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					                                                                            SCHEDULE 3




ANNUAL ACCOUNTABILITY REPORT
EXTENDED AGED CARE AT HOME DEMENTIA (EACH
DEMENTIA) PROGRAM
___________________________________________________________________________




Extended Aged Care at Home Dementia (EACH Dementia) Annual Reporting Form        1
EXTENDED AGED CARE AT HOME DEMENTIA (EACH DEMENTIA)
                     PROGRAM
           ANNUAL ACCOUNTABILITY REPORT


            NAME OF SERVICE                                NAME OF APPROVED PROVIDER




SERVICE ID. NUMBER


The service identification number is the four digit number on your monthly claim form.

STATE OR TERRITORY IN WHICH THE EACH DEMENTIA PROVIDER IS
LOCATED




The Annual Accountability Report is the mechanism for the collection of information from
Approved Providers in respect of their provision of EACH Dementia services in the
preceding financial year (ie. 1 July – 30 June).

The data collected through this form is used with other information held by the
Commonwealth (including approved places, claim form information, subsidy and
supplementary funding) to measure performance at both service and Program level. It is not
intended to cover all expenditure categories related to direct care and does not require
identification of expenditure in relation to management or administration.

This completed form including completed Section F (Certification of Audited Statement) is to
be provided to:

      Extended Aged Care at Home Dementia (EACH Dementia) Program Manager
      Department of Health and Ageing
      GPO Box 9848
      (City) (State) (Postcode)
      [ACT Office: GPO Box 634, CANBERRA ACT 2601]

by 30 September each year in respect of the preceding financial year.




Extended Aged Care at Home Dementia (EACH Dementia) Annual Reporting Form                2
SECTION A – CLIENT FEES


                                CATEGORY                                    AMOUNT
(1) Client Fees                                                               ($)
This is the total amount of client fees collected in the financial year.

                                                                            …………




Extended Aged Care at Home Dementia (EACH Dementia) Annual Reporting Form     3
SECTION B – SALARY/WAGES DIRECT CARE STAFF AND DIRECT CARE
BROKERAGE EXPENSES

                           CATEGORY                                                      AMOUNT
DIRECT CARE EXPENSES:                                                                      ($)
Care Related Wages including:

(2)Wages/salary of people who deliver “hands-on” care and assistance,
including nursing care, allied health care, personal care, and domestic
assistance.                                                                              …………

(3)Wages/salary attributable to assessment, care planning, case
management and care planning reviews for individual care recipients                      …………
Note: Where staff undertake both care functions and administration or management
please apportion their wages/salary and include only the wages/ salary attributable to
care provision as defined above in (2) and (3).

(4) Total :Sum of (2) and (3)                                                            …………

                                                                                           ($)
(5) Brokered Direct Care
This is the contracted cost of brokered (ie subcontracted or “contracted-
in”) direct care services. This will include case management, nursing,
allied health, personal care, domestic assistance and any other contracted
in services which provide direct care to individual clients.                             …………
Note: Where services broker all direct care activity ie both “hands on” care and
assistance, and assessment, care planning, case management and care planning reviews
for individual care recipients, then only this box (Brokered Direct care) in Section B
should be completed
                                                                                          Km’s
(6) Mileage (in kilometres). Motor vehicle use for delivery of direct
EACH Dementia care services ie. For “hands-on” care and assistance,
including nursing care, allied health care, personal care, and domestic
assistance, and assessment, care planning, case management and care
planning reviews for individual care recipients.                                         …………


.




Extended Aged Care at Home Dementia (EACH Dementia) Annual Reporting Form                   4
SECTION C – STAFFING PROFILE – Equivalent Full Time staffing by staff category
Note: In Section C, please apportion the total salaries and wages recorded in the Total at (4) in Part B
into the categories of staff listed at (7), (8), (9) and (10) and record in the Amount column in the Table
below. Please convert the amount into equivalent full time staff and record in the column headed
“Equivalent full-time staff”.
                            CATEGORY                                           AMOUNT              EQUIV.
                                                                                 ($)             FULL TIME
                                                                                                   STAFF
(7) NURSING
Registered Nurses                                                              ………….               ………….

Enrolled Nurses                                                                ………..…              ………….


(8) ALLIED HEALTH
Physiotherapists                                                               ………….                …………

Occupational Therapists                                                        …………..               …………

Therapy Assistants and Aids                                                    ………….                …………

Other                                                                           …………                …………
 .
(9) PERSONAL CARE AND DOMESTIC ASSISTANCE
WORKERS                                                                         …………                …………

(10) OTHER
Please briefly
describe…………………………………………………………                                                  …………                …………
………..




Extended Aged Care at Home Dementia (EACH Dementia) Annual Reporting Form                           5
SECTION D – SELECTED EXPENDITURE (OTHER)

                     CATEGORY                                                               AMOUNT
(11) COST OF CONTINENCE MANAGEMENT PRODUCTS                                                   ($)
PROVIDED TO CARE RECIPIENTS DURING THE FINANCIAL
YEAR:                                                                                       ……………

                                                                                              ($)
(12) COST OF EQUIPMENT ASSETS PURCHASED DURING THE
FINANCIAL YEAR FOR USE IN CLIENT HOMES BUT WHICH
REMAIN THE PROPERTY OF THE SERVICE.                                                         …………
This covers equipment items used in direct care eg hoists which will remain the property
of the service provider despite their utilisation in a particular clients home during the
client’s EACH Dementia program ie items that will be returned upon program cessation
to the service provider and which in the normal course of events would be re-used.




Extended Aged Care at Home Dementia (EACH Dementia) Annual Reporting Form                      6
SECTION E - STATEMENT OF COMPLIANCE




I ……………………………………………… (name of authorised officer) being an

authorised officer of …………………………………………..(name of organisation)

state that in relation to ………………………………………………(name of service)

……………(provider ID)


for the financial year 1 July ………… to 30 June …………:

All conditions included in the Payment Agreement with the Commonwealth of Australia in
relation to Extended Aged Care at Home Dementia have been met, in particular:

     the requirements of the Aged Care Act 1997 and Aged Care Principles
     financial records have been kept which will allow separate identification of the subsidy
      from other income and expenditure
     public liability insurance of not less than $10 million is current at 30 June …………….
     workers compensation insurance as required by State Workers’ Compensation Legislation
      is current at 30 June ………….
     professional indemnity insurance of $5 million is current at 30 June …………
     all other insurances in respect of any liability that may arise out of the provision of
      Extended Aged Care at Home Dementia are current at 30 June …………
     all superannuation payments for employees are current at 30 June …………
     all sub-contracted or brokered services have been delivered in accordance with the
      requirements of the Aged Care Act 1997 and the Payment Agreement with the
      Commonwealth for the provision of Extended Aged Care at Home Dementia services.

and

the particulars given in this Annual Accountability Report are true and correct.



…………………………………………………………..
(signature of authorised officer)

………………………..
(date)

Title/Position:………………………………………………………….Tel:……………………
..




Extended Aged Care at Home Dementia (EACH Dementia) Annual Reporting Form            7
SECTION F – CERTIFICATION OF AUDITED STATEMENT


CERTIFICATION OF AUDITED EACH DEMENTIA ANNUAL ACCOUNTABILITY
REPORT

(This certification verifies that the information provided in this Annual Accountability
Report for the financial year concluding on 30 June …………is true and correct and
should be signed by a person who is legally empowered to do so ie. a qualified
accountant not being the Approved Provider or an employee of the Approved
Provider.)


I/We hereby certify that the information provided in this Annual Reporting Statement which
I/we have audited is true and correct.



 NAME
 POSITION
 TELEPHONE

 SIGNATURE

 DATE

 ORGANISATION



Please state below any Qualifications to this audited statement (attach a separate sheet if
required):




Extended Aged Care at Home Dementia (EACH Dementia) Annual Reporting Form               8

				
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