Adult Mental Health Initiatives (AMHI) Home and Community-Based Services (HCBS)-Federal Medical Assistance Percentage (FMAP) Quarterly Report

Quarterly Submission

The purpose of this survey is to collect progress data quarterly from AMHI HCBS-FMAP grantees.

This information is available in accessible formats for people with disabilities by calling 651-431-2460 or by using your preferred relay service. For other information on disability rights and protections, contact the agency’s ADA coordinator.

Q1	County/Region Name and Fiscal Agent:

Q2	Person Filling Out This Form:

Q3	Position:

Q4	Contact:

Q5	Reporting Date:

Please select the quarterly report that you are submitting (If you miss the due date, please submit your report, for the quarter it was due):

Due on 7/31/2023

Due on 10/31/2023

Due on 01/31/2024

Due on 04/30/2024

Responses to the questions below are needed in order for DHS to prepare Quarterly Reports that DHS is required to submit to CMS. Please include a response for every approved workplan category. (e.g., AMHI Coordination, renovations, technology, vehicle purchase and training).”

Q7	What activities have been started, continued, and completed with the HCBS FMAP funding this quarter?

Q8	Address the work plan progress on each approved category. Provide any requests to workplan if needed. Example: AMHI Coordinator, renovations, technology, vehicle purchase, and training.)

Q9	Is your HCBS FMAP grant spending on track? Is there a risk for grant underspending?

Q10	If there is a risk of HCBS FMAP grant underspending, what is the plan to address this?

Q11	Are there any key achievements or observations related to activities funded by HCBS FMAP funding this quarter?

Q12	What obstacles/barriers have you encountered related to activities funded by HCBS FMAP funding this quarter? How have you addressed them?

Q13	Is there technical assistance that DHS can provide?

Thank you for participating in the survey, please send any survey questions you have to MN_DHS_amhi.dhs@state.mn.us