Home-Delivered Meals

Home-Delivered Meals Frozen, Bulk, Emergency and Pre-plated Revised 2010 Table of Contents Section A. Definition, Purpose, and Legal Basis 1. Home-Delivered Meals Definition 2. Homebound Definition 3. Purpose 4. Legal Basis B. Eligibility C. Unit of Service 1. Home Delivered Meals 2. Nutrition Education 3. Nutrition Counseling D. Support Activities 1. Nutrition Screening 2. Nutrition Education 3. Nutrition Assessment and Counseling 4. Contributions E. Location F. Access 1. Waiting List Policy for home-delivered Meals 2. Fee for Service Meals Termination from the Program G. Service Delivery 1 State Meals Contract with sole vendor 2. Regular Meals 3. Frozen Meals 4. Emergency Shelf-Stable Meals 5. Medical Nutrition Therapy- (Liquid Meal Replacement) H. Special Meals Billing 1. Holidays/Special Days 2. Emergency Shelf-Stable Meals 3. Medical Nutrition Therapy – (Liquid Meal Replacement) I. Alternate Vendor J. Supplies: Ordering, Handling, and Storing K. Staff L. Training M. Records 1. General 2. Documents to Reconcile 3. Program Information 4. Participant Information N. Reports 1. Site to AAA or Service Provider 2. AAA to DAAS 3. Vendor Reports 4. State Reports O. Vendor Credits and Penalties 1. Credit 2. Penalties P. Monitoring 1. MS Department of Health 2. MS Department of Human Services AAA 4. Vendor A. Definition, Purpose, and Legal Basis 1. Definition – A home-delivered meal is a hot, cold, frozen, or other appropriate meal provided to an eligible homebound person in his/her home which (Older Americans Act of 1965, as amended (OAA), Section 336): a. Complies with the most current Dietary Guidelines for Americans published by the Secretaries of the United States Department of Health and Human Services and the United States Department of Agriculture (OAA, Section 339(1)); and b. Provides a minimum of thirty-three and one-third percent (33a%) of the dietary reference intakes (DRIs) as established by the Food and Nutrition Board of the National Research Council of the National Academy of Sciences (OAA, Section 339(2)(A)); and c. Is provided for a minimum of five meals per week, fifty-two weeks per year. Meals may be delivered daily or once a week to allow AAAs/service providers to serve eligible homebound adults who live in very rural, isolated, hard to reach areas and who would not receive a meal otherwise. 2. Definition- AoA defines a homebound person as an individual for whom leaving home is a major effort, who is normally unable to leave home unassisted, and when they leave home it is to get medical care or for short infrequent non-medical reasons such as a trip to get a haircut, or to attend religious services. Homebound is not a permanent classification nor is it based on transportation availability. 3. Purpose a. Provide eligible homebound, functionally impaired persons, particularly those in greatest economic and social need, low-income minorities, older individuals with limited English proficiency and those at nutritional risk (because they cannot afford to eat adequately or lack the knowledge, skills, mobility, or motivation to obtain and/or prepare adequate food), with five (5) or more nutritious meals per week at the lowest reasonable cost. b. Promote the physical and mental health and well-being of older adults through improved nutrition; and c. Enable eligible persons to maintain their self-sufficiency and quality of life, remain at home as long as possible, and avoid or delay institutionalization. 4. Legal Basis a. Title III- The legal basis for the operation of the Elderly Nutrition Program is found in the Older Americans Act of 1965, as amended (OAA), Title III, Part C; and the Code of Federal Regulations, Title 45, Part 1321, as amended (45 CFR Part 1321). b. Home delivered nutrition services to the homebound are specified under Title III, C-2, Section 336, however may be paid for by other state, local and federal funding sources. c. NSIP - Section 311 authorizes the Nutrition Services Incentive Program known as (NSIP), which provides supplemental funding for congregate and home delivered meals served under Title III in the form of cash in lieu of commodity foods to provide incentives for the effective delivery of nutritious meals to older adults, for meals which meet OAA requirements. NSIP funds may only be used for the purchase of agricultural commodities and other foods produced in the United States. (1) NSIP funds are no longer under USDA oversight and should not be referred to as a USDA program or USDA reimbursement. (The Consolidated Appropriations Resolution, 2003, Public Law 108-7, amended the OAA to transfer the NSIP from the USDA to the Administration of Aging (AoA) within the Department of Health and Human Services. (Sec.311, OAA 2000)). (2) The AAA MAY use NSIP funds for food purchases from U.S. sources, or as in the case of vendor-contracted meals at a set price, in general up to 1/3 of the cost of an entire eligible meal including transportation and labor; served to eligible participants. A meal is required to meet the OAA nutrition requirements stated in Part 1, Section 1 of this document; and Served to individuals who meet the eligibility requirements stated in Part II, Eligibility; and Who is not means tested; and Who is provided the opportunity to voluntarily contribute to the cost of service. (3) The AAA MAY NOT use NSIP funds for the following: Incomplete meals IF an alternate vendor is NOT used to fill the shortages or complete the meal; Second meals/helpings served to participants or Any meals served to guests or staff under 60 years of age or to anyone else who is not an eligible participant, regardless of age or circumstances. Any means tested programs such as Medicaid waiver and CACFP. d. Title XIX Medicaid Waiver- While a home-delivered meal funded by the Medicaid waiver program does not fall under Title III standards, a client may not receive a duplication of services in the form of a meal from both Medicaid waiver and Title III. If a participant qualifies for a meal under Medicaid waiver, this will be the first and only choice for meal funding. If they are not deemed eligible for Medicaid waiver they can be assessed for a meal under Title III. This is effective for both Title III home-delivered and congregate meal service. AAAs are required in their area plans to establish procedures for coordination of services with entities conducting other federal or federally assisted programs for older individuals at the local level, and shall include language addressing how they will prevent duplication of meal service from different funding sources and how they will monitor this. (Sec. 306 (42 U.S.C. 3026)) B. Eligibility (OAA, Section 307(a)(13)(A), (B), and (I); 45 CFR 1321.69) 1. When eligibility is determined by trained personnel and documented on a current Consumer Information Form (CIF), on file, or documented in the RTZ GetCare system, home-delivered meal services SHALL be available to the following potential service recipients: a. Any person who meets the OAA definition for homebound (Section A, 2), with a Level II score of 22 or above determined on a current Mississippi Consumer Information Form; and b. That person is 60 years of age or older; or c. The legal spouse of eligible persons as stated above, regardless of age, who will receive a meal. (The screening form of both the participant and the spouse must be clearly noted to link them together to show why the spouse receives a meal.) 2. Provided all eligible potential home-delivered meals recipients and their spouses are served and there are none on the home-delivered waiting list (See section F, Access), then home-delivered meals MAY be made available to: a. Disabled persons, regardless of age, when the disabled person resides at home with an older eligible participant, and there is a notation on the screening form specifying circumstances, with b. A disability being defined as a mental or physical impairment, or a combination of mental and physical impairment(s), that results in substantial functional limitations in one or more areas of major life activity such as self- care, learning, mobility, capacity for independent living, cognitive functioning, etc. Note: IF a meal is provided to a volunteer who regularly delivers meals to the homebound and IF providing a meal to a volunteer does not deprive an eligible homebound older person from having a meal, the volunteer=s meal shall be charged to the congregate meal budget, provided it is eaten at the site. The volunteer’s meal may not be charged to Title III, C-2, home-delivered meals. C. Unit of Service 1. Home-delivered Meals - One meal served to an eligible person is one unit of service. 2. Nutrition Education – as defined in” Section D Support Activities”, is entered in to the current state approved client tracking system as one unit per health education disease prevention or nutrition information. ‘Nutrition Education Unit’ is a required reporting area for the NAPIS report. 3. Nutrition Counseling – Entered into the current state approved client tracking system, is defined as one individualized session per participant provided by a medical doctor or designated health professional including a registered dietitian, and required on NAPIS reporting. D. Support Activities 2. Nutrition Screening-(OAA, Section 339(2)(J)) What and When - Nutrition screening is completed by trained personnel on every recipient of the Older Adults Nutrition Program through the Nutrition Risk Assessment of the Consumer Information Form (CIF) and/or the current state approved client tracking system The Nutrition Risk Assessment is comprised of the twelve questions in this section. Two scores are derived from the CIF. d. Nutritional screening is completed initially per CIF instructions and updated annually along with the CIF update. e. A Nutritional Risk Assessment score, with a possibility of 0 to 6 points, indicates the potential for nutritional concerns and risk. Nutrition risk scores are a required field and compiled and filed for the NAPIS report. This score contributes to the Total Consumer score. f. The Total Consumer score, which is the sum of all scores on the CIF, will determine participant level of services, including meals service. g. A Nutrition Risk Assessment Score of 6 or greater, which is defined as high risk by the OAA, signals the need for further nutrition intervention, such as referral to a medical doctor, or registered dietitian for nutritional assessment and counseling. High nutritional risk is not a single qualifying condition for home-delivered meals. A diagnosis of diabetes automatically places the participant at high nutritional risk with a score of 6, but again does not mean a home delivered meal is required. 2. Nutrition Education (OAA, Section 307(a)(13)(J), Section 336) a. What and When - Nutrition education is printed and verbal information about food and nutrition sent to the homebound participant and their caregivers, at least quarterly, which promotes good health practices and encourages general well-being. It may also be a home visit by a practitioner who would deliver a nutrition education event at a congregate site, such as a nurse, registered dietitian or extension agent. b. Documentation of the material topic and delivery date(s) shall be retained. c. Expenses, if any, shall be anticipated and included in the program budget. 3. Nutrition Assessment and Counseling (336, 339 (J)) NOTE: THE ACTIVITIES IN THE FOLLOWING SECTION ARE RECOMMENDED BY THE NEWEST REVISION TO THE OLDER AMERICANS ACT; HOWEVER DUE TO LIMITED FUNDING AND RESOURCES, MAY NOT BE FEASIBLE AT THIS TIME. WHILE THESE ACTIVITIES ARE NOT REQUIRED, DEVELOPMENT IS ENCOURAGED. a. What and When – (1) A more specialized activity, which may be included as a component of the nutrition education program. The provision of professional, individualized advice and guidance to individuals who are at nutritional risk because of their health or nutritional history, dietary intake, medications use or chronic illnesses, about options and methods for improving their nutritional status, performed by a Registered Dietitian (RD,LD), working with the individual’s physician as appropriate, in accordance with state law and policy. (2) Participants who are designated at high nutritional risk on the Nutrition Risk Assessment section of the CIF, through scoring a 6 or above, or have a diagnosis of Diabetes Mellitus are candidates for follow-up nutrition assessment and counseling. (3) Participants at high nutritional risk shall be referred to the appropriate health professional within six months of entry into services. b. Who and How – At this time, individual dietary evaluation and counseling for therapeutic needs is not provided directly. Participants needing these services are to be referred to a local hospital, their private physician or a registered dietitian. The AAA will assist in making this referral. (1) As this component of the OANP Nutrition Program is developing, clients may be referred to their individual physician until funding and/or contract services with a Registered Dietitian (RD, LD) are available. These services may be funded from III-D, Preventive Health budget. (2) The health care provider may choose to follow-up though his/her office, or refer the participant to a register dietitian. (3) The AAA/service provider may partner with a registered dietitian (RD/LD) through the local hospital, medical groups, a home health agency or private contractors. (4) Participants with a diagnosis of diabetes may be referred to a Registered Dietitian, Certified Diabetic Educator or a local diabetes self-management class. c. Documentation - A notation will be made on the CIF and/or the nutrition screening notes section of the current state approved client tracking system stating to whom the client was referred and the date referred. 4. Contributions (OAA, Section 307(a)(13)(C)(i)(ii); 45 CFR, 1321.67, and Sec. 315 (b)) - Participants shall be encouraged and provided an opportunity to contribute voluntarily and confidentially to the cost of the meals for the express purpose of expanding nutrition services. AAAs/service providers may develop a suggested contribution schedule, but shall not deny any eligible person a meal if he/she is unable or unwilling to contribute to the cost of the service, nor require disclosure of financial status. a. Suggested Collection Procedure - AAAs/service providers may want to send small, plain envelopes bearing the address of the AAA, to the homebound at regular intervals at the time meals are delivered. Recipients would then have a simple, sealable receptacle in which to place their anonymous contribution and could, at their convenience, give the sealed envelope to their meal delivery person who, in turn, would deliver the envelope(s) to designated personnel who account for program income; or mail it. b. Safekeeping and Documentation Procedure – Due to the variety of delivery methods within each AAA, it will be the responsibility of the AAA to develop a written procedure to address safekeeping of contributions. E. Location - Home-delivered meals, nutrition screening and nutrition education are provided in the eligible person=s home. F. Access - An eligible person may enter the service system through appropriate referral. 1. Waiting List for home-delivered meals-Each AAA is required to have a waiting list policy for home-delivered meals in their Area Plan, to include in the criteria; a. All potential participants for home-delivered meals will be screened for their need for home-delivered meals by completion of the Consumer Information Form (CIF). Participants who do not meet all the eligible requirements for home-delivered meals shall not be placed on the list. b. Priority of service, which takes into account quality assurance standard criteria, date of request for services and score on the Consumer Information Form. Current documentation will be maintained at the AAA through the current state approved client tracking system. Criteria to consider are: (1) Determination that the participant is homebound; (2) Determination that the participant is able to care for himself, including procurement and preparation of meals, (3) Determination that a member of the participant’s household is able to prepare the participant’s meals without causing undue stress to the household member; (4) Available transportation 2. Fee-For-Service Meals – Meals purchased at full cost by a participant. These meals may not be counted as Title III meals for reporting purposes on NAPIS nor for NSIP. a. Eligible for Home-delivered Meals - The AAA may make available to individuals who meet the criteria for a home-delivered meal, and who are on the waiting list, the option of purchasing a home-delivered meal. The participant will pay for the full cost of meal until the participant no longer needs the meal and cancels the service; or they reach the top of the waiting list and subsequently stop paying for the meal. This information must be clearly documented on the Consumer Information Form. b. Not Eligible for Title III Home Delivered Meals – A person who is 60 years or older, or their spouse, who does not meet the criteria for a home-delivered meal, but still desires one, for example, due to lack of transportation, may pay full price for a home-delivered meal. It must be clearly documented on their Consumer Information form that they do not meet the criteria, but they are a fee-for-service client. 3. Termination from the Program – Home-delivered meal service is not designed to be a permanent classification. Each AAA will establish a system delineating the criteria for termination of a participant from the home-delivered meals program. Once a participant is placed on the program, they will be reassessed at a minimum, annually. The AAA may elect to reassess quarterly or biannually if they have a long waiting list. When a participant is terminated from this service, the rationale will be documented on the participant’s Consumer Information Form. Recommendation for termination can be made by program staff with approval from the AAA director. Rationale for termination: a. Determination that the participant is not homebound; b. Determination that the participant is able to care for himself, including procurement and preparation of meals, and no longer need the service; c. Determination that a member of the participant’s household is able to prepare the participant’s meals without causing undue stress to the household member; d. Repeated failure of a participant to eat the meals, eat the meal in a timely enough basis to prevent spoilage, or to prohibit safe storage; e. Repeated failure of the participant to admit the delivery person, or be present at time of delivery or exhibition of hostile behavior by themselves or another occupant of the dwelling, which prevents the delivery person from determining whether the meal is accepted; f. Successive absence of the participant from his/her home when delivery is made without sufficient notification to the program G. Service Delivery 1. a. State Contract for Meals-Mississippi elects to contract with a sole statewide vendor through means of an open bid RFP process. All meals provided through the Older Adult Nutrition Program must be provided by the selected vendor. b. The exception to this rule are the few adult day care sites which have been grandfathered-in and self-prepare their meals. The AAA must request a waiver annually at the new fiscal year for these programs. No other programs may start a self-preparation site as this weakens the state contract and value pricing. Existing self-preparation sites must meet all food safety and sanitation standards of a food service establishment and have a ServeSafe certified employee on duty during service and preparations hours. 2. Regular Meals a. Regular Days -Meals that may have hot, cold, or room temperature components, not frozen, shall be delivered to the homebound five (5) days a week, 52 weeks a year. (1) Hot, bulk meals delivered from the vendor to a congregated site may be packed into appropriate containers and sealed for individual meal delivery. Appropriate portion sizes of the complete meal, at the appropriate temperatures will be placed in separate hot and cold thermal carriers to be delivered to the home. (2) Pre-plated meals are prepared and heated at the vendor facility and transported at ready-to-serve temperatures to a congregate site or directly to the home. They are held in a thermal carrier until delivery. Pre-plated meals are beneficial when a hot home-delivered meal is desired but facilities at the congregate site are not appropriate for bulk meal service, or the participant is not able to store or heat meals at home. (3) Special precautions must be taken, as outlined in Food Safety and Sanitation Manual, to ensure proper temperatures are maintained throughout the delivery process. (4) At sites from where both congregate and home-delivered meals are served, there must be a clear documentation trail showing that home delivered meals are paid for from Title III, C-2 funds and the congregates meals from C-1. b. Holidays and Special Days - Shelf stable meals in single units shall be delivered to homebound participants during the holidays designated by the DAAS, on days when field trips and outings are planned for congregate participants, any time that an unplanned emergency may occur, and/or any other time when the sites may be closed for any reason. (See Section 3 below for the Emergency Meal Protocol.) c. Meal Orders, Deliveries and Invoicing, and Meal Order Changes (1) Meal Orders for home-delivered meals on those days when sites will be closed shall be placed by the AAA nutrition coordinators/service providers (not site managers) via fax or e-mail (not the phone) at least two (2) weeks prior to the time they will be needed. (2) Deliveries of shelf-stable meals should be up to two (2) days before the holiday or closing. (For example, when a holiday falls on Monday, shelf-stable meals should be delivered on the prior Thursday to allow for corrections to be made on Friday.) The vendor=s invoice will reflect the meal delivery date, not the date participants are expected to consume the meals, and the AAA shall reimburse the vendor accordingly. (3) Meal Order Changes shall be made only in emergencies such as a death or placement of a participant into the hospital, nursing home, etc. Changes must be made to the commissary via fax or e-mail by AAA nutrition coordinators/service providers (not site managers) no later than 2:00 p.m. on the day before the change is to take effect. The vendor is not expected to honor phone orders/order changes or messages relayed through delivery personnel. 3. Frozen Meals a. Five-pack or seven-pack meals contain different frozen meals with appropriate components, are packed in a larger box, and are delivered in bulk quantities to sites or participant homes one (1) day a week. Meals are in trays that can be re-heated in a conventional oven or a microwave oven. It is the responsibility of the AAAs to assure that recipients have adequate storage and heating facilities and are able to prepare frozen meals by themselves or have available assistance. b. Meal Delivery Options available to AAAs/providers who provide frozen meals: (1) Nutrition Site - The vendor shall deliver 5-pack/7-pack frozen meals in bulk quantities one day a week to the sites from which staff, volunteers, and/or family members deliver them to the homebound. It is the ultimate responsibility of AAA to provide thermal protection for both hot and cold, not the vendor. If the AAA contracts with a provider, the AAA will insure the provider complies with all delivery requirements. (See equipment requirements in Food Service Safety and Sanitation Manual.) Meals must be transported in appropriate thermal protection carriers, regardless of the delivery time. (2) Door-to-Door - The vendor shall deliver 5-pack frozen meals directly to the recipient homes one day a week. If this option is chosen, the AAA(s) and the vendor shall make their own business arrangements, including having correlated software and/or any other tool(s) that will benefit each in meal verification, data collection, invoice reconciliation, and other record keeping. 4. Emergency Shelf-Stable Meals a. What - The emergency shelf stable meal will consist of the meal and powdered milk, or the meal and bottled water, without the powdered milk package, depending on the emergency situation and current state meals contract specifications. It is recommended that shelf-stable meals be ordered as single packs, which will reduce waste from unnecessary meals being given out, however they can be ordered as a five-pack. b. Goal - Each AAA impacted by hurricanes and any AAA who determines their participants may be affected in any way by extreme weather that will interfere with regular delivery of services, is to arrange with the vendor for shelf stable meals, optional water procurement, and their delivery prior to the emergency. c. Responsibility - The AAA shall assume the responsibility of assuring that all homebound participants have nourishment in bad weather or other emergencies when regularly scheduled meals cannot be delivered by the vendor. AAAs shall either (1) provide the homebound with emergency shelf- stable meals detailed below or (2) make other arrangements such as neighbor watch, church care, a buddy system, etc. d. Ordering, Delivering, and Invoicing - It is recommended that yearly, each affected AAA order approximately 1000 shelf stable meals to be spread out between the AAA office and senior centers or locations within the AAA network that are strategically located, accessible during adverse weather, and have adequate, safe and weatherproof storage. (1) Order Timeline for Hurricane and Summer/Fall Emergencies: April 15- Notify the vendor of total shelf stable meal numbers and delivery sites. July 1-Latest delivery date to designated locations. (Ex. July- December). (2) Order Timeline for Winter Weather Emergencies: September 15- Notify the vendor of total shelf stable meal numbers and delivery sites for AAA’s who experience power failures and transportation problems due to the weather for delivery during November 15- Latest delivery date (Ex. November-April). (3) Pre-delivery of Meals to all Current Participants - It may be deemed appropriate by your agency that a portion of these meals be delivered to home-delivered and congregate site participants to be kept at their homes during the storm season, to avert last minute deliveries during bad weather. Instructions shall be given to participants that these meals are for emergency consumption for days they will not be receiving a meal or attend a meal site. It will be up to the participant to save the meals for this, but you will have provided the meal to them. It is recommended that 2-3 days of shelf-stable meals and water be issued to each participant at the onset of the storm season. Thus, if the home-delivered meal schedule must be delayed for a few days or a site cannot be open again for a few days due to power outages, each participant has food and water. Home-delivered emergency meals that are not consumed in the course of an emergency may be consumed as a breakfast or dinner and counted on those designated days. (See special billing for emergency meals section H, 2) (4) Invoicing - The vendor=s invoice for the shelf-stable meals will reflect the delivery date, not the date it is anticipated that participants will consume the meals, and the AAA shall reimburse the vendor accordingly. (See special billing for emergency meals section H, 2) b. Meal Changes When Threat is Imminent - The above mentioned shelf stable meals are meant to be an emergency supply when regular meal delivery is not possible. When a hurricane is deemed to be approaching, the AAA may request from the vendor that regular frozen and hot meals be replaced by shelf stable for a period of a week or ‘ongoing until further notice’. As we usually know several days or a week in advance if we are potentially facing a hurricane, contact the vendor as early as possible to make this change. Again, they will not automatically substitute shelf-stable meals for frozen or hot, nor will they necessarily produce shelf-stable meals in anticipation of your need. Stay in contact with your vendor’s Commissary Manager regarding any necessary changes in delivery schedule and location. Evacuations may prevent meal delivery and alter your service numbers. Keep the State Unit on Aging informed of your emergency plans as they progress. We are in direct contact with MEMA and the governor’s office and must provide regular updates. This way we can also assist you and facilitate communication between all parties involved. c. Meals Not Used - Shelf-stable meals not be needed for an emergency shall be used for the next holiday, picnic, special event or interspersed with regular meals. Shelf-stable meals must be kept in well-ventilated and pest-free dry storage areas at normal room temperature so that contents will remain intact without refrigeration; they should not remain in stock longer than six (6) months. d. Nutritional Content - Shelf-stable meals are ordered with emergency use in mind, however as stated above, in the event of not being used they will be served out rather than wasted. Emergency meals are nutritious and may be funded by Title III and NSIP when served to eligible participants. A complete nutrient analysis is on record at the State Unit of Aging. e. Special Considerations - for the general aging population in times of disaster - These meals are for distribution to any seniors aged 60 or over or their spouses living in the AAA’s service area during times of emergency, regardless if they already participate in your meals program. Service providers, case managers, neighbors, law enforcement, medical services… all may be referrals for people who need these meals. Do not focus only on participants you currently provide meals to. You have already identified their needs. 5. Medical Nutrition Therapy-Liquid Meal Replacement (MNT) a. Definition and Legal Basis (Federal Register, June 17, 1996; Use of Medical Food and Food for Special Dietary Uses in Elderly Nutrition Programs, National Policy and Resource Center on Nutrition and Aging, June 14, 1996) Medical Nutrition Therapy-Liquid Supplements, defined by the Orphan Drug Amendment of 1988, Public Law 100-290, is Afood which is formulated to be consumed or administered entirely under supervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation.@ Medical Nutrition Therapy- is NOT products such as Slim Fast, Sweet Success, etc. Medical food also differs from common dietary supplements of vitamins and minerals in that medical food provides macro nutrients such as protein, carbohydrates, fats, calories, in addition to vitamins and minerals. b. Use - Liquid nutritional supplements such as Ensure, Ensure Plus, Boost, etc. may be provided to terminally ill or other eligible homebound persons who can no longer process regular food or who are at nutritional risk because of a condition, illness, or injury IF the guidelines below are strictly followed: (1) A physician, registered/licensed dietitian, or other qualified health professional evaluates the person initially, recommends/prescribes a liquid supplement, and permits the person and/or his caregiver to participate in the decision; (2) The product is within the legal and medical definition of medical food/nutritional supplements as stated in federal law; (3) The recommended product contains at least 1/3 DRI and is the only food provided and consumed at a meal, The supplement may not be consumed in addition to other food paid for with Title III funds; (4) The medical food is just one component in an overall comprehensive care plan that is in writing and on file; and (5) The MD himself, or an order is written for a registered dietitian or other health professional to review the client’s intake of the supplement, toleration and continued need for the nutritional supplement with periodic reevaluation, no longer than six months, who updates and files the written updated care plan c. Funding and Supplier – MNT-Liquid supplements may be paid for from federal funds granted to the DAAS and the AAAs. However, each AAA/service provider shall make its own business arrangement with the vendor or another source for the provision of supplies. H. Special Meals Billing 1. Holidays/Special Days - Holiday and special day meals shall be recorded for billing and reimbursement on the day(s) the vendor delivers the meal(s) to the site or home, not the day(s) the participant is supposed to consume the meal(s). (For example, if a holiday falls on a Monday and the holiday meal is delivered on Thursday or Friday the week before, the vendor=s invoice will list the billing date as the Thursday or Friday the meals were delivered, not the Monday holiday.) 2. Emergency Meals-Emergency shelf-stable or frozen meals shall be recorded for billing and reimbursement on the day(s) the vendor delivers the meals to the sites or the home for distribution to the participants, not the date(s) participants are expected to consume the meal. Because participants may receive more than one meal each day (not two meals at the same meal), recording two (2) units for a participant for a day is allowed as long as sign-in and delivery sheets show clearly that a supply of emergency meals were delivered to the participant. 3. Liquid Meals - Liquid meals shall be recorded for billing and reimbursement on the day(s) the vendor delivers the meals to the participants. I. Alternate Vendor 1. AAA Nutrition Coordinators/service providers/site managers may purchase meals or portions of meals from an alternate meal source to substitute for meals ineligible only in the following situations: a. The vendor fails to deliver any meal(s)*, or an entree which is equal in value to an entire meal, or any other portion of the meal(s); b. All or any portion of the meal(s) is deemed unacceptable, for any reason(s), including time temperature violations; c. Meals are not delivered by 11:15 a.m. and/or according to the specifications in the contract executed by the vendor and the DAAS. * Frozen Meals Exception - If, after frozen meals have been delivered to recipient homes, it is learned that they lack components or contain unacceptable components, the vendor shall discuss the matter with the AAAs and make the adjustments to the invoice accordingly. 2. Payment - If an alternate meal source is used, the AAA shall pay the alternate meal source(s) or individual who paid for the meals per AAA policies. The AAA will bill the vendor the contract price of the food replaced, less the mileage expense, for picking up food from the alternate meal source. 3. Commencement - The AAA will maintain a list including the complete name(s), mailing address(es), and phone number(s) of prospective alternate meal sources in their site areas to be used when meals or portions of meals need to be replaced. The vendor will be notified when alternate meals have been ordered and the reason. 4. Agreement - The AAA will maintain an agreement with the prospective alternate meal source(s). The AAA Nutrition Coordinator shall send the list to their service providers and/or site managers. 5. Food Substitution -At the beginning of the contract, the vendor shall provide the AAA Nutrition Coordinators/service providers with a food substitution list so that food purchased from an alternate meal source, in the event of default by the vendor, may be of like value to that being replaced. 6. Credit - When an alternate meal source is NOT used to replace vendor shortages, the vendor shall issue a credit to the AAA based on the following allocations: Food Group Meal Cost Percentage Meat/Meat Alternative 100% Fruit/Salad 15% Milk 15% Vegetable 10% Dessert (other than fruit) 10% Bread/Bread Alternative 5% Margarine 2% Condiments 2% CACFP reimbursed meals, provided through Adult Day Care Centers may not be credited, all components must be provided for the meal. 7. Alternate Meal Sources - Should alternate meals be obtained, that is, not from the state contract approved meals vendor, the alternate meals must be procured from a licensed food service establishment with a current ‘A’ rating from the MS State Department of Health, exhibited by a copy on file at the site. A copy of the establishment’s health inspection must be obtained before food may be served. This may be obtained from the MS State Department of Health website for all licensed food establishments. J. Supplies: Ordering, Handling, and Storing - AAAs/service providers/site managers shall keep one week=s disposable home-delivered supplies on hand at each site at all times and order necessary supplies from the vendor on the day/time schedule requested by the vendor. 3. If due to storage or delivery limitations, this schedule is not beneficial to both the site and the vendor, an alternative arrangement for supplies is acceptable, if both parties are in agreement. 2. Site personnel shall make every effort to safeguard all supplies from pilferage and/or inappropriate use, such as packing home-delivered meals in congregate supplies or serving congregate meals in home-delivered supplies. The vendor shall maintain an ongoing record of supplies delivered to each site. 3. Supplies shall be commercially packaged for individual use and shall be stored at the site in closed containers on clean shelves above the floor and handled in a way that they are protected from contamination at all times. Supplies may not be stored on the same shelf, next to or below chemicals. K. Staff -There shall be an adequate number of staff to manage the program=s fiscal and administrative responsibilities. Records for documenting in-kind match shall be kept of volunteers= time and activities. 1. Registered Dietitian - The meals program shall be operated under the direction of the DAAS registered and licensed dietitian (RD, LD) at the state level. Menus and nutritional information is prepared by a registered and licensed dietitian. AAAs and local service providers may contract with a registered dietitian to provide nutritional counseling and assessment of high nutritional risk participants. 2. Nutrition Coordinator - The AAA nutrition coordinator shall oversee the management and administration of the entire meals program. She/he or the service provider shall determine the supervisory functions of the site managers; plan training in food service safety and sanitation techniques and practices for all site personnel, including volunteers; and consult with the dietitian when desired and as necessary. 3. Site Manager - The site manager shall direct the day-to-day details and logistics of the entire meal program under and according to the oversight of the AAA nutrition coordinator/service provider. 4. Volunteers may be recruited and shall be supervised. Volunteers who handle food, including delivery must adhere to all food safety and sanitation requirements. 5. Delivery Drivers for congregate feeding sites that also serve as distribution points for home-delivered meals, delivery drivers hired by the AAA or service provider must adhere to all standards of food safety. L. Training - The following training is required; training documentation shall be retained; and sufficient funds shall be budgeted to cover training expenses, if necessary: 1. Personnel Orientation and In-service Training - All paid staff and volunteer food service workers shall have orientation training prior to working in the program and at a minimum, annually therafter. AAA nutrition coordinators/service providers shall plan and schedule the training which shall include, at a minimum, the following: c. Nutrition Coordinator/Service Provider - Routine management and administrative procedures, record keeping systems, reporting requirements, program requirements and sanitation and food safety and meal service; d. Site Manager – (1) Food safety and sanitation based on the The Food Safety and Sanitation Standards Manual for the OAA Nutrition Program; (2) Meal service, with detailed instruction on congregate meal service requirements, counting and claiming, participant eligibility, and correct food portioning using the Site Serving Instructions guide; (3) Site operations; (4) Site record keeping; (5) Contribution policy and cash reconciliation (6) Community resources; (7) Coordinating volunteers; and (8) Methods of referrals. c. Volunteers - Site procedures and various volunteer activities when they first enter the program and anytime thereafter as deemed necessary by the AAA/ service provider. Specifically, any volunteer which deals with the handling, distribution and/or delivery of meals must receive training on basic food safety and sanitation and meal eligibility. d. All Staff - Participant confidentiality; all aspects of food safety and sanitation; and procedures for handling emergencies – medical, fire or disaster, which includes being able to locate participants' emergency contact information and to evacuate participants safely. e. Any person who administers a Consumer Information Form must receive training, with documentation retained. 2. Nutrition Coordinator Training Opportunities – While not mandatory, the following are opportunities to learn and share regarding the Older American’s Act Nutrition Program. d. Quarterly Menu and Nutrition Program Meetings- While not mandatory, attendance by the nutrition coordinator at the quarterly menu meetings and the DAAS meetings that follow, as well as any other special meetings called by the DAAS dietitian is encouraged to allow input and discussion from all areas of the state, due to the rapidly changing Title III program. e. ServeSafe –While not mandatory, it is recommended that at least one person under advisement of the AAA, for example, a service provider or site manager, or the Nutrition Coordinator, for each AAA, be ServeSafe certified to act as a resource person and lead trainer due to the importance of food safety and sanitation in the high risk older population we serve. 3. Fire/Emergency and Evacuation Drills for participants should take place at least twice a year. 4. First Aid Instruction in general first aid, cardiopulmonary resuscitation (CPR), and the Heimlich maneuver is recommended for everyone working with older persons. M. Records 6. General - Adequate records shall be maintained on each participant to ensure the accuracy and authenticity of the number of eligible home-delivered participant meals served each day. To the greatest extent possible, all participant information and service records will be recorded in and all forms, sign-in sheets, and records should be drawn from the current state approved client tracking system. All records and reports shall be made available for audit, assessment, or evaluation on demand by authorized representatives of area, state, and federal agencies. Except for audit purposes, recipient confidentiality shall not be violated and information about or obtained from an individual shall not be disclosed without that individual's written consent. However, the individual shall not be denied services if he refuses to provide written consent. HIPPA requirements are to be followed. 2. Documents to Reconcile - To verify that homebound persons received meals on certain dates and to assure that the meals paid for were served to eligible homebound persons, the meal numbers on the following documents must reconcile: a. Signature Sheets (1) Specific Forms - Each AAA/service provider shall design and furnish to site managers/meal deliverers signature sheets (daily, weekly, or monthly) listing the names of all homebound participants (which must match the Monthly Client Service Report); the dates (or spaces to insert dates) when meals are to be delivered to each participant; and space for the signatures of the person(s) delivering the meal(s),the participant or caregiver receiving the meal, and the site manager who shall also put the date beside her/his name. The Daily Service Unit Form, large spacing, printed from the current state approved client tracking system is recommended or a similar form The signature sheets shall be retained for monitoring purposes. (The AAA/service provider may want to print the signature sheets on colored paper to easily distinguish home-delivered meal verification from other site paperwork.) (2) General Forms - For persons (perhaps differing each day/week) who pick up meals for family members, neighbors, or friends who are not on an organized route, the AAA/service provider shall provide the site with a general form on which to list (either pre-printed by the AAA/service provider or legibly handwritten) the date and the names of the meal recipients with a line/space beside the recipient=s name for the signature of the person who delivers the meals, attesting that he/she delivered the meal to that person on that date. (3) Consistent Forms - All documents verifying home-delivered meals shall be uniform in appearance within the AAA/service provider. Various odd pieces of paper devised at the site level, etc. will not be accepted as documentation, even if signed, except in an emergency. b. Monthly Client Service Reports (also known as AService Logs@) - AAAs/local service providers shall print and send a Monthly Client Service Report from the current state approved client tracking system to each site manager who shall complete and return it to the AAA/service provider who shall, in turn, reconcile by funding source the number of meals listed on the monthly report to the number of meals paid for. c. Meal Tickets d. Vendor Invoice 3. Program Information shall include: a. Signature Sheets addressed above; b. Waiting List of persons eligible for home-delivered meal service; c. Contribution Policy material provided to the homebound; d. Nutrition Education Documentation noting the topic and the date(s) sent; and e. Program Income Record noting the daily/weekly contribution amounts. 4. Participant Information is contained in the Consumer Information Form which shall: a. Clearly identify homebound status; b. Be completed prior to services being received, or if deemed an emergency, within three working days and, c. Be completed and updated annually (on the anniversary date of the participant=s entrance into the system OR at a single point in time, e.g. October) for continuation or termination of meal services with additional assessments made whenever necessary and/or appropriate, (AAAs may elect to reassess homebound status on a more frequent basis due to their waiting list policy.) d. Contain emergency information such as the participant=s family or contact person and a record of any special health, medical, or dietary needs, when appropriate; and e. List all services provided the participant in accordance with NAPIS/MIS reporting procedures f. Be entered into the current state approved client tracking system within ten days of completion. g. All forms with each previous form filed together kept at the AAA, and a copy of the most recent form kept at the site. N. Reports - 1. Site to AAA or Service Provider On Friday or the last food service day of each week, site managers shall mail to the AAAs the site=s delivery tickets and original sign-in sheets for that week, retaining a copy at the site. 7. AAA Nutrition Coordinator to DAAS AAA personnel shall enter all required meal count and nutrition information for NAPIS into the current software based on the previous month=s events and delivery ticket information. 8. Vendor Reports The vendor will provide to DAAS, in May and November, a Semi-annual Meal Numbers Report; and a Self-assessment Report, which includes the results of client satisfaction surveys administered prior to the second and fourth quarter menu cycles. 9. State Reports NAPIS reporting is crucial in representing Mississippi to the nation, in regards to OAA programs. The AAAs shall provide any additional information or reports requested by the DAAS. The current state approved client tracking system is an important tool in compiling accurate data. The state nutrition coordinator shall do a periodic statewide analysis of the vendor from information submitted by the AAAs. O. Vendor Credits and Penalties 1. The AAA MAY claim vendor credit IF: a. The vendor fails to deliver meals or portions of meals or fails to deliver meals by the stated time, or if meals or portions of meals are deemed unacceptable AND b. The site manager/service provider/AAA does NOT use an alternate vendor to fill the shortage. 2. The vendor shall credit the AAA according to percentages listed below: Meat/Meat Alternative 100% Fruit/Salad 41% Milk 15% Vegetable 10% Dessert (other than fruit) 10% Bread/Bread Alternative 5% Margarine 2% Condiments 2% 3. Penalties to Vendor - After three occurrences per site, at the discretion of the AAA, a penalty is permitted to be imposed upon the vendor, in addition to the cost the AAA bills the vendor for meal replacement. a. These occurrences reflect the most critical situations when the provider will impose the penalty of $100 per site, in addition to, the delivery cost of substitute meals, including salary, mileage and food purchase. Vendor must credit the Area Agency on Aging in each planning and service area as need arises. These occurrences include: (1) No meal delivery; (2) Meals arriving beyond the agreed upon time; (3) Meal shortages; and, (4) Sub-standard temperatures at point of delivery and /or unacceptable food quality. b. The penalty for Hot Home Delivered Meals will be $100 per 20 meals even if an alternate meal source is used. c. The penalty for Frozen Meals delivered to the site at any time other than the agreed upon designated date will include $100, plus one shelf-stable meal for each participant, the expense of paying a driver an hourly wage to deliver meals to participants, and vehicle mileage for delivering meals. This amount shall be credited to the AAA. P. Monitoring – 1. The Mississippi Department of Health, Division of Sanitation will annually conduct a site inspection of distribution sites and sites where meals are packaged for home delivery to determine food safety and sanitation standards are followed per the current Food Code. This is not a pass/fail inspection, however corrective action must be taken and follow up by the inspector will take place within the time period determined by the inspector. A report will be sent to the AAA. While some local health departments may maintain a schedule, it is the responsibility of the AAA or the provider to call for an appointment before an inspection has passed one year. The cost for this service, if any, shall be anticipated and included in the program budget. 2. The State Department of Human Services' Office of Monitoring/Program Integrity shall monitor once a year the: a. AAA nutrition program; and the b. Food service vendor. 3. AAA nutrition coordinators shall visit, observe and document: a. the vendor commissary during early morning hours once a year or as often as possible for the benefit of themselves and the overall nutrition program they manage; and b. all distribution sites for monitoring of proper storage techniques and equipment; and c. delivery routes which should be verified for time and excessive length, and proper transportation equipment; and d. any congregate sites from which home-delivered meals are served in bulk from, packaged frozen for home delivery or as a holding point for pre-plated meals. e. Utilize the current MDHS Office of Monitoring, Nutrition Sites Monitoring Tool - Older Adult Nutrition Program 4. The vendor shall conduct a site visit at 75% of all sites yearly. These include bulk, pre-plated and frozen routes. The vendor does not go to the home where the meal is delivered, however goes to the distribution site. Concerns about delivery schedules, particularly lengthy routes, can be followed up by observation. While monetary penalties are not incurred from these reports, the findings are meant to give the site, service provider and AAA knowledge of problems and potential problems on meal service, food safety and sanitation; as well as health inspections.