OSA Quarterly Waiting List Report Form

Select Agency:*  
Napis Provider:*  
Fiscal Year:
Quarter:*  
Completed By:
Date:*
Section I. Home-Delivered Meals Waiting List

Home-Delivered Meals Waiting List Information (Non-Medicaid Waiver Clients)
1. Enter the number of individuals on the home-delivered meals program waiting list:*  
2. Describe the length of stay for individuals on the home-delivered meals waiting list (i.e., of the total on Line 1 above):
  a. Less than 30 days  
  b. 30 – 59 days  
  c. 60 - 179 days  
  d. 180 days or greater  
2a. Enter the number of individuals that currently receive home-delivered meals that are "underserved" (e.g. served meals at less than assessed level, etc.): 
2b. Describe the reasons that HDM clients in questions 2a above are “underserved” (check all that apply):
    Reduced or closed weekend meal programs/options
    Client served/provided frozen meals in place of home-delivered hot meal
    Client served fewer meals per week than assessed or requested number of meals
    Reduced or closed local meal programs that supplement OSA/AAA HDM program
    Shortages of HDM volunteers/drivers
    Prioritization of HDM clients leads to “underservice” for some clients based on priority level
    Service delays and/or disruptions
    Other (please describe below):
   
3. Describe any assistance/referrals provided to individuals that are placed on the home-delivered meals waiting list:
    Referred to a local non-AAA funded food assistance program (e.g. Project FRESH) that is currently accepting clients
    Referred to a local food bank/pantry shelf
    Referred to local DHS office
    Referred to HCBS/ED Waiver Program
    Referred to CLP for service options
    Referred to private pay program
    Other assistance (please describe below):
    
4. Additional comments on the home-delivered meals waiting lists (e.g. changes, events, issues impacting the list, etc.):
  
5. Does the demand for home-delivered meal services exceed service availability?
 
5a. If yes, describe below (check all that apply):
    Limited funding for services
    Limited service area/service delivery availability
    Driver/worker shortage
    Client choice
6. In order to address service demand that exceeds service availability, are home-delivered meals provided:
  6a. At levels less than identified need (underserved):
   
  6b. To all clients at their identified need level. Individuals that cannot be served at identified need level are placed on the waiting list:
   
7. Additional comments on “underservice”:
  
8. If a “0” count of individuals is being reported on the home-delivered meals waiting list, please describe:
    Service capacity/funding is sufficient to serve all individuals that are eligible
    Other (describe):
    
Access, In-Home, and Priority Services Waiting List Report

In-Home, Access, and Priority Services Waiting List Information (Non-Medicaid Waiver Clients)
1. Enter the total number of individuals on the in-home, access, and priority service waiting list:*  
2. Describe the length of stay for individuals on the waiting list (i.e., of the total on Line 1 above):
  a. Less than 30 days  
  b. 30 – 59 days  
  c. 60 - 179 days  
  d. 180 days or greater  
2a. Enter the number of individuals that currently receive in-home, access, and priority services that are "underserved" (e.g. received in-home, access and priority services at less than assessed level, etc.): 
2b. Describe the reasons that clients in question 2a above are “underserved” (check all that apply):
    Reduced or closed services or programs
    Loss of caregivers or informal support that supplemented OSA/AAA services or programs
    Clients served fewer hours of service than assessed or requested service hours
    Shortages of in-home service staff/direct care workers
    Prioritization of clients leads to “underservice” for some clients based on priority level
    Service delays and/or disruptions
    Other (please describe below):
    
3. Describe any assistance/referrals provided to individuals that are placed on the waiting list:
    Referred to a local non-AAA funded food assistance program (e.g. Project FRESH) that is currently accepting clients
    Referred to a local food bank/pantry shelf
    Referred to local DHS office
    Referred to HCBS/ED Waiver Program
    Referred to CLP for service options
    Referred to private pay program
    Other assistance (please describe below):
    
4. Additional comments on waiting list (waiting list changes, local events impacting list, etc.):
  
5. Does the demand for in-home, access, and priority services exceed service availability?
 
5a. If yes, describe below (check all that apply):
    Limited funding for services
    Limited service area/service delivery availability
    Driver/worker shortage
    Client choice
6. In order to address service demand that exceeds service availability, are services provided:
  6a. At levels less than identified need (underserved):
   
  6b. To all clients at identified need level. Individuals that cannot be served at identified need level placed on the waiting list:
   
7. Additional comments on “underservice”:
  
8. If a “0” count of individuals is being reported on the waiting list, please describe:
    Service capacity/funding to serve all individuals that are eligible
    Other (describe):