
SOCIAL SERVICES BLOCK GRANT PROGRAM COMPLIANCE MONITORING TOOL
	RECORD ID:				1 of 3
	COUNTY:
	DATE COMPLETED
	PCR:
	Max Points Applicable	Applicable	Available Points	Points Earned	Percentage Earned
I. APPLICATION FOR SERVICES
A. DSS-5027 or another approved equivalent is in the record	2		0 - 1 - 2
1. Name of specific service(s) requested/needed is listed	2		0 - 1 - 2
2. Service request dated	2		0 - 2
3. Signed and dated by client or representative (unless exempt) OR	2 OR		0 - 2
4. Signature witnessed- if signed with (X)	2		0 - 1 - 2
5. If documentation indicates notice was mailed to the client, he was informed regarding confidentiality of notice and asked how notice should be conveyed	2		0 - 1 - 2
6. Income is determined and documented if service provided is based on income	2		0 - 1 - 2
SUBTOTALS:	12	0		0
II. ELIGIBILITY CRITERIA FOR SERVICES
A. Documentation indicates client is in need of the service(s) (meets the target population)	2		0 - 1 - 2
B. Documentation indicates client meets N.C. established income requirements	2		0 - 1 - 2
SUBTOTALS:	4	0		0
III. DECISION ON ELIGIBILITY FOR SERVICES
A. Made within 30 calendar days of date the application was made/received or the applicant failed to cooperate with the agency	2		0 - 2
B. Decision is consistent with eligibility criteria for the service(s)	2		0 - 2
C. For income eligible service, the eligibility period is documented	2		0 - 1 - 2
D. Purchase of service, if applicable, is completed and correct on the DSS-5027 or other agency approved form.	2		0 - 1 - 2
E. Effective date for decision is documented	2		0 - 1 - 2
F. Social Worker signed and dated DSS-5027	2		0 - 1 - 2


SOCIAL SERVICES BLOCK GRANT PROGRAM COMPLIANCE MONITORING TOOL
	RECORD ID:				2 of 3
G. Notice is mailed/given to client (except when exempt) within 15 calendar days after the decision, or within 30 calendar days of the application, whichever comes first	2		0 - 1 - 2
H. If denied, reason for denial is based on policy and clearly stated on the notice	2		0 - 1 - 2
SUBTOTALS:	16	0		0
IV. ADDITIONAL SERVICE(S) REQUESTED OR NEEDED -after initial application
A. Additional service(s) is added to specific service(s) requested on DSS-5027	2		0 - 1 - 2
B. Eligibility for this specific service(s) is documented	2		0 - 1 - 2
C. Decision on eligibility is made and notice is mailed/given to client (except when exempt) within 15 calendar days after the new request is made or received	2		0 - 1 - 2
SUBTOTALS:	6	0		0
V. PROMPT SERVICE PROVISION
A. Service is provided within 15 calendar days of date notice of eligibility was sent/given or the effective date if client is exempt from notice (unless documentation states client was placed on waiting list)	2		0 - 1 - 2
B. For service(s) added after the initial application, service is provided within 30 calendar days of the new request	2		0 - 1 - 2
C. The agency has written approved policy concerning the use of waiting lists.	2		0 - 1 - 2
D. Contacts are accurately documented on the DSS-4263 and consistent with services authorized on the DSS-5027	2		0- 1 - 2
SUBTOTALS:	8	0		0
VI. ONGOING SERVICE PROVISION AND REDETERMINATIONS
A. Ongoing eligibility related to need, target population, or income is reviewed and documented quarterly (Refer to instructions for further guidance on scoring this item)	2		0 - 1 - 2
B. Eligibility is reviewed within 30 days of a reported change in the client's circumstances (need or income)	2		0 - 2
C. Reassessment of need for service is done at least every 12 months for In Home Aide Service (within the month due). (Refer to instructions for further guidance on scoring this item)	2		0 - 1 - 2


SOCIAL SERVICES BLOCK GRANT PROGRAM COMPLIANCE MONITORING TOOL
	RECORD ID:				3 of 3
D. Redetermination of service eligibility is done every 12 months for income based services (prior to the expiration of the eligibility period).	2		0 -1 - 2
SUBTOTALS:	8	0		0
VII. SERVICES THAT ARE SUBJECT TO COST SHARING
A. Client has received a copy of the agency percentage cost sharing schedule	2		0 - 1 - 2
B. Copy of the Service Cost Sharing Form is in the record and addresses:	2		0 - 2
1. Purpose of cost sharing	2		0 - 2
2. List of services received	2		0 - 1 - 2
3. Total cost of the service	2		0 - 1 - 2
4. Agency's procedures for requesting cost sharing	2		0 - 2
5. Contact person for questions regarding cost sharing	2		0 - 1 - 2
6. A statement indicating that service(s) will not be terminated for failure to share in the cost of services provided	2		0 - 2
7. Form is reviewed, signed and dated by the client/representative and social worker	2		0 - 1 - 2
8. Form is completed annually for services subject to cost sharing	2		0 - 1 - 2
C. Agency has made reasonable efforts to collect cost sharing revenue when client has agreed to participate	2		0 - 2
SUBTOTALS:	22	0		0
VIII. REDUCTION OR TERMINATION OF SERVICES
A. Documentation indicates that Notice is mailed/given to client at least 10 working days prior to the effective date of the change (unless exempt)	2		0 - 1 - 2
B. Reasons for the reduction or termination are in accordance with policy	2		0 - 1 - 2
C. Reasons for reduction or termination are clearly stated in the notice to the client	2		0 - 1 - 2
SUBTOTALS:	6	0		0
TOTALS:	82	0		0

Note: For questions with an asterisk (*) below, the client is categorically eligible for this service as a recipient of SSI, TANF, or as a child receiving IV-E foster care payments or adoption assistance payments, or an adult or child with transportation being provided in conjunction with a protective services plan that remains in effect no longer than 12 months.


I.	APPLICATION FOR SERVICES

	A.	Locate the DSS-5027 or equivalent form approved by the NCDSS
		2 = it is in the record
		1 = County form is not equivalent
		0 = it is not in the record
		[10 NCAC 35D .0201]
		[FSM, Volume VI, Chapter II, Section 8065, IV.F., 2.]

		1.	See if the name of specific service(s) that the client requested or needs is listed in section 9 of the DSS-5027 or on county equivalent form along with the date requested.
			2 = all are listed
			1 = only some are listed or date is missing
			0 = none are listed
			[10 NCAC 35D .0204]
			[FSM Volume VI, Chapter II, Section 8065, IV.F., 1.]
			[SIS Manual, DSS-5027, page 5, Section B.]

		2.	Check to see that the client or representative dated the form or the written request for service unless exempt (See Attachment A).
			2 = it is dated.
			0 = it is not dated.
			N/A = signed /dated application not required
			[10 NCAC 35D.0302]
			[FSM Volume VI, Chapter II, Section 8065, IV.F.,]

		3.	Check to see if the applicant or representative signed the form (unless exempt or signed with (X)) (See Attachment A).
			2 = form is signed.
			0 = form is not signed and there is no documentation to indicate why not
			N/A = signature is not required for:
			If signing the DSS-5027 would create a barrier to receiving the service the client is not required to sign. If this is the reason it is not signed, it must be documented as such in the record. If it is not documented score 0, if it is documented score 2.
			Note: A signature is ALWAYS required for Health Support Services, Family Planning Component.

			OR

		4.	If the client signed with an (X) there must be a witness who also signed
			2 = There is an (X) and a witness signature
			1 = There is an (X) but no witness signature
			0 =There is no (X) or witness signature
			N/A= client can sign his name or service is exempt from signature
			[ 10 NCAC 35D .0204]
			[ FSM Volume VI, Chapter II, Section 8065, IV.F. ]

		5.	If documentation indicates that the notice regarding eligibility for service was mailed to the client:
			2 = There is signed documentation (e.g., the DSS-5001 or other signed documentation) that the Social Worker spoke to the client about confidentiality of notice and how he wanted his notice conveyed
			1 = Documentation indicates discussion of confidentiality of notice,
			OR how client wanted notice conveyed, but there is not signed documentation
			0 = There is no documentation that the Social Worker discussed confidentiality or how notice should be conveyed
			N/A = Documentation does not indicate that the notice was mailed to the client. Applicant is exempt from notice (See Attachment B).
			[10 NCAC 35d .0402]
			[FSM Volume VI, Chapter II, Section 8080, VII.D.]

	*	6.	Check the record for income and family size (transportation only)
			2 = Documented both income and income unit size
			1 = Income OR income unit size not documented
			0 = No documentation on income or income unit size
			N/A = Service is provided without regard to income
			[10 NCAC 35E .0103 ]
			[FSM Volume VI, Chapter II, Section 8100, XI.A,2.,b.]


II.	ELIGIBILITY CRITERIA FOR SERVICES

	Using Attachment C, determine if the requested service(s) is provided without regard to income or is provided with regard to income. For services provided without regard to income, complete question A. below, and score question B. as N/A. For services provided with regard to income, complete questions A. and B. below.

	A.	2 = Documentation in record indicates client needs the service (meets the criteria for the target population for the specific service). (See Attachment D).
		1 = Documentation does not clearly indicate need for the service
		0 = No documentation regarding need for service
		[10 NCAC 35E .0101]
		[FSM Volume VI, Chapter II, Section 8100, XI.A.,1.,2.]

	B.	2 = Documentation indicates that client's income is less than 60% of the State's Established Income (See Attachment E).
		1 = Documentation is unclear or incomplete regarding the client' s income
		0 = No documentation on income in record
		N/A=Service requested is provided without regard to income
		[10 NCAC 35E .0105]
		[FSM Volume VI, Chapter II, Section 8100, XI. B.]

III.	DECISION ON ELIGIBILITY FOR SERVICES

	A.	Determine the date the eligibility decision was made for the service(s) (unless specifically documented otherwise, the date the social worker signed the DSS-5027 is considered the date of the eligibility decision).
		2 = Date was within 30 calendar days of date of application or there is documentation as to why decision was more than 30 days (indication that the client is not cooperating and therefore decision is delayed beyond 30 days).
		0 = Date was not within 30 calendar days of date of application and there is no documentation as to why decision was more than 30 days.
		N/A = No decision has been made on the application, and there is documentation to indicate Social Worker is waiting on information.
		[10 NCAC 35A .0103]
		[FSM Volume VI, Chapter II, Section 8100,XI. F.]

	B.	2 = Decision is consistent with eligibility criteria (target population) for the service. (See Attachment D).
		0 = Decision is not consistent with eligibility criteria (target population) for the service. (See Attachment D).
		N/A = No decision has been made on the application and there is
		documentation to indicate SW is waiting on information; or the decision was to deny based on the lack of availability or lack of funding.
		[10 NCAC 35E .0204]
		[FSM Volume VI, Chapter II, Section 8100,XI. E.]

	C.	2 = Eligibility period (in section C on the DSS-5027) is documented in the record for income based service (transportation). Ending date is twelve months from the date of the eligibility determination or redetermination.
		1 = Eligibility period is unclear or incorrect in record (no ending date or wrong dates).
		0 = No eligibility period is documented in the record
		N/A = No decision has been made on the application and there is documentation to indicate Social Worker is waiting on information or the eligibility decision was to deny services.
		[10 NCAC 35A .0103]
		[FSM Volume VI, Chapter II, Section 8100, XI.F.]

	D.	2 = Purchase of service section D. is complete and correct on DSS-5027 or the information is complete and correct on other documentation given to the provider.
		1 = Purchase of service section D. is incomplete and/or incorrect on DSS-5027 or the information is incomplete and/or incorrect on other documentation given to the provider.
		0 = Purchase of service section D. is not completed on the DSS-5027; there is no other documentation of this information being given to the provider; and there is purchase of service.
		N/A = There is no purchase of service involved for this application or eligibility decision has not been made.

		Note: In section D. on the DSS-5027, the last line does not have to be completed if the DSS is responsible for collecting cost sharing money. The provider does not need this information.

		[10 NCAC 43L .0208]
		[FSM Volume VI, Chapter II, Section 8055, II.D.1.]
		[SIS Manual, DSS-5027 Section]

	E.	2 = Effective (beginning) date of eligibility is documented in section C. on DSS-5027 or on approved form.
		1 = Effective date of eligibility is unclear or incorrect in record.
		0 = Effective date of eligibility is not documented.
		N/A = No decision has been made on the application.
		(If F. below is dated and this date is the effective date of eligibility, score 2. If date is after service is provided score 0 here.)
		[10 NCAC 35A .0103]
		[FSM Volume VI, Chapter II, Section 8100,XI. F.]
		[SIS Manual, DSS-5027 Section]

	F.	2 = Social Worker signed and dated (eligibility decision date) DSS-5027.
		1 = Social Worker's signature OR date was missing on DSS-5027.
		0 = No social worker signature or date on DSS-5027.
		N/A = No decision has been made on the application.
		[10 NCAC 35A .0103]
		[FSM Volume VI, Chapter II, Section 8070, V.E. 2.]
		[SIS Manual, DSS-5027 Section]

	G.	2 = Notice of eligibility decision is mailed/given (except when exempt-see Attachment B) within 15 calendar days after the decision or within 30 days of application, whichever comes first.
		1 = Notice is given/mailed, but not within specified timeframes.
		0 = No notice is given and case is not exempt.
		N/A = Client is exempt from receiving notice (See Attachment B) or no eligibility decision has been made.

		[10 NCAC 35A .0103]
		[FSM Volume VI, Chapter II, Section 8080, VII.C. 1.]

	H.	2 = Reason for denial is clearly stated in the notice and according to policy (See Attachment F).
		1 = Reason for denial is not clearly stated in the notice or not according to policy (See Attachment F).
		0 = No reason for denial is given.
		N/A = Decision was not denial or no decision has been made on the application
		[10 NCAC 35D .0303]
		[FSM Volume VI, Chapter II, Section 8080,VII. B. 2.]

IV.	REQUEST FOR ADDITIONAL SERVICES (may be client requested or assessed to be needed such as APS)

	A.	2 = Additional name of service(s) requested (provided according to the day sheet) is added to specific services on DSS-5027 or equivalent form.
		1 = Some but not all of requested services are added to DSS-5027.
		0 = Additional service(s) requested or needed are not added to DSS-5027.
		N/A = There are no additional service(s) requested or needed.
		[10 NCAC 35A .0103]
		[FSM Volume VI, Chapter II, Section 8065,IV. F.]
		[SIS Manual, Section for DSS-5027]

*	B.	Client eligibility for additional services is documented
		2 = Documentation reflects that client meets the target population for the specific service or meets the income requirements for services with regard to income (transportation). (See Attachment D and/or E).
		1 = Documentation is not clear that client meets the target population for the specific service or the income requirements for services with regard to income (transportation).
		0 = There is no documentation regarding meeting the target population for the specific service or the income requirements for services with regard to income (transportation).
		N/A = No additional service(s) requested or needed or service is denied.
		[10NCAC 35E .0204]
		[FSM Volume VI, Chapter II, Section 8100, XI. A.1.a.]

	C.	2 = Decision is made and notice sent/given (except when exempt-see Attachment B) within 15 calendar days of the date the request is made or received.
		1 = Decision is made, but notice is not sent or given within timeframes (service not exempt from notice).
		0 = No notice sent or given (service not exempt from notice).
		N/A = No additional service(s) requested or needed or service is exempt from notice.
		[10 NCAC 35A .0103]
		[FSM, Volume VI, Chapter II, Section 8080,VII. C.1.]



V.	PROMPT SERVICE PROVISION

	A.	Service provision means delivery of service directly by agency staff or delivery of service by another provider who is authorized by DSS to provide the service.
		2 = Documentation indicates that service is provided or arranged for within 15 calendar days of date notice was sent/given or 15 calendar days from the date the service was requested when exempt from notice. If there is documentation as to why services could not be provided timely and/or attempts were made-give 2 points.
		1 = Service is provided, but not within 15 days of notice, no documentation as to why not.
		0 = No service provided.
		N/A = Client placed on waiting list, service denied, or eligibility decision not yet made.
		[10 NCAC 35D .0502]
		[FSM, Volume VI, Chapter II, Section 8085, VIII.]

	B.	2 = For service(s) added after initial application, service is provided within 30 calendar days of the request.
		1 = Service(s) provided, but not within mandated timeframes.
		0 = Service(s) not provided.
		N/A = No additional service(s) requested or needed, client unavailable to receive service, client placed on waiting list, service denied or eligibility decision on this service not yet made.
		[10 NCAC 35D .0502]
		[FSM, Volume VI, Chapter II, Section 8085, VIII.]

	C.	2 = The agency has a written local waiting list policy approved by the Board of Social Services which designates the list as a waiting list for meeting prompt provision requirements or simply an inquiry list or both, and gives equitable guidelines on priority for specific services, and limits the the time the individual is on the list to 90 days or less.
		1 = The agency has a local waiting list policy, but it does not fulfill the above requirements.
		0 = The agency has a waiting list, but does not have a policy for it.
		N/A = The agency does not use a waiting list
		[10 NCAC 35D .0502]
		[FSM, Volume VI, Chapter II, Section 8100, XI. H.]

	D.	2 = Contacts are documented on the day sheets and indicate the correct service code and program.
		1 = Only some of the contacts are on the day sheets and/or the service code and program code are incorrect.
		0 = Contacts are not documented on the day sheets.
		[10 NCAC 35A .0103]
		[FSM, Volume VI, Chapter II, Section 8055,II. C.]
		[SIS Manual, Section on DSS-4263]


VI.	ONGOING SERVICE PROVISION AND REDETERMINATIONS

	A.	2 = Documentation indicates that ongoing eligibility (i.e., the client meets the target population) is assessed quarterly (within the month it is due based on the effective date for the service). Transportation is exempt from quarterly review.
		1 = Documentation indicates that ongoing eligibility is assessed less often than quarterly (after the month it is due).
		0 = No ongoing eligibility assessment is documented.
		N/A = Service is terminated before 3 months, service was denied, eligibility decision on application not yet made. Service is exempt (transportation).
		[10 NCAC 35A .0103]
		[FSM, Volume VI, Chapter II, Section 8100, V. F.]

*	B.	2 = Documentation reflects that eligibility is reviewed within 30 days of a reported change in need for services (relates to all services regardless of whether they are provided with or without regard to income) OR for services provided with regard to income (transportation), a change in income.
		0 = Documentation reflects that eligibility is not reviewed within 30 days of a reported change in need or income.
		N/A = No reported change in need or income indicated in record.
		[10 NCAC 35A .0103]
		[FSM Volume VI, Chapter II, Section 8070 V. F.]

	C.	2 = For In Home Aide Services, documentation indicates that a reassessment is completed at least every 12 months in the month it is due.
		1 = Documentation indicates that a reassessment is completed less often than every 12 months (the reassessment is completed after the month it is due).
		0 = No annual reassessment is completed for In Home Aide Services
		N/A = Service is terminated before 12 months expire, a service is requested other than In-Home Aide Services.

*	D.	2 = Documentation for services provided with regard to income (transportation) indicates that eligibility is redetermined every 12 months prior to expiration of eligibility period.
		1 = Documentation indicates eligibility is redetermined, but after the expiration of eligibility period. (it is completed late)
		0 = Documentation does not indicate eligibility is redetermined every 12 months (there is no 12 month redetermination in the record)
		N/A = Service does not require redetermination of eligibility every 12 months.
		[10 NCAC 35D .0304]
		[FSM Volume VI, Chapter II, Section 8070 V. F.]

VII.	SERVICES THAT ARE SUBJECT TO COST SHARING (See Attachment G)

	A.	2 = Record indicates that the client has received a copy of the Agency Cost Sharing Schedule.
		1 = Record indicates the Social Worker reviewed the Agency Cost Sharing Schedule with the client, however there is no documentation that the client received a copy.
		0 = Documentation does not indicate that the Agency Cost Sharing Schedule was used or given to the client.
		N/A = Service is not subject to cost sharing; client is in exempt group for cost sharing.
		[10 NCAC 35F .0306]
		[FSM Volume VI, Chapter III, Section 8165, B.]

	B.	2 = Agency Cost Sharing Schedule, including below 150% of poverty, is complete and correct.
		1 = Agency Cost Sharing Schedule is complete or correct, but not both complete and correct.
		0 = There is no Agency Cost Sharing Schedule.
		N/A = Service is not subject to cost sharing; client is in exempt group for cost sharing.
		[10 NCAC 35F .0306]
		[FSM Volume VI, Chapter III, Section 8165, B.]

	C.	2 = Service Cost Sharing Form is in the record.
		0 = Service Cost Sharing Form is not in the record.
		N/A = Service is not subject to cost sharing; client is in exempt group for cost sharing.
		[10 NCAC 35F .0305]
		[FSM Volume VI, Chapter III, Section 8165, C.]

		1.	2 = Purpose of cost sharing is on Form.
			0 = Purpose of cost sharing is not on Form.
			N/A = Service is not subject to cost sharing; client is in exempt group for cost sharing.
			[10 NCAC 35F .0305]
			[FSM Volume VI, Chapter III, Section 8165, C.]

		2.	2 = Service(s) received are listed on Form.
			1 = Some but not all services received and subject to cost sharing are listed on the Form.
			0 = Service(s) received are not listed on Form.
			N/A = Service is not subject to cost sharing; client is in exempt group for cost sharing.
			[10 NCAC 35F .0305]
			[FSM Volume VI, Chapter III, Section 8165, C.]

		3.	2 = Total cost of the service (according to agency staff or other documentation or the unit rate as stated in the vendor agreement) is on the Service Cost Sharing Form.
			1 = Total cost of the service is on the Form, but is incorrect. (Differs from what staff or other documentation indicates or unit rate as stated in the vendor agreement).
			0 = Total cost of the service is not on the Form.
			N/A = Service is not subject to cost sharing; client is in exempt group for cost sharing.
			[10 NCAC 35F .0305]
			[FSM Volume VI, Chapter III, Section 8165, C.]

		4.	2 = Agency procedures for requesting cost sharing are on the Form.
			0 = Agency procedures for requesting cost sharing are not on the Form.
			N/A = Service is not subject to cost sharing; client is in exempt group for cost sharing.
			[10 NCAC 35F .0305]
			[FSM Volume VI, Chapter III, Section 8165, C.]

		5.	2 = Contact person and phone number for questions regarding cost sharing are listed on Form.
			1 = Either the name or phone number of the contact person is missing from the Form.
			0 = Neither contact person or the phone number for questions regarding cost sharing is listed on Form.
			N/A = Service is subject to cost sharing; client is in exempt group for cost sharing.
			[10 NCAC 35F .0305]
			[FSM Volume VI, Chapter III, Section 8165, C.]

		6.	2 = Form has a statement that services will not be terminated due to failure to share in the cost of services.
			0 = Form does not have a statement that services will not be terminated due to failure to share in the cost of services.
			N/A = Service is not subject to cost sharing; client is in exempt group for cost sharing.
			[10 NCAC 35F .0305]
			[FSM Volume VI, Chapter III, Section 8165, C.]

		7.	2 = Form has been signed by the client and social worker and dated.
			1 = There is at least one signature and/or date on the Form.
			0 = There are no signatures or date on the Form.
			N/A = Service is subject to cost sharing; client is in exempt group for cost sharing.
			[10 NCAC 35F .0305]
			[FSM Volume VI, Chapter III, Section 8165, C.]

		8.	2 = Form is completed at least annually (within the month it is due).
			1 = Form is completed annually, but later than the month it is due
			0 = Form is not completed at all.
			N/A = Service is not subject to cost sharing; client is in exempt group for cost sharing.
			[10 NCAC 35F .0303]
			[FSM Volume VI, Chapter III, Section 8160, B.,2.]

	D.	2 = Record indicates agency has made reasonable efforts to collect cost sharing revenue when the client has agreed to cost share.
		0 = There is no indication that there has been any effort to collect cost sharing revenue.
		N/A = Service is not a cost sharing service, client is in exempt group for cost sharing.
		[10 NCAC 35F .0307]
		[FSM Volume VI, Chapter III, Section 8170, A.,6.]

VIII.	REDUCTION OR TERMINATION OF SERVICES

	A.	2 = Documentation indicates that notice is sent/given to client at least 10 working days prior to effective date of the change.
		1 = Documentation indicates that notice was sent/given, but not within specified timeframes.
		0 = No documentation that notice was given/sent.
		N/A = Documentation indicates notice was not required (see Attachment B for reasons for exemption), there has been no reduction or termination of service-case is ongoing.
		[10 NCAC 35A .0103]
		[FSM Volume VI, Chapter II, Section 8080 VII. C.]

	B.	2 = Reason for the reduction or termination is according to policy. (See Attachment F).
		1 = Reason for the reduction or termination is according to policy, but is not stated on the notice.
		0 = Reason is not in accordance with policy.
		N/A = Documentation indicates notice was not required (see Attachment B for reasons for exemption), there has been no reduction or termination of service-case is ongoing, agency did not give the client notice of reduction or termination of services (score of 0 in A. above).
		[10 NCAC 35D .0303]
		[FSM Volume VI, Chapter II, Section 8080 VII. B.2]

	C.	2 = Reason for the reduction or termination is clearly stated for the client on the notice.
		1 = Reason for reduction or termination of service is not clearly stated on the notice.
		0 = No reason is given in the notice as to why the service is being reduced or terminated.
		N/A = Documentation indicates notice was not required (see Attachment B for reasons for exemption), there has been no reduction or termination of service-case is ongoing, agency did not give the client notice of reduction or termination of services (score of 0 in A. above).
		[10 NCAC 35D .0303]
		[FSM Volume VI, Chapter II, Section 8080 VII. B.2.b.]

Each item on the SSBG tools carries equal weight since all items are requirements. A score of 70% and above is a passing score. A score of 69% or less requires corrective action. Each of the scorable items on the tool are summed across the entire sample to determine what the overall score is for each particular item. For example, using a sample size of 10, sum all 10 scores for item I.,A.1. and determine what the overall score is. That item on the tool relates to whether the specific SSBG requested service is listed on the application for services. If more than 3 records reviewed do not have applications with the specific service requested, then we would determine that to be a finding requiring corrective action. This is done for all the remaining items on the tool to determine where there are areas of non compliance.

LIST OF ATTACHMENTS

A.	Situations that do not require applicant/representative signature or mark
	[10 NCAC 35D .0201]

B.	Reasons for being exempt from receiving notice on eligibility or modification
	[10 NCAC 35A .0103]

C.	List of services provided without regard to income/with regard to income
	[10 NCAC 35A .0103]

D.	List of service specific eligibility criteria
	[10 NCAC 35E .0300]

E.	Income Scale for services provided with regard to income
	[10 NCAC 35E .0105]

F.	Basis for denial or termination of services
	[10 NCAC 35D .0303]

G.	Services that require cost sharing/type cases that are exempt
	[10 NCAC 35F .0301]

ATTACHMENT A

SITUATIONS THAT DO NOT REQUIRE APPLICANT/REPRESENTATIVE SIGNATURE AND DATE

APS (202 and 204 under court order)
CPS (210 and 215)
Situations when the social worker signs the application on behalf of the client, e.g., for example foster care or guardianship

ATTACHMENT B

REASONS FOR EXEMPTION FROM NOTICE REQUIREMENT

Individuals receiving only APS (202 or 204 under court order ) or CPS (210 or 215)
Individuals for whom the agency has custody or guardianship and the social worker is making the application for services
Individual is incompetent or incapacitated and the social worker has applied on his behalf.
The agency is terminating because it has factual information confirming the death of the client.
The service is being terminated at the end of an established period of eligibility and the individual has not requested that the service(s) be continued. (services provided with regard to income only)


Attachment C TABLE 1. SUMMARY OF AVAILABLE SERVICES BY ELIGIBILITY CATEGORY
Social Services Block Grant Funded Services	Available to Income Maintenance Clients & to Those With Less Than 60% of Est.Inc.	Available to Clients With 80% to 60% of Established Income	Available to Clients With 80% to 100% of Established Income	Available Without Regard to Income ¹
Adjustment Services for Blind & Visually Impaired	X	X	X	X
Adoption Services	X	X	X	X ²
Adult Placements Services	X	X	X	X
Community Living Services	X	X	X	X
Day Care Services for Adults	X	X	X	X
Day Care Services for Children	X	X	X	X ²
Day/Night Services for Children and Adults Needing MH/DD/SAS Services	X	X	X	X
Delinquency Prevention Services	X	X	X	X
Employment and Training Support Services	X	X	X	X
Family Planning Services	X	X	X	X
Family Preservation Services	X	X	X	X
Family Support Services	X	X	X	X
Foster Care Services for Adults	X	X	X	X
Foster Care Services for Children	X	X	X	X ²
Health Support Services	X	X ³	X ⁴	X ⁴
Home Care Services includes Skilled Nursing, Physical Therapy, Speech Therapy, Occupational Therapy, Medial Social Services, and/or Nutrition Care				X
Housing and Home Improvement Services	X	X	X	X
Individual and Family Adjustment Services	X	X	X	X
In-Home Aide Services for Adults	X	X	X	X
In-Home Aide Services for the Blind	X	X	X ⁵
Intensive Family Preservation Services	X	X	X	X
Periodic Services for Children and Adults Needing MH/DD/SAS Services	X	X	X	X
Personal and Family Counseling	X	X	X	X
Preparation and Delivery of Meals	X	X	X	X
Problem Pregnancy Services	X	X	X	X
Protective Services for Adults	X	X	X	X
Protective Services for Children	X	X	X	X
Residential Treatment for Emotionally Disturbed	X	X	X	X
Respite Care Services	X	X	X	X ⁶
Transportation Services	X
24-Hour Services for Children and Adults Needing MH/DD/SAS Services	X	X	X	X
Youth Services	X	X	X	X
1) Services based on need and without regard to income; for some services, clients are requested to contribute towards cost. Any services listed in this table, including those in this column, may be provided to an adult or child who is in immediate and present danger of neglect, abuse or exploitation, without regard to income and at no cost to the client, if the service is available in the county where the client lives, during the first 12 months after Protective Services for Children or Adults is initiated. 2) Services available to individuals based on need and without regard to income except when funded with TANF monies transferred to SSBG, in which case the family income must not exceed 200% of the Federal Poverty Level for the size of the family served. 3) Excludes eligibility for the transportation component. 4) Excludes sterilization as a resource item. 5) "In-Home Aide Services for the Blind: Level I-Home Management" is available to clients with income up to but not including 100% of Established Income. 6) Services available to caregivers who are less than 60 years of age who are caring for persons 60 years or older, or caregivers who are 60 years or older who are caring for persons 18 years of age or older.

SERVICE DEFINITIONS AND TARGET POPULATIONS FOR SSBG SERVICES

I. SECTION .0300 - SERVICE DEFINITIONS

10 NCAC 35E .0301 ADOPTION SERVICES

(a) Primary Service. Adoption services are: the recruitment, study and selection of adoptive homes; social casework and other diagnostic and treatment services to prepare the child and prospective parents for placement; casework services to the child and adoptive parents to support and maintain the placement and to facilitate legal consummation of the adoption including supervision and reports to the court; casework counseling and court related services in independent placements and in adoptions by stepparents and relatives as required by statute; and casework services to facilitate interstate and intercountry adoptions including those activities required to bring such interstate planning and placements into compliance with the interstate compact on the placement of children; and the provision of post-adoption services including, but not limited to, casework services designed to support the achievement of long range adjustment between the child and members of the adoptive family, and to assist the adoptee to gain understanding of his biological heritage to the extent allowed by law. At its option, the county may provide payment of costs incidental to preplacement and placement visits as a resource to facilitate the provision of adoption services, and payment of the cost of legal services to facilitate legal adoption of a child.

(b) Components. None.

(d) Target Population. Children for whom legal adoption is planned or in process.

History Note: Authority G.S. 143B-153;

Eff. February 8, 1977;

Amended Eff. October 1, 1981; October 1, 1979; July 1, 1979; October 1, 1977;

Transferred from T10.43D .0201 Eff. July 1, 1983;

Amended Eff. July 1, 1984.

10 NCAC 35E .0302 COMMUNITY LIVING SERVICES

(a) Primary Service. Community living services are provided to support continuation of the individual's family or community-based situation, or to prepare him for leaving institutional care and facilitate his transition to living in the community. Such services include training in community living skills and work activity training commensurate with the individual's age and developmental level; recreational and other activities which promote normalization outside an institutional setting; and assistance in arranging for and utilizing community services and resources which support this regimen of services. On an optional basis, services may also include remedial and treatment services necessary to ameliorate the handicapping effects of the disability which prevent or constrain personal, social, and work adjustment (e.g., physical therapy, speech therapy), and food and food services to provide a nutritious meal and snacks during the time clients participate in on-site services; and transportation when needed and not otherwise available to access community living services programs.

(b) Components. None.

(d) Target Population:

(1) individuals who are mentally retarded;

(2) individuals who are severely physically disabled.

History Note: Authority G.S. 143B-153;

Eff. July 1, 1979;

Transferred from T10.43D .0234 Eff. July 1, 1983;

Amended Eff. July 1, 1984.

10 NCAC 35E .0303 DAY CARE SERVICES FOR ADULTS

(a) Primary Service. Day care services for adults is the provision of an organized program of services during the day in a community group setting for the purpose of supporting adults' personal independence, and promoting their social, physical, and emotional well-being. Services must include a variety of program activities designed to meet the individual needs and interests of the participants, and referral to and assistance in using appropriate community resources. Also included are medical examinations required for individual participants for admission to day care and periodically thereafter when not otherwise available without cost, and food and food services to provide a nutritional meal and snacks as appropriate to the program. Services must be provided in a home or center certified to meet state standards for such programs. Services include recruitment, study and development of adult day care programs, evaluation and periodic re-evaluation to determine if the programs meet the needs of the individuals they serve, and consultation and technical assistance to help day care programs expand and improve the quality of care provided. Transportation to and from the service facility is an optional service that may be provided by adult day care programs.

(b) Target Population. Adults who because of age, disability or handicap need the service to enable them to remain in or return to their own homes. Within the target population, eligible clients shall be provided day care services for adults in the following order of priority:

(1) adults who require complete, full-time daytime supervision in order to live in their own home or prevent impending placement in substitute care (e.g. nursing home, domiciliary home), and adults who need the service as part of a protective services plan;

(2) adults who need help for themselves with activities of daily living or support for their caregivers in order to maintain themselves in their own homes or both;

(3) adults who need intervention in the form of enrichment and opportunities for social activities in order to prevent deterioration that would lead to placement in group care;

(4) individuals who need time-limited support in making the transition from independent living to group care, or individuals who need time-limited support in making the transition from group care to independent living.

History Note: Authority G.S. 143B-153;

Eff. February 8, 1977;

Amended Eff. July 1, 1982; October 1, 1979; July 1, 1979; October 1, 1977;

Transferred from T10.43D .0204 Eff. July 1, 1983;

Amended Eff. May 1, 1990; July 1, 1984;

Temporary Amendment Eff. October 1, 2001;

Amended Eff. August 1, 2002.

10 NCAC 35E .0304 DELINQUENCY PREVENTION SERVICES

(a) Primary Service. Delinquency prevention services are services to youths who are in danger of being confined to a correctional facility, including counseling and other treatment services to provide guidance and direction to youths who are having behavior problems which, if not corrected, may result in their being brought before the court and committed or recommitted to a correctional facility. Also included are counseling or instructions for parents or other caretakers to improve parent or caretaker capacity to supervise the youth; vocational counseling and, where appropriate, assistance in obtaining employment; assistance in establishing better child-school, child-parent, child-community, relationships, assistance in securing better living arrangements; assistance in relieving unnecessary psychosocial pressures on the child or family or both and provision, as appropriate, of information and counseling on drug and alcohol abuse. At county option, residential care, including room and board for up to six months for any one placement, may be provided where necessary to the provision of a comprehensive and intensive regimen of the services described in Paragraph (a) of this Rule. Medical or remedial care are included in such residential care when they are integral, but subordinate parts of the regimen of services. Included are psychiatric diagnosis and treatment and drug therapy as prescribed by a physician.

(b) Components. None.

(d) Target Population. Children between 8 and 18 who are in clear and present danger of being committed or recommitted to the juvenile correctional system.

History Note: Authority G.S. 143B-153;

Eff. February 8, 1977;

Amended Eff. October 1, 1979; October 1, 1977;

Transferred from T10.43D .0206 Eff. July 1, 1983;

Amended Eff. May 1, 1990; July 1, 1984.

10 NCAC 35E .0305 EMPLOYMENT AND TRAINING SUPPORT SERVICES

(a) Primary Service. Employment and training support services are services provided as part of an individual service plan to enable appropriate individuals to secure paid employment or training leading to employment, including basic education and continuing education. Services include counseling to explore with the individual his current readiness or potential for employment and to assess the feasibility of seeking training or employment in relation to the total needs of the family; providing information about and referral to educational resources, training programs, and possible sources of employment; and counseling and information to encourage and support the individual's employment objectives with respect to such topics as grooming, how to apply to appropriate resources, employer expectations, and constructive resolution of work related problems. Also included is arrangement for or provision of general and specialized diagnostic tests and evaluations to assess the individual's potential for employment and any limitations which affect employment or training. Transportation, when needed to enable individuals to make application and interview for employment and to participate in training leading to employment, may be provided on an optional basis.

(b) Components. None.

(c) Resource Items. At provider option, payment for resource items may be provided to facilitate the provision of employment and training support services. Resource items include tuition, supplies, and rental or purchase of books when needed to assist in meeting the usual expenses of obtaining vocational training, basic education, or a high school education or its equivalent in public or private technical institutes or community colleges; lunches, uniforms, and subject to state office approval, tools and other equipment necessary to enable individuals to accept training or employment when such items are not otherwise available.

(d) Target Population. Individuals who are unable to obtain or retain adequate employment.

History Note: Authority G.S. 143B-153;

Eff. February 8, 1977;

Amended Eff. October 1, 1979; July 1, 1979; October 1, 1978; October 1, 1977;

Transferred from T10.43D .0208 Eff. July 1, 1983;

Amended Eff. July 1, 1984.

10 NCAC 35E .0306 FOSTER CARE SERVICES FOR ADULTS

(a) Primary Service. Foster care services for adults means recruitment, study and development of family care homes and group care facilities; evaluation and periodic re-evaluation to determine if the home or facility meets the needs of the individuals it serves; and consultation and technical assistance to help family care homes and group care facilities to expand and improve the quality of care provided.

(b) Components. None.

(d) Target Population. Aging, blind, or disabled individuals (18 years or older) or other adults needing to find licensed substitute homes when unable to stay in own home or moving out of institutional care.

History Note: Authority G.S. 143B-153;

Eff. February 8, 1977;

Amended Eff. October 1, 1979; October 1, 1977;

Transferred from T10.43D .0210 Eff. July 1, 1983;

Amended Eff. March 1, 1994; May 1, 1990; July 1, 1984.

10 NCAC 35E .0307 FOSTER CARE SERVICES FOR CHILDREN

(a) Primary Service. Foster care services for children means social casework services through which a plan for substitute care appropriate to a child's needs is evaluated, arranged, maintained and supervised either in the home of an approved relative or in a licensed or approved home or facility when neither of the child's parents are able to care for him adequately or to provide a suitable environment. Services include diagnostic study and evaluation, and medical examinations when not otherwise available, to determine the appropriate plan for service and type of placement to meet the child's needs; preparation of the child and natural family for the separation and placement; supervision of the care of the child and of the foster care facility to assure that the child receives proper care during placement, the provision of social casework and other treatment services to facilitate the child's psychosocial adjustment and to assist the parents or other responsible relatives to improve conditions and enable the child to return to his own home; planning and providing services as necessary for the placement of the child in the home of other relatives, in an adoptive home or in continued foster care as appropriate. Foster care services includes providing casework services and supervision to a child and his family from the time the child is returned to the home of his parents to the time court action is completed returning legal custody of the child to the parents. At county option, services may include the provision of legal services to facilitate permanent planning for a child. Foster care services includes identifying children who require placement across state lines, ensuring that such placements are in suitable environments with persons or caretaking facilities having appropriate licenses and effecting such placements pursuant to the interstate compact on the placement of children. "Placement" pursuant to the interstate laws means the arrangement for the care of a child in either a family or foster care facility but does not include any medical facility or facility licensed under standards adopted by mental health. Services include ongoing supervision. Services also include recruitment, study and development of foster families and child care facilities, assessment and periodic reassessment to determine if the home or facility meets the needs of children it serves, and consultation, technical assistance, and training to assist foster families and care facilities to expand and improve the quality of care provided.

(b) Components. At county option, the provision by a foster family home of services, in addition to basic foster care, which meet the special needs of children in that home.

(c) Resource Items. At county option, payment of resource items may be provided to support the child's participation in school. Resource items include supplies, special clothes, and fees for membership in school sponsored extracurricular activities.

(d) Target Population. Children in need of a supervised plan of substitute care.

History Note: Authority G.S. 143B-153;

Eff. February 8, 1977;

Amended Eff. October 1, 1981; October 1, 1979; July 1, 1979; October 1, 1978;

Transferred from T10.43D .0211 Eff. July 1, 1983;

Amended Eff. May 1, 1990; July 1, 1984.

10 NCAC 35E .0308 HEALTH SUPPORT SERVICES

(a) Primary Service. Health support services means helping individuals and families to recognize health needs including those related to alcohol and drug abuse; to cope with incapacities and limited functioning resulting from aging, disability, or handicap and to choose, obtain and use resources and mechanisms of support under Medicaid (including the early and periodic screening, diagnosis and treatment program), medicare, maternal and child health programs and from other public or private agencies or providers of health services; counseling and planning, as appropriate, with individuals, families, and health providers to help assure continuity of treatment and the carrying out of health recommendations; helping individuals to secure admission to medical institutions and children to secure admission to other health-related facilities as needed; and family planning services as described in Paragraph (b) of this Rule. At county option, transportation, when not otherwise available, may be provided as necessary to access needed medical and health care resources.

(b) Components. Family planning services to enable individuals and families to voluntarily limit the family size or to space the children, and to prevent or reduce the incidence of births out of wedlock. Such services include educational activities, the provision of printed materials, counseling about family planning and genetics, and help in utilizing medical and educational services available in the community and state. Also included are educational services in human sexuality appropriate to an individual's emotional and social adjustment and physical development.

(1) Medical Services: For individuals who are recipients of AFDC, SSI, or protective services or whose family income is less than 80 percent of the state's established income maximum for social services eligibility, payment for medical services for nontherapeutic sterilization.

(2) Resources for the Aging, Disabled or Handicapped. At county option any combination of the following resource items may be provided as needed and appropriate to enable aging, disabled or handicapped individuals to attain or maintain the highest level of functioning possible, to promote their well-being and to prevent or reduce inappropriate institutional care:

(A) Assistance with communication to enable individuals to utilize needed health and medical resources and other community services and resources through the provision of interpreters for the deaf and the provision of telephones when not otherwise available for the aging, disabled, or handicapped who are alone and homebound, or who have a health or medical condition which necessitates ready access to or frequent use of a telephone in their home.

(B) Mobility assistance for aging, disabled and handicapped persons, through the installation of ramps, rails and other safety measures at the individual's home and the provision of escort service to health facilities and other needed resources for individuals unable to travel or wait alone.

(C) Arranging for or providing friendly visitors or companions for part of a day to assist individuals who, because of frailty, physical or mental disability or social isolation, have limited contacts with other people. Such companionship service offers mental and physical stimulation and provides an opportunity for observation as to the need for professional help of any kind.

(D) Provision of special health needs and supplies such as ostomy supplies, oxygen, bandages, orthopedic and other appliances needed by aging and disabled individuals in their own homes and not available through Medicaid, Medicare or resources without cost.

(d) Target Population:

(1) individuals or families experiencing health related problems;

(2) for the family planning component, individuals (male or female) who are of age to produce children.

History Note: Authority G.S. 143B-153;

Eff. February 8, 1977;

Amended Eff. March 1, 1983; September 1, 1982; March 1, 1982; October 1, 1979;

Transferred from T10.43D .0212 Eff. July 1, 1983;

Amended Eff. March 1, 1994; July 1, 1984;

Temporary Amendment Eff. October 21, 1996;

Amended Eff. July 1, 1998.

10 NCAC 35E .0309 HOUSING AND HOME IMPROVEMENT SERVICES

(a) Primary Service. Housing and home improvement services means assistance to individuals and families in obtaining or retaining adequate housing and basic furnishings or appliances, or both. The service has three elements:

(1) Provision of counseling, advocacy and training to individuals or to groups;

(2) Provision of labor and materials for renovations and repairs to dwellings to remedy conditions which are a risk to the personal health and safety of individuals or families or to enhance mobility for functionally impaired individuals; and

(3) Provision of basic furnishings or appliances, or both, to remedy deficiencies which pose a risk to the basic health and safety of individuals and families.

(b) Components. None.

(d) Target Population. Individuals or families needing one or more elements of the service, such as counseling, advocacy, and training; renovations or repairs to dwellings; or basic furnishings or appliances, to obtain or retain adequate housing that enables them to remain in, or return to, their own homes and alleviates risk to their personal health and safety. Persons acting on behalf of an eligible client may be allowed to access the service. Within the target population eligible clients must be served in the following order of priority:

(1) adults and children for whom the need for protective services has been substantiated and the service is needed as part of a protective services plan as defined in 10 NCAC 35E .0316 and .0317, including all subsequent amendments. Copies of these Rules may be obtained from the Office of Administrative Hearings, Post Office Drawer 27447, Raleigh, North Carolina, 27611-7447, (919) 733-2678 at a cost of two dollars and fifty cents ($2.50) for up to 10 pages plus applicable sales tax;

(2) adults who are at risk of abuse, neglect or exploitation and children who are at risk of abuse, neglect, or dependency as defined in 10 NCAC 26B .0122, including all subsequent amendments. Copies of this Rule may be obtained from the Office of Administrative Hearings, Post Office Drawer 27447, Raleigh, North Carolina, 27611-7447, (919) 733-2678 at a cost of two dollars and fifty cents ($2.50) for up to 10 pages plus applicable sales tax;

(3) adults with extensive ADL or IADL impairment who are at risk of placement in substitute care and children who are at risk of placement in substitute care;

(4) children who need the service as part of a plan of preventive services designed to strengthen the family and preserve the home for the child, or as part of permanency planning to enable a child to return home from substitute care; and adults with three or more ADL or IADL impairments;

(5) adults with one or two ADL or IADL impairments.

(e) The terms ADL and IADL as used in this Subchapter are defined in 10 NCAC 42T .0001, including all subsequent amendments. A copy of this Rule may be obtained from the Office of Administrative Hearings, Post Office Drawer 27447, Raleigh, North Carolina, 27611-7447, (919) 733-2678 at a cost of two dollars and fifty cents ($2.50) for up to 10 pages plus applicable sales tax.

History Note: Authority G.S. 143B-153;

Eff. February 8, 1977;

Amended Eff. July 1, 1982; October 1, 1980; October 1, 1979; October 1, 1977;

Transferred from T10.43D .0215 Eff. July 1, 1983;

Amended Eff. December 1, 1992; July 1, 1984.

10 NCAC 35E .0310 INDIVIDUAL AND FAMILY ADJUSTMENT SERVICES

(a) Primary Service. Individual and family adjustment services are designed to offer assistance to individuals and their family members in support of attempts to restructure or solidify the individual's environment. Activities include counseling to enable the individual to recognize, understand, and cope with problems and conflicts in regard specifically to such areas as household management, consumer affairs, family life, alcoholism, drug addiction, mental retardation, emotional disturbance, and school related problems. Such counseling is also designed to help individuals independently utilize community resources, including other social services; take advantage of natural support systems; and achieve an adequate level of functioning within the family. Also included is arranging for other services when needed to support the provision of individual and family adjustment services; diagnostic psychological study and evaluation necessary to determine the appropriate plan of service; activities associated with fulfilling the agency's responsibility to serve as guardian or representative payee for individual clients; and social development through therapeutic groups as a part of a service plan to give individuals opportunities for participation in structured group activities focused on helping them cope with personal problems, develop capacities for more adequate social functioning and relieve social isolation.

(b) Components. Day or residential camp experience for school-age children and therapeutic camp for developmentally disabled or handicapped individuals and their families and for youths whose behavior is delinquent or undisciplined may be provided at county option.

(d) Target Population:

(1) individuals who need assistance in order to fully and appropriately utilize social services;

(2) individuals who need assistance in coping with specific problems, such as household management, consumer affairs, family life, alcoholism, drug addiction, mental retardation, emotional disturbance, and school related problems.

History Note: Authority G.S. 143B-153;

Eff. July 1, 1979;

Transferred from T10.43D .0237 Eff. July 1, 1983;

Amended Eff. July 1, 1984; December 1, 1983.

10 NCAC 35E .0311 INFORMATION AND REFERRAL

History Note: Authority G.S. 143B-10; 143B-153; 45 C.F.R. 1396.26;

Eff. February 8, 1977;

Amended Eff. October 1, 1979;

Transferred from T10.43D .0216 Eff. July 1, 1983;

Repealed Eff. July 1, 1984.

10 NCAC 35E .0312 IN-HOME AIDE SERVICES

In-home aide services are provided to enable individuals and families to remain in or return to their own homes and communities. To this end, at least one level of this service must be available in each geographic area.

(1) Primary Service. In-Home Aide Services are those paraprofessional services which assist individuals and children and their families with essential home management tasks, personal care tasks, or supervision, or all of the tasks in this Paragraph, to enable individuals and children and their families to remain, and function effectively, in their own homes as long as possible.

(2) Component. In-Home Aide Services may be used for the purpose of providing respite for a primary caregiver or for parents. For this purpose, In-Home Aide Services may be provided to individuals in their own homes or in the home of their primary caregiver and to children and their families in their own homes. Respite Care may consist of any level of home management or personal care tasks.

(3) Resource Items. None.

(4) Target Population. Individuals who are unable to carry out tasks essential to the activities of daily living or the instrumental activities of daily living, or both, who have no responsible person available to perform these tasks, and who need the service in order to remain in their own homes. Children and their families who need help remaining in their own homes, or who need help in maintaining, strengthening, and safeguarding their functioning because of economic dependency, physical or emotional illness or handicap or to preserve and strengthen family functioning. Also included are children and functionally impaired individuals whose primary caregivers or parents need relief from everyday caregiving responsibilities in order for the children and impaired individuals to remain at home. Within the target population eligible clients must be served in the following order of priority:

(a) adults and children for whom the need for protective services has been substantiated and the service is needed as part of a protective services plan;

(b) adults who are at risk of abuse, neglect or exploitation and children who are at risk of abuse, neglect, or dependency;

(c) adults with extensive ADL or IADL impairment who are at risk of placement in substitute care and children who are at risk of placement in substitute care;

(d) children who need the service as part of a plan of preventive services designed to strengthen the family and preserve the home for the child, or as a part of permanency planning to enable a child to return home from substitute care; and adults with three or more ADL or IADL impairments;

(e) adults with one or two ADL or IADL impairments.

History Note: Authority G.S. 143B-153;

Eff. July 1, 1979;

Amended Eff. July 1, 1982; October 1, 1981; October 1, 1980; October 1, 1979;

Transferred from T10.43D .0238 Eff. July 1, 1983;

Amended Eff. December 1, 1991; May 1, 1985; July 1, 1984.

10 NCAC 35E .0313 PERSONAL AND FAMILY COUNSELING

(a) Primary Service. Personal and family counseling means the rendering of counseling services or therapy to individuals, either singly or in groups, for the purpose of resolving emotional conflicts within social relationships. It operates through a process of mobilizing the strengths inherent in the person which are needed to deal with immediate situations and developing the coping ability of the family and its members to use themselves effectively in life roles and tasks. The process involves a professional relationship with a skilled counselor to help the clients assess the situation, to plan steps for dealing with it, and to take appropriate action.

(b) Components. None.

(d) Target Population. Individuals experiencing stress which impedes satisfactory emotional adjustment and is causing serious conflicts in interpersonal relationships.

History Note: Authority G.S. 143B-153;

Eff. February 8, 1977;

Amended Eff. October 1, 1979;

Transferred from T10.43D .0219 Eff. July 1, 1983;

Amended Eff. May 1, 1990; July 1, 1984.

10 NCAC 35E .0314 PREPARATION AND DELIVERY OF MEALS

(a) Primary Service. This service means the preparation and delivery of nutritious meals to a blind, aging, or disabled individual in his own home or in a central dining facility as necessary to prevent institutionalization or malnutrition. The cost of raw food necessary to provide the meal service is included.

(b) Components. None.

(d) Target Population. Blind, aging, or disabled individuals needing nutritious meals in their own home or in a central dining facility as necessary to prevent malnutrition or institutionalization. Within the target population, eligible clients shall be provided meal services in the following order of priority:

(1) aged or disabled individuals who need the service to avoid impending placement in substitute care (e.g. nursing home, domiciliary home, foster home) and adults who need the service as part of a protective services plan;

(2) aged or disabled adults who live alone and need the service to maintain self-sufficiency and prevent deterioration that may lead to placement in substitute care;

(3) aged and disabled individuals who can receive some needed care from others but who need the service to enable their caregivers to maintain employment of to otherwise support the caregiver's efforts to keep them in their own homes.

History Note: Authority G.S. 143B-153;

Eff. February 8, 1977;

Amended Eff. July 1, 1982; October 1, 1979;

Transferred from T10.43D .0220 Eff. July 1, 1983;

Amended Eff. July 1, 1984.

10 NCAC 35E .0315 PROBLEM PREGNANCY SERVICES

(a) Primary Service. Problem pregnancy services are services to individuals who are involved with an undesired pregnancy. Services include counseling to assist such individuals in looking at alternative solutions to the unwanted pregnancy (i.e., abortion, adoption, or keeping the baby), and at the probable consequences of each alternative, and assistance in arranging for and utilizing other needed services. Residential care, including a concentrated regimen of services as described in (a) of this Rule, room and board for up to six months, medical supervision, and medications required for health maintenance in pregnancy as prescribed by a physician may be provided when such care is provided in an approved living arrangement prescribed in 10 NCAC 42F .0006 (5) and .0007 (f). Psychiatric counseling specifically related to help in coping with the pregnancy may also be included as an integral but subordinate part of the regimen of residential services.

(b) Components. None.

(d) Target Population. Individuals (male or female) involved with an undesired pregnancy. The residential care component is available to females.

History Note: Authority G.S. 143B-153(2a)b.;

Eff. February 8, 1977;

Amended Eff. October 1, 1979; July 1, 1978;

Transferred from T10.43D .0221 Eff. July 1, 1983;

Amended Eff. May 1, 1990; October 1, 1987; July 1, 1984.

10 NCAC 35E .0316 PROTECTIVE SERVICES FOR ADULTS

(a) Primary Service. Protective services for adults are services provided to correct or prevent further abuse, neglect, exploitation or hazardous living conditions of individuals 18 years of age or older or lawfully emancipated minors who are unable to manage their own resources, carry out the activities of daily living or protect their own interests. Services include acceptance and evaluation of reports of the need of individuals for protective services; planning and counseling with such individuals and their relatives or caretakers to identify, remedy or prevent problems which result in abuse, neglect or exploitation; assisting in arranging for appropriate alternate living arrangements in the community or in an institution; and arranging for the provision of medical, legal and other services as needed and appropriate. Also included are assistance in arranging for protective placement, guardianship or commitment when needed as part of the protective services plan, and carrying out the duties of guardian or representative payee when part of a protective services plan; and the provision of medical and psychological diagnostic studies and evaluations where needed to substantiate and assess the circumstances of abuse or neglect. At its option, the county may provide advocacy, including legal services, to assure receipt of rights and entitlements due to adults at risk, and services of lawyers to represent the agency where court action is necessary to protect adults.

(b) Components. None.

(d) Target Population. "Disabled" adults (18 years or older or lawfully emancipated minor) who are unable to manage their own resources, carry out activities of daily living, or protect their own interests.

History Note: Authority G.S. 143B-153;

Eff. February 8, 1977;

Amended Eff. October 1, 1981; October 1, 1979; October 1, 1977;

Transferred from T10.43D .0222 Eff. July 1, 1983;

Amended Eff. May 1, 1990; July 1, 1984; December 1, 1983.

10 NCAC 35E .0317 PROTECTIVE SERVICES FOR CHILDREN

(a) Primary Service. Protective services for children are social services provided to children and their parents or other caretakers in response to instances of actual or suspected child neglect, abuse or exploitation. The primary elements of protective services consist of identifying children at risk; receiving and investigating reports of neglect, abuse or exploitation; evaluating the degree of damage or risk to the child; cooperation with law enforcement agencies as required to obtain suitable care and services for children in or out of their own homes and initiation of court action where necessary; counseling and planning with the child's family toward the solution and prevention of problems causing neglect, abuse or exploitation; and arranging for the provision of, and assisting families in utilizing appropriate services and community resources such as foster care, day care, health and mental health services, homemaker services, etc. as needed. These services are included for runaways, harmed or threatened with harm by virtue of their status as runaways. Included also are service activities necessary to carry out statutory responsibility to approve or disapprove the separation of a child under six months of age from its parent. At its option, the county may provide counseling and therapy for children and their parents or guardians, training courses for parents or guardians of the individual child, and services of lawyers to represent the agency where court action is necessary to protect children.

(b) Components:

(1) the provision of medical, psychological and medicolegal diagnostic studies and evaluations where needed to substantiate and assess the circumstances of abuse or neglect are included;

(2) the provision of emergency shelter, at county option.

(d) Target Population. Children (birth through 17 years) in actual or suspected danger of child neglect, abuse, or exploitation.

History Note: Authority G.S. 143B-153;

Eff. February 8, 1977;

Amended Eff. October 1, 1979; October 1, 1977;

Transferred from T10.43D .0223 Eff. July 1, 1983;

Amended Eff. July 1, 1984; December 1, 1983.

10 NCAC 35E .0318 RESIDENTIAL TREATMENT FOR THE EMOTIONALLY DISTURBED

(a) Primary Service. Residential treatment means services provided in an environment effectively structured and designed as a therapeutic milieu to meet individualized needs of emotionally disturbed individuals. Services should initiate and direct recovery from the incidence and debilitating effects of emotional disturbance in such manner that rehabilitation toward adequate social and emotional functioning can be continued by follow-up support and treatment in home and community. Included are room and board for up to six consecutive months for any one placement in residential treatment. Psychiatric counseling and drug therapy specifically related to the treatment of the individual's emotional disturbance may be provided as integral but subordinate to the regimen of residential treatment services.

(b) Components. None.

(d) Target Population. Emotionally disturbed children who are a placement responsibility (by legal custody or voluntary agreement) of county departments of social services and for whom other program resources are not available.

History Note: Authority G.S. 143B-153;

Eff. July 1, 1979;

Amended Eff. April 1, 1983;

Transferred from T10.43D .0240 Eff. July 1, 1983;

Amended Eff. July 1, 1984.

10 NCAC 35E .0319 SERVICES FOR SPECIAL NEEDS OF AGING: DISABLED: HANDICAPPED

10 NCAC 35E .0320 SOCIAL DEVELOPMENT THROUGH THERAPEUTIC GROUP SERVICES

History Note: Authority G.S. 143B-10; 143B-153; 45 C.F.R. 1396.26;

Eff. February 8, 1977;

Amended Eff. October 1, 1981; October 1, 1979; October 1, 1977;

Transferred from T10.43D .0229 Eff. July 1, 1983;

Repealed Eff. July 1, 1984.

10 NCAC 35E .0321 TRANSPORTATION SERVICES

(a) Primary Service. Transportation services mean providing transportation as part of a service plan to enable individuals for whom transportation is not otherwise available to have access to medical and health resources, shopping facilities, education, recreational and employment and training opportunities, and other community facilities and resources, and to support the delivery of other social services.

(b) Components. None.

(d) Target Population. All individuals in need of the service who meet the general eligibility criteria.

History Note: Authority G.S. 143B-153;

Eff. February 8, 1977;

Amended Eff. July 1, 1979;

Transferred from T10.43D .0230 Eff. July 1, 1983;

Amended Eff. July 1, 1984.

10 NCAC 35E .0322 ADULT PLACEMENT SERVICES

(a) Primary Service. Adult Placement Services are activities necessary to assist aging or disabled individuals and their families or representatives in finding substitute homes or residential health care facilities suitable to their needs when they are unable to remain in their current living situations. Activities include completing an initial screening and assessment while providing counseling to help the individual and his family or representative to determine the need for initial or continued placement; assisting in the process for completing necessary financial applications and medical evaluations; helping to locate and secure placement in a suitable setting and level of care; supporting an individual and his family or representative in the individual's transition from one location to another; and providing counseling and other services to help the individual adjust to the new setting and maintain the placement. Adult Placement Services also include assisting individuals, when requested, to return to more independent settings in the community, or to relocate in more appropriate settings when new levels of care are needed.

Adult Placement Services must be provided by every county department of social services.

(b) Components. None.

(d) Target Population. An individual is considered to be in the target population if Adult Placement Services are appropriate and desired based on one of the following client needs:

(1) Adults who are unable to maintain themselves in their own homes independently or with available community or family supports.

(2) Adults who are living in substitute homes, residential health care facilities or institutions, and who need assistance in relocating due to changes in the level of care needed or other factors indicating that alternative settings may be more appropriate.

(3) Adults who are living in substitute homes, residential health care facilities or institutions, and who need assistance in returning to more independent living arrangements in the community.

(4) Adults who are living in substitute homes or residential health care facilities, and who need assistance in adjusting to or maintaining their placements due to individual or family problems or a lack of resources.

This target population includes wards for whom the director or assistant director of the county department of social services is the guardian.

(e) Once an individual is determined to be in the target population, Adult Placement Services are provided in the following order of priority:

(1) Adults receiving protective services for whom Adult Placement Services is in their protective services plans.

(2) Adults who are at risk of abuse, neglect, or exploitation because:

(A) they need assistance with activities of daily living, instrumental activities of daily living, or health care and they have no caregiver, or the caregiver is not able, willing or responsible to provide the amount or type of assistance needed; or

(B) they were previously abused, neglected or exploited and the conditions leading to that situation continue to exist.

(3) Adults who have problems which place them at risk of losing their current living situations.

(4) Adults who do not meet any of the first three priority groups but whose quality of life would be improved with Adult Placement Services.

History Note: Authority G.S. 143B-153;

Eff. March 1, 1994.

II. NORTH CAROLINA'S ESTABLISHED INCOME

III. Gross Annual Income Levels by Size of Income Unit

Size of Income Unit	60% of Established Income	80% of Established Income	State's Established Income
1	$ 6,132	$ 8,172	$ 10,224
2	8,268	11,028	13,788
3	10,404	13,872	17,352
4	12,552	16,740	20,928
5	14,688	19,584	24,492
6	16,836	22,452	28,068
7	18,972	25,296	31,632
8	21,120	28,164	35,208
9	23,256	31,008	38,772
10	25,404	33,876	42,348
11	27,540	36,720	45,912
12	29,688	39,588	49,488

IV. Gross Monthly Income Levels by Size of Income Unit

Size of Income Unit	60% of Established Income	80% of Established Income	State's Established Income
1	$ 511	$ 681	$ 852
2	689	919	1,149
3	867	1,156	1,446
4	1,046	1,395	1,744
5	1,224	1,632	2,041
6	1,403	1,871	2,339
7	1,581	2,108	2,636
8	1,760	2,347	2,934
9	1,938	2,584	3,231
10	2,117	2,823	3,529
11	2,295	3,060	3,826
12	2,474	3,299	4,124

ATTACHMENT F

BASIS FOR DENIAL OR TERMINATION OF SERVICES
10 NCAC 35D .0303

Reasons for denial of an application for services and reasons for the termination of services include the following:

The individual has failed to cooperate with the agency in determining (or redetermining) eligibility;
The individual cannot be located to allow for determination (or redetermination) of eligibility;
The individual has been determined to be not eligible for the services requested on the basis that he does not meet (or because of changing circumstances, no longer meets) the conditions of eligibility for the program funding sources under which the service is provided or the definition of the target population for receipt of the service;
The service is not available in the county in which the individual lives;
There is reasonable certainty that the service will not be available in sufficient time to ensure its prompt provision, as set forth in Section .0500 of this Subchapter;
The agency has exhausted its funds for the provision of the service for that program year;
The individual has notified the agency that he no longer wants or needs the service;
The agency has determined that the individual is no longer able to avail himself of the service because he has moved to another county or has been admitted to an institution;
The individual has failed to utilize the service or to cooperate in service delivery;
The individual fails to meet any other conditions set forth in policies governing delivery of the service.

V. Services that are subject to cost sharing

TYPE CASES THAT ARE EXEMPT
[10 NCAC 35F .0301]

Adult Day Care, including transportation
Adult Day Health, including transportation
Housing and Home Improvement
In Home Aide Services
Personal and Family Counseling
Preparation and Delivery of Meals

030
155
140
041-046
170
180

OR

LIST OF ATTACHMENTS

ATTACHMENT A

SITUATIONS THAT DO NOT REQUIRE APPLICANT/REPRESENTATIVE SIGNATURE AND DATE

ATTACHMENT B

REASONS FOR EXEMPTION FROM NOTICE REQUIREMENT

Attachment C TABLE 1. SUMMARY OF AVAILABLE SERVICES BY ELIGIBILITY CATEGORY

Attachment D

SERVICE DEFINITIONS AND TARGET POPULATIONS FOR SSBG SERVICES

I. SECTION .0300 - SERVICE DEFINITIONS

II. NORTH CAROLINA'S ESTABLISHED INCOME

III. Gross Annual Income Levels by Size of Income Unit

IV. Gross Monthly Income Levels by Size of Income Unit

ATTACHMENT F

ATTACHMENT G

V. Services that are subject to cost sharing

TYPE CASES THAT ARE EXEMPT
[10 NCAC 35F .0301]

OR

LIST OF ATTACHMENTS

ATTACHMENT A

SITUATIONS THAT DO NOT REQUIRE APPLICANT/REPRESENTATIVE SIGNATURE AND DATE

ATTACHMENT B

REASONS FOR EXEMPTION FROM NOTICE REQUIREMENT

Attachment C TABLE 1. SUMMARY OF AVAILABLE SERVICES BY ELIGIBILITY CATEGORY

Attachment D

SERVICE DEFINITIONS AND TARGET POPULATIONS FOR SSBG SERVICES

I. SECTION .0300 - SERVICE DEFINITIONS

II. NORTH CAROLINA'S ESTABLISHED INCOME

III. Gross Annual Income Levels by Size of Income Unit

IV. Gross Monthly Income Levels by Size of Income Unit

ATTACHMENT F

ATTACHMENT G

V. Services that are subject to cost sharing

TYPE CASES THAT ARE EXEMPT [10 NCAC 35F .0301]

TYPE CASES THAT ARE EXEMPT
[10 NCAC 35F .0301]