this Agreement will be printed using both sides of 

the paper.

18. Certification Regarding Debarment: Party certifies under pains and penalties of perjury 

that, as of the date that this Agreement is signed, neither Party nor Party’s principals 

(officers, directors, owners, or partners) are presently debarred, suspended, proposed for 

debarment, declared ineligible or excluded from participation in federal programs, or 

programs supported in whole or in part by federal funds. 

Party further certifies under pains and penalties of perjury that, as of the date that this 

Agreement is signed, Party is not presently debarred, suspended, nor named on the State’s 

debarment list at: http://bgs.vermont.gov/purchasing/debarment

19. Certification Regarding Use of State Funds: In the case that Party is an employer and this 

Agreement is a State Funded Grant in excess of $1,001, Party certifies that none of these 

State funds will be used to interfere with or restrain the exercise of Party’s employee’s rights 

with respect to unionization. 

State of Vermont – Attachment C 

Revised AHS – 6-9-2014

Vermont AAA Dementia Respite Grant with Monitoring Information 80
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 12 of 31 

ATTACHMENT E

BUSINESS ASSOCIATE AGREEMENT 

This Business Associate Agreement (“Agreement”) is entered into by and between the State of 

Vermont Agency of Human Services, operating by and through its Department of Disabilities, 

Aging and Independent Living, (“Covered Entity”) and Central Vermont Council on Aging, Inc. 

(“Business Associate”) as of July 1 2014 (“Effective Date”). This Agreement supplements and 

is made a part of the contract/grant to which it is attached. 

Covered Entity and Business Associate enter into this Agreement to comply with standards 

promulgated under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 

including the Standards for the Privacy of Individually Identifiable Health Information, at 45 

CFR Parts 160 and 164 (“Privacy Rule”), and the Security Standards, at 45 CFR Parts 160 and 

164 (“Security Rule”), as amended by Subtitle D of the Health Information Technology for 

Economic and Clinical Health Act (HITECH), and any associated federal rules and regulations. 

The parties agree as follows: 

1. Definitions. All capitalized terms used but not otherwise defined in this Agreement have 

the meanings set forth in 45 CFR Parts 160 and 164 as amended by HITECH and associated 

federal rules and regulations. 

“Agent” means those person(s) who are agents(s) of the Business Associate, in accordance with 

the Federal common law of agency, as referenced in 45 CFR § 160.402(c). 

“Breach” means the acquisition, access, use or disclosure of protected health information (PHI) 

which compromises the security or privacy of the PHI, except as excluded in the definition of 

Breach in 45 CFR § 164.402. 

“Business Associate shall have the meaning given in 45 CFR § 160.103.

“Individual” includes a person who qualifies as a personal representative in accordance with 45 

CFR § 164.502(g). 

“Protected Health Information” or PHI shall have the meaning given in 45 CFR § 160.103, 

limited to the information created or received by Business Associate from or on behalf of 

Agency. 

“Security Incident” means any known successful or unsuccessful attempt by an authorized or 

unauthorized individual to inappropriately use, disclose, modify, access, or destroy any 

information or interference with system operations in an information system. 

“Services” includes all work performed by the Business Associate for or on behalf of Covered 

Entity that requires the use and/or disclosure of protected health information to perform a 

business associate function described in 45 CFR § 160.103 under the definition of Business 

Associate. 

“Subcontractor” means a person or organization to whom a Business Associate delegates a 

Vermont AAA Dementia Respite Grant with Monitoring Information 81
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 13 of 31 

function, activity or service, other than in the capacity of a member of the workforce of the 

Business Associate. For purposes of this Agreement, the term Subcontractor includes 

Subgrantees. 

2. Identification and Disclosure of Privacy and Security Offices. Business Associate and 

Subcontractors shall provide, within ten (10) days of the execution of this agreement, written 

notice to the Covered Entity’s contract/grant manager the names and contact information of both 

the HIPAA Privacy Officer and HIPAA Security Officer. This information must be updated any 

time either of these contacts changes. 

3. Permitted and Required Uses/Disclosures of PHI. 

3.1 Except as limited in this Agreement, Business Associate may use or disclose PHI to 

perform Services, as specified in the underlying grant or contract with Covered Entity. 

The uses and disclosures of Business Associate are limited to the minimum necessary, to 

complete the tasks or to provide the services associated with the terms of the underlying 

agreement. Business Associate shall not use or disclose PHI in any manner that would 

constitute a violation of the Privacy Rule if used or disclosed by Covered Entity in that 

manner. Business Associate may not use or disclose PHI other than as permitted or 

required by this Agreement or as Required by Law. 

3.2 Business Associate may make PHI available to its employees who need access to 

perform Services provided that Business Associate makes such employees aware of the 

use and disclosure restrictions in this Agreement and binds them to comply with such 

restrictions. Business Associate may only disclose PHI for the purposes authorized by 

this Agreement: (a) to its agents and Subcontractors in accordance with Sections 9 and 17 

or, (b) as otherwise permitted by Section 3. 

3.3 Business Associate shall be directly liable under HIPAA for impermissible uses 

and disclosures of the PHI it handles on behalf of Covered Entity, and for impermissible 

uses and disclosures, by Business Associate’s Subcontractor(s), of the PHI that Business 

Associate handles on behalf of Covered Entity and that it passes on to Subcontractors. 

4. Business Activities. Business Associate may use PHI received in its capacity as a 

Business Associate to Covered Entity if necessary for Business Associate’s proper management 

and administration or to carry out its legal responsibilities. Business Associate may disclose PHI 

received in its capacity as Business Associate to Covered Entity for Business Associate’s proper 

management and administration or to carry out its legal responsibilities if a disclosure is 

Required by Law or if Business Associate obtains reasonable written assurances via a written 

agreement from the person to whom the information is to be disclosed that the PHI shall remain 

confidential and be used or further disclosed only as Required by Law or for the purpose for 

which it was disclosed to the person, and the Agreement requires the person or entity to notify 

Business Associate, within two (2) business days (who in turn will notify Covered Entity within 

two (2) business days after receiving notice of a Breach as specified in Section 6.1), in writing of 

any Breach of Unsecured PHI of which it is aware. Uses and disclosures of PHI for the purposes 

identified in Section 3 must be of the minimum amount of PHI necessary to accomplish such 

purposes. 

Vermont AAA Dementia Respite Grant with Monitoring Information 82
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 14 of 31 

5. Safeguards. Business Associate, its Agent(s) and Subcontractor(s) shall implement and 

use appropriate safeguards to prevent the use or disclosure of PHI other than as provided for by 

this Agreement. With respect to any PHI that is maintained in or transmitted by electronic 

media, Business Associate or its Subcontractor(s) shall comply with 45 CFR sections 164.308 

(administrative safeguards), 164.310 (physical safeguards), 164.312 (technical safeguards) and 

164.316 (policies and procedures and documentation requirements). Business Associate or its 

Agent(s) and Subcontractor(s) shall identify in writing upon request from Covered Entity all of 

the safeguards that it uses to prevent impermissible uses or disclosures of PHI. 

6. Documenting and Reporting Breaches. 

6.1 Business Associate shall report to Covered Entity any Breach of Unsecured PHI, 

including Breaches reported to it by a Subcontractor, as soon as it (or any of its 

employees or agents) becomes aware of any such Breach, and in no case later than two 

(2) business days after it (or any of itsemployees or agents) becomes aware of the Breach, 

except when a law enforcement official determines that a notification would impede a 

criminal investigation or cause damage to national security. 

6.2 Business Associate shall provide Covered Entity with the names of the 

individuals whose Unsecured PHI has been, or is reasonably believed to have been, the 

subject of the Breach and any other available information that is required to be given to 

the affected individuals, as set forth in 45 CFR § 164.404(c), and, if requested by 

Covered Entity, information necessary for Covered Entity to investigate the 

impermissible use or disclosure. Business Associate shall continue to provide to Covered 

Entity information concerning the Breach as it becomes available to it. Business 

Associate shall require its Subcontractor(s) to agree to these same terms and conditions. 

6.3 When Business Associate determines that an impermissible acquisition, use or 

disclosure of PHI by a member of its workforce is not a Breach, as that term is defined in 

45 CFR § 164.402, and therefore does not necessitate notice to the impacted 

individual(s), it shall document its assessment of risk, conducted as set forth in 45 CFR § 

402(2). When requested by Covered Entity, Business Associate shall make its risk 

assessments available to Covered Entity. It shall also provide Covered Entity with 1) the 

name of the person(s) making the assessment, 2) a brief summary of the facts, and 3) a 

brief statement of the reasons supporting the determination of low probability that the 

PHI had been compromised. When a breach is the responsibility of a member of its 

Subcontractor’s workforce, Business Associate shall either 1) conduct its own risk 

assessment and draft a summary of the event and assessment or 2) require its 

Subcontractor to conduct the assessment and draft a summary of the event. In either 

case, Business Associate shall make these assessments and reports available to Covered 

Entity. 

6.4 Business Associate shall require, by contract, a Subcontractor to report to 

Business Associate and Covered Entity any Breach of which the Subcontractor becomes 

aware, no later than two (2) business days after becomes aware of the Breach. 

7. Mitigation and Corrective Action. Business Associate shall mitigate, to the extent 

practicable, any harmful effect that is known to it of an impermissible use or disclosure of PHI, 

Vermont AAA Dementia Respite Grant with Monitoring Information 83
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 15 of 31 

even if the impermissible use or disclosure does not constitute a Breach. Business Associate 

shall draft and carry out a plan of corrective action to address any incident of impermissible use 

or disclosure of PHI. If requested by Covered Entity, Business Associate shall make its 

mitigation and corrective action plans available to Covered Entity. Business Associate shall 

require a Subcontractor to agree to these same terms and conditions. 

8. Providing Notice of Breaches. 

8.1 If Covered Entity determines that an impermissible acquisition, access, use or 

disclosure of PHI for which one of Business Associate’s employees or agents was 

responsible constitutes a Breach as defined in 45 CFR § 164.402, and if requested by 

Covered Entity, Business Associate shall provide notice to the individual(s) whose PHI 

has been the subject of the Breach. When requested to provide notice, Business 

Associate shall consult with Covered Entity about the timeliness, content and method of 

notice, and shall receive Covered Entity’s approval concerning these elements. The cost 

of notice and related remedies shall be borne by Business Associate. 

8.2 If Covered Entity or Business Associate determines that an impermissible 

acquisition, access, use or disclosure of PHI by a Subcontractor of Business Associate 

constitutes a Breach as defined in 45 CFR § 164.402, and if requested by Covered Entity 

or Business Associate, Subcontractor shall provide notice to the individual(s) whose PHI 

has been the subject of the Breach. When Covered Entity requests that Business 

Associate or its Subcontractor provide notice, Business Associate shall either 1) consult 

with Covered Entity about the specifics of the notice as set forth in section 8.1, above, or 

2) require, by contract, its Subcontractor to consult with Covered Entity about the 

specifics of the notice as set forth in section 8.1. 

8.3 The notice to affected individuals shall be provided as soon as reasonably possible 

and in no case later than 60 calendar days after Business Associate reported the Breach to 

Covered Entity. 

8.4 The notice to affected individuals shall be written in plain language and shall 

include, to the extent possible, 1) a brief description of what happened, 2) a description of 

the types of Unsecured PHI that were involved in the Breach, 3) any steps individuals can 

take to protect themselves from potential harm resulting from the Breach, 4) a brief 

description of what the Business Associate is doing to investigate the Breach, to mitigate 

harm to individuals and to protect against further Breaches, and 5) contact procedures for 

individuals to ask questions or obtain additional information, as set forth in 45 CFR § 

164.404(c). 

8.5 Business Associate shall notify individuals of Breaches as specified in 45 CFR § 

164.404(d) (methods of individual notice). In addition, when a Breach involves more 

than 500 residents of Vermont, Business Associate shall, if requested by Covered Entity, 

notify prominent media outlets serving Vermont, following the requirements set forth in 

45 CFR § 164.406. 

9. Agreements with Subcontractors. Business Associate shall enter into a Business 

Associate Agreement with any Subcontractor to whom it provides PHI received from Covered 

Vermont AAA Dementia Respite Grant with Monitoring Information 84
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 16 of 31 

Entity or created or received by Business Associate on behalf of Covered Entity in which the 

Subcontractor agrees to the same restrictions and conditions that apply through this Agreement 

to Business Associate with respect to such PHI. Business Associate must enter into this Business 

Associate Agreement before any use by or disclosure of PHI to such agent. The written 

agreement must identify Covered Entity as a direct and intended third party beneficiary with the 

right to enforce any breach of the agreement concerning the use or disclosure of PHI. Business 

Associate shall provide a copy of the Business Associate Agreement it enters into with a 

subcontractor to Covered Entity upon request. Business associate may not make any disclosure 

of PHI to any Subcontractor without prior written consent of Covered Entity. 

10. Access to PHI. Business Associate shall provide access to PHI in a Designated Record 

Set to Covered Entity or as directed by Covered Entity to an Individual to meet the requirements 

under 45 CFR § 164.524. Business Associate shall provide such access in the time and manner 

reasonably designated by Covered Entity. Within three (3) business days, Business Associate 

shall forward to Covered Entity for handling any request for access to PHI that Business 

Associate directly receives from an Individual. 

11. Amendment of PHI. Business Associate shall make any amendments to PHI in a 

Designated Record Set that Covered Entity directs or agrees to pursuant to 45 CFR § 164.526, 

whether at the request of Covered Entity or an Individual. Business Associate shall make such 

amendments in the time and manner reasonably designated by Covered Entity. Within three (3) 

business days, Business Associate shall forward to Covered Entity for handling any request for 

amendment to PHI that Business Associate directly receives from an Individual. 

12. Accounting of Disclosures. Business Associate shall document disclosures of PHI and 

all information related to such disclosures as would be required for Covered Entity to respond to 

a request by an Individual for an accounting of disclosures of PHI in accordance with 45 CFR § 

164.528. Business Associate shall provide such information to Covered Entity or as directed by 

Covered Entity to an Individual, to permit Covered Entity to respond to an accounting request. 

Business Associate shall provide such information in the time and manner reasonably designated 

by Covered Entity. Within three (3) business days, Business Associate shall forward to Covered 

Entity for handling any accounting request that Business Associate directly receives from an 

Individual. 

13. Books and Records. Subject to the attorney-client and other applicable legal privileges, 

Business Associate shall make its internal practices, books, and records (including policies and 

procedures and PHI) relating to the use and disclosure of PHI received from Covered Entity or 

created or received by Business Associate on behalf of Covered Entity available to the Secretary 

in the time and manner designated by the Secretary. Business Associate shall make the same 

information available to Covered Entity, upon Covered Entity’s request, in the time and manner 

reasonably designated by Covered Entity so that Covered Entity may determine whether 

Business Associate is in compliance with this Agreement. 

14. Termination. 

14.1 This Agreement commences on the Effective Date and shall remain in effect until 

terminated by Covered Entity or until all of the PHI provided by Covered Entity to 

Business Associate or created or received by Business Associate on behalf of Covered 

Entity is destroyed or returned to Covered Entity subject to Section 18.7. 

Vermont AAA Dementia Respite Grant with Monitoring Information 85
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 17 of 31 

14.2 If Business Associate breaches any material term of this Agreement, Covered 

Entity may either: (a) provide an opportunity for Business Associate to cure the breach 

and Covered Entity may terminate the contract or grant without liability or penalty if 

Business Associate does not cure the breach within the time specified by Covered Entity; 

or (b) immediately terminate the contract or grant without liability or penalty if Covered 

Entity believes that cure is not reasonably possible; or (c) if neither termination nor cure 

are feasible, Covered Entity shall report the breach to the Secretary. Covered Entity has 

the right to seek to cure any breach by Business Associate and this right, regardless of 

whether Covered Entity cures such breach, does not lessen any right or remedy available 

to Covered Entity at law, in equity, or under the contract or grant, nor does it lessen 

Business Associate’s responsibility for such breach or its duty to cure such breach.

15. Return/Destruction of PHI. 

15.1 Business Associate in connection with the expiration or termination of the 

contract or grant shall return or destroy, at the discretion of the Covered Entity, all PHI 

received from Covered Entity or created or received by Business Associate on behalf of 

Covered Entity pursuant to this contract or grant that Business Associate still maintains in 

any form or medium (including electronic) within thirty (30) days after such expiration or 

termination. Business Associate shall not retain any copies of the PHI. Business 

Associate shall certify in writing for Covered Entity (1) when all PHI has been returned 

or destroyed and (2) that Business Associate does not continue to maintain any PHI. 

Business Associate is to provide this certification during this thirty (30) day period. 

15.2 Business Associate shall provide to Covered Entity notification of any conditions 

that Business Associate believes make the return or destruction of PHI infeasible. If 

Covered Entity agrees that return or destruction is infeasible, Business Associate shall 

extend the protections of this Agreement to such PHI and limit further uses and 

disclosures of such PHI to those purposes that make the return or destruction infeasible 

for so long as Business Associate maintains such PHI. This shall also apply to all Agents 

and Subcontractors of Business Associate. 

16. Penalties and Training. Business Associate understands that: (a) there may be civil or 

criminal penalties for misuse or misappropriation of PHI and (b) violations of this Agreement 

may result in notification by Covered Entity to law enforcement officials and regulatory, 

accreditation, and licensure organizations. If requested by Covered Entity, Business Associate 

shall participate in training regarding the use, confidentiality, and security of PHI. 

17. Security Rule Obligations. The following provisions of this section apply to the extent 

that Business Associate creates, receives, maintains or transmits Electronic PHI on behalf of 

Covered Entity. 

17.1 Business Associate shall implement and use administrative, physical, and 

technical safeguards in compliance with 45 CFR sections 164.308, 164.310, and 164.312 

with respect to the Electronic PHI that it creates, receives, maintains or transmits on 

behalf of Covered Entity. Business Associate shall identify in writing upon request from 

Covered Entity all of the safeguards that it uses to protect such Electronic PHI. 

Vermont AAA Dementia Respite Grant with Monitoring Information 86
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 18 of 31 

17.2 Business Associate shall ensure that any Agent and Subcontractor to whom it 

provides Electronic PHI agrees in a written agreement to implement and use 

administrative, physical, and technical safeguards that reasonably and appropriately 

protect the Confidentiality, Integrity and Availability of the Electronic PHI. Business 

Associate must enter into this written agreement before any use or disclosure of 

Electronic PHI by such Agent or Subcontractor. The written agreement must identify 

Covered Entity as a direct and intended third party beneficiary with the right to enforce 

any breach of the agreement concerning the use or disclosure of Electronic PHI. 

Business Associate shall provide a copy of the written agreement to Covered Entity upon 

request. Business Associate may not make any disclosure of Electronic PHI to any Agent 

or Subcontractor without the prior written consent of Covered Entity. 

17.3 Business Associate shall report in writing to Covered Entity any Security Incident 

pertaining to such Electronic PHI (whether involving Business Associate or an Agent or 

Subcontractor). Business Associate shall provide this written report as soon as it 

becomes aware of any such Security Incident, and in no case later than two (2) business 

days after it becomes aware of the incident. Business Associate shall provide Covered 

Entity with the information necessary for Covered Entity to investigate any such Security 

Incident. 

17.4 Business Associate shall comply with any reasonable policies and procedures 

Covered Entity implements to obtain compliance under the Security Rule. 

18. Miscellaneous. 

18.1 In the event of any conflict or inconsistency between the terms of this Agreement 

and the terms of the contract/grant, the terms of this Agreement shall govern with respect 

to its subject matter. Otherwise, the terms of the contract/grant continue in effect. 

18.2 Business Associate shall cooperate with Covered Entity to amend this Agreement 

from time to time as is necessary for Covered Entity to comply with the Privacy Rule, the 

Security Rule, or any other standards promulgated under HIPAA. 

18.3 Any ambiguity in this Agreement shall be resolved to permit Covered Entity to 

comply with the Privacy Rule, Security Rule, or any other standards promulgated under 

HIPAA. 

18.4 In addition to applicable Vermont law, the parties shall rely on applicable federal 

law (e.g., HIPAA, the Privacy Rule and Security Rule, and the HIPAA omnibus final 

rule) in construing the meaning and effect of this Agreement. 

18.5 As between Business Associate and Covered Entity, Covered Entity owns all PHI 

provided by Covered Entity to Business Associate or created or received by Business 

Associate on behalf of Covered Entity. 

18.6 Business Associate shall abide by the terms and conditions of this Agreement 

with respect to all PHI it receives from Covered Entity or creates or receives on behalf of 

Vermont AAA Dementia Respite Grant with Monitoring Information 87
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 19 of 31 

Covered Entity even if some of that information relates to specific services for which 

Business Associate may not be a “Business Associate” of Covered Entity under the 

Privacy Rule. 

18.7 Business Associate is prohibited from directly or indirectly receiving any 

remuneration in exchange for an individual’s PHI. Business Associate will refrain from 

marketing activities that would violate HIPAA, including specifically Section 13406 of 

the HITECH Act. Reports or data containing the PHI may not be sold without Agency’s 

or the affected individual’s written consent.

18.8 The provisions of this Agreement that by their terms encompass continuing rights 

or responsibilities shall survive the expiration or termination of this Agreement. For 

example: (a) the provisions of this Agreement shall continue to apply if Covered Entity 

determines that it would be infeasible for Business Associate to return or destroy PHI as 

provided in Section 14.2 and (b) the obligation of Business Associate to provide an 

accounting of disclosures as set forth in Section 11 survives the expiration or termination 

of this Agreement with respect to accounting requests, if any, made after such expiration 

or termination. 

(Rev: 9/21/13) 

Vermont AAA Dementia Respite Grant with Monitoring Information 88
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 20 of 31 

ATTACHMENT F

AGENCY OF HUMAN SERVICES’ CUSTOMARY GRANT PROVISIONS 

1. Agency of Human Services – Field Services Directors will share oversight with the 

department (or field office) that is a party to the grant for provider performance using 

outcomes, processes, terms and conditions agreed to under this grant. 

2. 2-1-1 Data Base: The Grantee providing a health or human services within Vermont, or near 

the border that is readily accessible to residents of Vermont, will provide relevant descriptive 

information regarding its agency, programs and/or contact and will adhere to the 

"Inclusion/Exclusion" policy of Vermont's United Way/Vermont 211. If included, the 

Grantee will provide accurate and up to date information to their data base as needed. The 

“Inclusion/Exclusion” policy can be found at www.vermont211.org

3. Medicaid Program Grantees: 

Inspection of Records: Any grants accessing payments for services through the Global 

Commitment to Health Waiver and Vermont Medicaid program must fulfill state and federal 

legal requirements to enable the Agency of Human Services (AHS), the United States 

Department of Health and Human Services (DHHS) and the Government Accounting Office 

(GAO) to: 

Evaluate through inspection or other means the quality, appropriateness, and timeliness of 

services performed; and inspect and audit any financial records of such Grantee or 

subgrantee. 

Subcontracting for Medicaid Services: Having a subcontract does not terminate the Grantee, 

receiving funds under Vermont’s Medicaid program, from its responsibility to ensure that all 

activities under this agreement are carried out. Subcontracts must specify the activities and 

reporting responsibilities of the Grantee or subgrantee and provide for revoking delegation or 

imposing other sanctions if the Grantee or subgrantee’s performance is inadequate. The 

Grantee agrees to make available upon request to the Agency of Human Services; the 

Department of Vermont Health Access; the Department of Disabilities, Aging and 

Independent Living; and the Center for Medicare and Medicaid Services (CMS) all grants 

and subgrants between the Grantee and service providers. 

Medicaid Notification of Termination Requirements: Any Grantee accessing payments for 

services under the Global Commitment to Health Waiver and Medicaid programs who 

terminates their practice will follow the Department of Vermont Health Access, Managed 

Care Organization enrollee notification requirements. 

Encounter Data: Any Grantee accessing payments for services through the Global 

Commitment to Health Waiver and Vermont Medicaid programs must provide encounter 

data to the Agency of Human Services and/or its departments and ensure that it can be linked 

to enrollee eligibility files maintained by the State. 

Federal Medicaid System Security Requirements Compliance: All Grantees and 

subcontractors must provide a security plan, risk assessment, and security controls review 

document within three months of the start date of this agreement (and update it annually 

thereafter) to support audit compliance with 45CFR95.621 subpart F, ADP (Automated Data 

Processing) System Security Requirements and Review Process. 

Vermont AAA Dementia Respite Grant with Monitoring Information 89
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 21 of 31 

4. Non-discrimination Based on National Origin as evidence by Limited English 

Proficiency

The Grantee agrees to comply with the non-discrimination requirements of Title VI of the Civil 

Rights Act of 1964, 42 USC Section 2000d, et seq., and with the federal guidelines promulgated 

pursuant to Executive Order 13166 of 2000, which require that Grantees and subgrantees 

receiving federal funds must assure that persons with limited English proficiency can 

meaningfully access services. To the extent the Grantee provides assistance to individuals with 

limited English proficiency through the use of oral or written translation or interpretive services 

in compliance with this requirement, such individuals cannot be required to pay for such 

services. 

5. Voter Registration. When designated by the Secretary of State, the Grantee agrees to 

become a voter registration agency as defined by 17 V.S.A. §2103 (41), and to comply with 

the requirements of state and federal law pertaining to such agencies. 

6. Drug Free Workplace Act. The Grantee will assure a drug-free workplace in accordance 

with 45 CFR Part 76. 

7. Privacy and Security Standards. 

Protected Health Information: The Grantee shall maintain the privacy and security of all 

individually identifiable health information acquired by or provided to it as a part of the 

performance of this grant. The Grantee shall follow federal and state law relating to privacy 

and security of individually identifiable health information as applicable, including the 

Health Insurance Portability and Accountability Act (HIPAA) and its federal regulations. 

Substance Abuse Treatment Information: The confidentiality of any alcohol and drug abuse 

treatment information acquired by or provided to the Grantee or subgrantee shall be 

maintained in compliance with any applicable state or federal laws or regulations and 

specifically set out in 42 CFR Part 2. 

Other Confidential Consumer Information: The Grantee agrees to comply with the 

requirements of AHS Rule No. 08-048 concerning access to information. The Grantee agrees 

to comply with any applicable Vermont State Statute, including but not limited to 12 VSA 

§1612 and any applicable Board of Health confidentiality regulations. The Grantee shall 

ensure that all of its employees and subgrantees performing services under this agreement 

understand the sensitive nature of the information that they may have access to and sign an 

affirmation of understanding regarding the information’s confidential and non-public nature. 

Social Security numbers: The Grantee agrees to comply with all applicable Vermont State 

Statutes to assure protection and security of personal information, including protection from 

identity theft as outlined in Title 9, Vermont Statutes Annotated, Ch. 62. 

8. Abuse Registry. The Grantee agrees not to employ any individual, use any volunteer, or 

otherwise provide reimbursement to any individual in the performance of services connected 

with this agreement, who provides care, custody, treatment, transportation, or supervision to 

children or vulnerable adults if there is a substantiation of abuse or neglect or exploitation 

against that individual. The Grantee will check the Adult Abuse Registry in the Department 

of Disabilities, Aging and Independent Living. Unless the Grantee holds a valid child care 

license or registration from the Division of Child Development, Department for Children and 

Families, the Grantee shall also check the central Child Protection Registry. (See 33 V.S.A. 

§4919(a)(3) & 33 V.S.A. §6911(c)(3)). 

Vermont AAA Dementia Respite Grant with Monitoring Information 90
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 22 of 31 

9. Reporting of Abuse, Neglect, or Exploitation. Consistent with provisions of 33 V.S.A. 

§4913(a) and §6903, any agent or employee of a Grantee who, in the performance of services 

connected with this agreement, has contact with clients or is a caregiver and who has 

reasonable cause to believe that a child or vulnerable adult has been abused or neglected as 

defined in Chapter 49 or abused, neglected, or exploited as defined in Chapter 69 of Title 33 

V.S.A. shall make a report involving children to the Commissioner of the Department for 

Children and Families within 24 hours or a report involving vulnerable adults to the Division 

of Licensing and Protection at the Department of Disabilities, Aging, and Independent 

Living within 48 hours. This requirement applies except in those instances where particular 

roles and functions are exempt from reporting under state and federal law. Reports involving 

children shall contain the information required by 33 V.S.A. §4914. Reports involving 

vulnerable adults shall contain the information required by 33 V.S.A. §6904. The Grantee 

will ensure that its agents or employees receive training on the reporting of abuse or neglect 

to children and abuse, neglect or exploitation of vulnerable adults. 

10. Intellectual Property/Work Product Ownership. All data, technical information, materials 

first gathered, originated, developed, prepared, or obtained as a condition of this agreement 

and used in the performance of this agreement - including, but not limited to all reports, 

surveys, plans, charts, literature, brochures, mailings, recordings (video or audio), pictures, 

drawings, analyses, graphic representations, software computer programs and accompanying 

documentation and printouts, notes and memoranda, written procedures and documents, 

which are prepared for or obtained specifically for this agreement - or are a result of the 

services required under this grant - shall be considered "work for hire" and remain the 

property of the State of Vermont, regardless of the state of completion - unless otherwise 

specified in this agreement. Such items shall be delivered to the State of Vermont upon 30 

days notice by the State. With respect to software computer programs and / or source codes 

first developed for the State, all the work shall be considered "work for hire,” i.e., the State, 

not the Grantee or subgrantee, shall have full and complete ownership of all software 

computer programs, documentation and/or source codes developed. 

The Grantee shall not sell or copyright a work product or item produced under this agreement 

without explicit permission from the State. 

If the Grantee is operating a system or application on behalf of the State of Vermont, then the 

Grantee shall not make information entered into the system or application available for uses 

by any other party than the State of Vermont, without prior authorization by the State. 

Nothing herein shall entitle the State to pre-existing Grantee’s materials. 

11. Security and Data Transfers. The State shall work with the Grantee to ensure compliance 

with all applicable State and Agency of Human Services' policies and standards, especially 

those related to privacy and security. The State will advise the Grantee of any new policies, 

procedures, or protocols developed during the term of this agreement as they are issued and 

will work with the Grantee to implement any required. 

The Grantee will ensure the physical and data security associated with computer equipment - 

including desktops, notebooks, and other portable devices - used in connection with this 

agreement. The Grantee will also assure that any media or mechanism used to store or 

transfer data to or from the State includes industry standard security mechanisms such as 

continually up-to-date malware protection and encryption. The Grantee will make every 

Vermont AAA Dementia Respite Grant with Monitoring Information 91
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 23 of 31 

reasonable effort to ensure media or data files transferred to the State are virus and spyware 

free. At the conclusion of this agreement and after successful delivery of the data to the State, 

the Grantee shall securely delete data (including archival backups) from the Grantee's 

equipment that contains individually identifiable records, in accordance with standards 

adopted by the Agency of Human Services. 

12. Computing and Communication: The Grantee shall select, in consultation with the Agency 

of Human Services’ Information Technology unit, one of the approved methods for secure 

access to the State’s systems and data, if required. Approved methods are based on the type 

of work performed by the Grantee as part of this agreement. Options include, but are not 

limited to: 

1. Grantee’s provision of certified computing equipment, peripherals and mobile devices, on 

a separate Grantee’s network with separate internet access. The Agency of Human 

Services’ accounts may or may not be provided. 

2. State supplied and managed equipment and accounts to access state applications and data, 

including State issued active directory accounts and application specific accounts, which 

follow the National Institutes of Standards and Technology (NIST) security and the 

Health Insurance Portability & Accountability Act (HIPAA) standards. 

The State will not supply e-mail accounts to the Grantee. 

13. Lobbying. No federal funds under this agreement may be used to influence or attempt to 

influence an officer or employee of any agency, a member of Congress, an officer or 

employee of Congress, or an employee of a member of Congress in connection with the 

awarding of any federal contract, continuation, renewal, amendments other than federal 

appropriated funds. 

14. Non–discrimination. The Grantee will prohibit discrimination on the basis of age under the 

Age Discrimination Act of 1975, on the basis of handicap under section 504 of the 

Rehabilitation Act of 1973, on the basis of sex under Title IX of the Education Amendments 

of 1972, or on the basis of race, color or national origin under Title VI of the Civil Rights Act 

of 1964. No person shall on the grounds of sex (including, in the case of a woman, on the 

grounds that the woman is pregnant) or on the grounds of religion, be excluded from 

participation in, be denied the benefits of, or be subjected to discrimination, to include sexual 

harassment, under any program or activity supported by state and/or federal funds. 

The grantee will also not refuse, withhold from or deny to any person the benefit of services, 

facilities, goods, privileges, advantages, or benefits of public accommodation on the basis of 

disability, race, creed, color, national origin, marital status, sex, sexual orientation or gender 

identity under Title 9 V.S.A. Chapter 139. 

15. Environmental Tobacco Smoke. Public Law 103-227, also known as the Pro-children Act 

of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility 

owned or leased or contracted for by an entity and used routinely or regularly for the 

provision of health, child care, early childhood development services, education or library 

services to children under the age of 18, if the services are funded by federal programs either 

directly or through state or local governments, by federal grant, contract, loan or loan 

guarantee. The law also applies to children's services that are provided in indoor facilities 

that are constructed, operated, or maintained with such Federal funds. 

Vermont AAA Dementia Respite Grant with Monitoring Information 92
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 24 of 31 

The law does not apply to children's services provided in private residences; portions of 

facilities used for inpatient drug or alcohol treatment; service providers whose sole source of 

applicable federal funds is Medicare or Medicaid; or facilities where Women, Infants, & 

Children (WIC) coupons are redeemed. 

Failure to comply with the provisions of the law may result in the imposition of a civil 

monetary penalty of up to $1,000 for each violation and/or the imposition of an 

administrative compliance order on the responsible entity. 

Grantees are prohibited from promoting the use of tobacco products for all clients. Facilities 

supported by state and federal funds are prohibited from making tobacco products available 

to minors. 

Attachment F- Revised AHS- 12/10/10 

Vermont AAA Dementia Respite Grant with Monitoring Information 93
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 25 of 31 

Vermont AAA Dementia Respite Grant with Monitoring Information 94
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 26 of 31 

Vermont AAA Dementia Respite Grant with Monitoring Information 95
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 27 of 31 

Vermont AAA Dementia Respite Grant with Monitoring Information 96
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 28 of 31 

Vermont AAA Dementia Respite Grant with Monitoring Information 97
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 29 of 31 

Vermont AAA Dementia Respite Grant with Monitoring Information 98
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 30 of 31 

Vermont AAA Dementia Respite Grant with Monitoring Information 99
STATE OF VERMONT Grant#«Grant_» 

GRANT AGREEMENT Page 31 of 31 

Vermont AAA Dementia Respite Grant with Monitoring Information 100