2015 Aged Care Approvals Round

2015 AGED CARE APPROVALS ROUND

PART B - RESIDENTIAL AGED CARE PLACES

Organisation name:
(if approved provider, insert approved provider name) /
Service name: /

Please select the state/territory and specify the Aged Care Planning Region in which the residential aged care places are sought

Select StateACTNSWNTQLDSATASWAVIC / (insert Aged Care Planning Region) /

Form Instructions

Complete the Part A - Residential Aged Care Places application form once for your organisation.

If you are applying for residential aged care places only you must complete:

· Part A – Residential Aged Care Places application form once for your organisation

· Part B – Residential Aged Care Places application form for each service for which you are seeking residential aged care places in the selected Aged Care Planning Region.

If you are applying for residential aged care places and a capital grant you must complete:

· Part A – Residential Aged Care Places application form once for your organisation

· Part B – Residential Aged Care Places application form for each service for which you are seeking residential aged care places in the selected Aged Care Planning Region, and

· Part C – Capital Grant application form for each service.

Only attachments specifically requested should be included with your application.

Detailed information about completing this application form is included in the
2015 ACAR Essential Guide.

PART B - SECTION 1: SERVICE DETAILS

1.1 Applicant:

Is this an existing aged care service? / Select oneYesNo
/
Approved Provider ID (NAPS ID) /
RAC Service ID
(existing service only) /

1.2 Physical address of the service:

Street number
Street name
Street Type (Street/Avenue etc)
Suburb/Town
State/Territory / Select a stateACTNSWNTQLDSATASVICWA / Postcode

1.3 Contact details:

Are your contact details the same in Part A? If ‘yes’ you are not required to provide these contact details again.

Select oneYesNo
Primary Contact / Alternative Contact
Name of contact person
Position in organisation
Telephone number
Mobile number
Best hours to call
Email address
How many hours did your organisation take to complete this ACAR Residential Aged Care Places application?

This form is approved under paragraph 13-1(c) of the Aged Care Act 1997 Page 13 of 13

PART B – SECTION 2: RESIDENTIAL AGED CARE PLACES SOUGHT

2.1 Total number of places sought for this service

Before completing this section, refer to Chapter 3 of the 2015 ACAR Essential Guide.

Specify the total number of places sought for this service. The total number of places sought will be the sum of:

- (a) General access places sought

- (b) Priority of access places sought

Total number of places sought
Enter the total number of places sought for this service = General Places (a) + Priority of Access Places (b) / Max places / Min places /

(a) General access places sought

Enter the total number of general access places you are seeking for this service in this Aged Care Planning Region.

If 'nil' either type '0' or leave each field blank.

General access places sought
Enter the total number of general access places you are seeking for this service / Max places / Min places /

(b) Priority of access places sought

Enter the total number of priority of access places you are seeking for this service in this Aged Care Planning Region.

If 'nil' either type '0' or leave each field blank.

Priority of access places sought /
Geographic Location
(if any) / Special needs group(s)
(if any) / CALD language group(s)
(if any) / Key issue
(if any) / Max places / Min places /

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2.2 When will the majority of the places that are the subject of this application be made operational (from the date of allocation)?

Select a timeframeImmediatelyWithin 1 month2-3 months4-6 months7-12 months13-18 months19-24 months25 or more months

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2.3 Describe how your organisation will meet these timeframes.

Responses should align with information provided in Section 3 to Section 5 of this application form.

Word limit 500

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Residential respite
2.4 How many new residential respite bed days per annum will be provided at this service?

Days

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PART B – SECTION 3: SERVICE PROPOSAL

3.1 Provide a detailed description of your proposal for this service.

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Word limit 1,000

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3.2 Provide a detailed description of:

A. What aged care needs will be met, and how you will address them.

B. What evidence has been relied on to determine the aged care need(s) in this region

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Word limit 1,000

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3.3 Provide examples of how your service will provide continuity of care for current and future care recipients.

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Word limit 500

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3.4 Describe the measures your service will use to deliver appropriate care to targeted special needs groups and/or key issues identified as being a priority at 2.1(b).

If you did not identify any special needs groups and/or key issues at 2.1(b), you are not required to complete this question.

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Word limit 500 for each special needs group or key issues identified

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If you are making changes to buildings or establishing new buildings for the delivery of

aged care – Go to SECTION 4

If you are not making changes to buildings or establishing new buildings for the delivery of

aged care – Go to SECTION 5

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PART B – SECTION 4: SERVICE PLANNING AND DEVELOPMENT

IF YOU ARE SEEKING A CAPITAL GRANT TO MAKE CHANGES TO BUILDINGS OR ESTABLISH A NEW BUILDING/SERVICE FOR THE DELIVERY OF AGED CARE DO NOT COMPLETE SECTION 4 OR 5. YOU ARE REQUIRED TO COMPLETE PART C – CAPITAL GRANT APPLICATION FORM IN ITS ENTIRETY
IF YOU ARE NOT MAKING CHANGES TO BUILDINGS OR ESTABLISHING NEW BUILDINGS FOR THE DELIVERY OF AGED CARE DO NOT ANSWER SECTION 4 - PROCEED TO SECTION 5

4.1 Describe your proposal to extend, refurbish or develop new buildings for the delivery of aged care services.

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Word limit 750

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4.2 Provide the key milestones in the development of your service.

Key Milestone / Date achieved
(dd/mm/yyyy) / Date to be achieved
(dd/mm/yyyy) / Have you attached evidence?
Acquisition of land (if applicable) / Select oneYesNo
Approval of finance / Select oneYesNo
Development Application approved (including map detailing location of acquired/proposed land or building(s)) / Select oneYesNo
Building Application approved / Select oneYesNo
Arrangements for existing residents* / Select oneYesNo
Commencement of building work / Select oneYesNo
Completion of building work / Select oneYesNo
Approval from appropriate state/territory and/or local government authorities / Select oneYesNo
Admission of residents (must align with response at Question 2.2) / Select oneYesNo

* This relates to the arrangements that your organisation will establish to provide temporary accommodation and/or care arrangements for residents during the construction or redevelopment work.

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4.3 Identify any known risks that may affect your ability to meet the above key milestones.

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A. Identify risks.
B. How are you going to manage identified risks?
Word limit 500

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Land and building development financial details

4.4 List the type and number of residential aged care places, in respect of any works to be undertaken, including any associated land and/or building development costs.

Type of existing and/or new places / Number of
existing and/or new places / Total land and/or building development costs ($)
Extend/Refurbish / New Building / Do not include GST
Number of operational or offline places to be accommodated.
Number of provisionally allocated places from previous ACARs to be accommodated.
Number of places applied for in the
2015 ACAR to be accommodated*.
Total new and existing places and total associated costs

*Assuming you will be allocated all of the new residential aged care places you are seeking.

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4.5 Sources of funds for capital works.

Internal sources / $
Do not include GST
Drawn from reserves (excluding any amounts from accommodation bonds, refundable accommodation deposits and refundable accommodation contributions)
Internal borrowings from within the applicant organisation or a parent/allied group – repayable
Please provide audited financial statements to demonstrate the funder’s financial capacity to provide funding to the applicant.
Contributions from parent/allied group – non-repayable
Please provide audited financial statements to demonstrate the funder’s financial capacity to provide funding to the applicant.
Sale of assets
Describe:
Resident sources
Accommodation bonds – existing places (do not include any provisionally allocated places)
Refundable accommodation deposits and refundable accommodation contributions – for existing places
Refundable accommodation deposits and refundable accommodation contributions – for existing provisionally allocated places or places sought through this application
External sources
Borrowings from an external organisation, including loans from financial institutions
Other sources
Special fund raising activities
Describe:
Other
Describe:
Additional sources of funding
Capital funding from state/territory government
Capital grant(s) allocated in previous ACAR(s)
Zero Real Interest Loans allocated in previous ACAR(s)
Other additional sources of funding
Describe:
Total funds

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4.6 Current status of funds negotiations.

Discussions held / Agreement
in-principle / Contract in place / Other (Provide detail at Question 4.5) / Have you attached evidence?
If borrowings are planned, indicate, by ‘checking’ one box only, the stage your negotiations have reached with the proposed lender.
Internal sources / Select oneYesNo
External sources / Select oneYesNo
Bridging finance / Select oneYesNo

This form is approved under paragraph 13-1(c) of the Aged Care Act 1997 Page 13 of 13

PART B – SECTION 5: FINANCIAL INFORMATION – SERVICE LEVEL

SERVICE LEVEL

5.1 Operating surplus (deficit) – projections for the residential aged care service.

A / B / C / D
In columns B, C and D please insert the date in the following format dd/mm/yyyy / Actual position
As at
30 June 2015* / Forecast situation immediately BEFORE places are operational
As at / Forecast situation immediately AFTER places are operational**
As at / Forecast situation at the financial year end when max occupancy is achieved
As at
$ / $ / $ / $
Income
Expenses (not including interest payments)
Interest payments (including interest associated with a Zero Real Interest Loan)
Operating surplus/(deficit)
Depreciation on buildings
Depreciation on plant and equipment
Zero Real Interest Loan principal repayments
Other debt principal repayments
NET Accommodation bonds, refundable accommodation deposits and refundable accommodation contributions
Total number of operational places
Total number of provisional places
Total number of places

* If your organisation’s financial year ends on a date other than 30 June, please provide your forecast in accordance with your financial year end. That is, please do not adjust your actual/forecast position to 30 June.

** For applicants with multiple applications for places, this would represent the financial year end closest to when the majority (at least 50 per cent) of the organisation’s new places are expected to become operational.

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5.2 Describe the assumptions underlying the projections.

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Word limit 150

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5.3 Outline how your organisation will fund any operating deficit or cash flow shortfall.

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Word limit 150

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5.4 Service overview.

A / B / C / D
In columns B, C and D please insert the date in the following format dd/mm/yyyy / Actual position
As at
30 June 2015 / Forecast situation immediately BEFORE places are operational
As at / Forecast situation at the financial year end immediately AFTER places are operational
As at / Forecast situation at the financial year end when max occupancy is achieved
As at
Number of allocated places
Number of unfunded places
Total places
Total residents
Occupancy rate (%)
Number of residents paying accommodation bonds, refundable accommodation deposits and refundable accommodation contribution
Number of residents paying daily accommodation payments and daily accommodation contributions
Liability for accommodation bonds, refundable accommodation deposits and refundable accommodation contributions ($)
Reserve funds for the service ($)

This form is approved under paragraph 13-1(c) of the Aged Care Act 1997 Page 13 of 13