Service Delivery Procedures and Characteristics 650-25-60-05

(Revised 7/1/23 ML #3733)

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Legal References:

• North Dakota Administrative Code Chapter 33-33-04.01 Food Code

• North Dakota Century Code Chapter 50-06 (Department of Health & Human Services)

• North Dakota Department of Health & Human Services Contract

• Public Law 114-144, Older Americans Act of 1965, as amended in 2020

• 45 CFR Part 1321, Grants for State and Community Programs

• 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, as applicable

• Older American Act Policies and Procedures manual located on-line at: http://www.nd.gov/dhs/policymanuals/65025/65025.htm

The contract entity must establish and administer nutrition services with the advice of the following:

• Licensed registered dietitian(s) or individual(s) with comparable expertise, including a licensed nutritionist, a dietary technician, or a certified dietary manager.

The contract entity must publicly display the menus at each congregate site as well as provide a copy to the home-delivered eligible individuals.

An older individual must be offered all the required menu components; however, the older individual does not have to take a specific menu component. If an older individual does not want a specific menu component, it should not be served or delivered. A meal is considered eligible based on nutritional content and not on how much is eaten.

 

New congregate meal individuals must complete the Congregate Meal Program Assessment form and Nutrition Screening Checklist. The contract entity may choose to allow a first-time guest to dine at the meal site without completing the Congregate Meals Program Assessment form and Nutrition Screening Checklist; however, the meal cannot be counted as an eligible meal and cannot be submitted for reimbursement.

 

Congregate meal reassessments must be completed annually (minimum) via:

• In-person (preferred method)

• Telephone

• Virtual

The Home-Delivered Meal Program Registration form must be completed for all eligible individuals. Initial determination of eligibility may be accomplished by telephone and an in-person assessment must be completed prior to or within ten working days after beginning meal delivery.

 

Home-delivered meal reassessments must be completed annually (minimum) via:

• In-person (preferred method)

• Telephone

• Virtual

Documentation must include the following but not limited to:

 

• Why the congregate and/or home-delivered meal reassessment was completed via telephone and/or virtual along with verification of continued eligibility.

• If the assessment was not completed in its entirety, i.e., individual refused to complete.

• If even one question is not answered, it must remain “not answered” in the web-based data collection site. Accessors may not make assumptions or guessing to the responses.

 

The Administration for Community Living (ACL) requires states to report in the annual State Performance Report (SPR) characteristic profiles by type of service(s) (Cluster 1 & 2 Services). ACL stresses the importance of collecting quality data to advocate for funding from Congress.

 

Older Individual’s records must be:

• In its own individualized file.

• Secured in a locked file cabinet, locked area, or in a secure computer that requires an access code.

   

Nutrition Screening

Congregate and home-delivered meal eligible individuals must be screened at initial registration for nutritional risk using the DETERMINE Nutrition Screening Checklist:

• The checklist is based on the following warning signs for poor nutrition:

  • Disease

  • Eating Poorly

  • Tooth Loss/Mouth Pain

  • Economic Hardship

  • Reduced Social Contact

  • Multiple Medicines

  • Involuntary Weight Loss/Gain

  • Needs Assistance in Self- Care

  • Elder Years Above Age 80

Screening results should be used for referrals to appropriate services and planning for nutrition education programs.

Screening must be conducted on an annual basis or sooner if needed for congregate and/or home-delivered eligible individuals.

 

Eligible Individuals who:

• Score six or more are considered high nutritional risk.

• Contract entities shall consider a referral to a healthcare provider or licensed registered dietitian for follow-up and possible nutrition counseling.

• Screening results and outcomes for all eligible older individuals must be recorded in the narrative section of the web-based data collection system.

 

Nutrition Education

Nutrition education defined by ACL, Administration on Aging, is “A program to promote better health by providing accurate and culturally sensitive nutrition, physical fitness, or health (as it relates to nutrition) information and instruction to participants, caregivers, or participants and caregivers in a group or individual setting.”

 

Nutrition education must be provided to both congregate and home-delivered individuals. A licensed registered dietitian or person with comparable expertise must provide input regarding the content of the nutrition education prior to the presentation or distribution of materials.

 

Nutrition education must be provided at each congregate site at a minimum of an annual basis. Some acceptable formats are, but not limited to:

• Nutrition one-to-one and/or group presentations.

• Nutrition printed materials.

• Nutrition videos.

• Food demonstrations.

• Cooking classes.

Nutrition education for congregate meal sites. Documentation must include:

• Meal site.

• Date of distribution.

• Presenter (as applicable) and topic.

• Number of individuals.

• Number of service units.

Nutrition education must be provided to home-delivered individuals at a minimum of an annual basis. Some acceptable formats are, but not limited to:

• Webinars.

• Printed materials.

Nutrition education for home-delivered meals. Documentation must include:

• A copy of the printed nutrition education material.

• Date of distribution.

• Number of individuals receiving the material.

• Number of service units.

Nutrition Education must be tracked in the web-based data collection site and the four most common types of events are:

1. Congregate meal individual;

2. Home Delivered meal individual;

3. Presentation(s); and/or

4. Face to Face/One-to-One individual.

Of these types, the first three will be recorded in consumer groups. For any face to face/one-to-one you will go to the older individual’s consumer record and record a unit of service in the service delivery section and select the “Subservice” One-to-One Consumer Event. Please note this service is in an older individual’s consumer record and not in a consumer group. Comments must be provided in the comment section in the service delivery section explaining what education was provided.

 

Expenses for the provision of nutrition education are included in the unit cost of a congregate and home-delivered are not a separate billable unit. Units of service and the estimated cost must be reported on the Monthly Data & Payment Report.

 

Contract entities are also encouraged to provide eligible individuals with available medical information approved by healthcare professionals, such as informational brochures and information on how to get vaccines such as COVID-19, influenza, pneumonia, and shingles, in the older individual’s community./

 

Nutrition Counseling

 

Nutrition counseling defined by the ACL, Administration on Aging, is “Provides personalized guidance to individuals who are at nutritional risk because of their health or nutritional history, dietary intake, chronic illness, or medication use. Nutrition programs can find resources and best practices for creating a supportive counseling process where goals and priorities are set, and the individual takes responsibility for self-care.”

 

Counseling is provided one-on-one by a registered dietician and addresses the options and methods for improving nutrition status with a measurable goal.

 

Menus and Menu Planning

 

All Title-III C1 & C2 meals must adhere to the current 2020-2025 Dietary Guidelines for Americans (DGAs) and Dietary Reference Intakes (DRIs). The DGAs are created by the U.S. Departments of Agriculture and Health and Human Services to provide advice on what to eat and drink to promote health, reduce risk of chronic disease, and meet nutrient needs. Recipes and menus that currently meet the DGAs and DRI requirements have been developed and approved by Dietary Solutions, Inc. All meals provided must:

• Provide a minimum of 33 percent of the DRIs if the program only provides one meal per day.

• Provide a minimum of 66 percent of the DRIs if the program provides two meals per day.

• Provide 100 percent of the DRIs if the program provides three meals per day.

Contract entities that do not use the menus developed by Dietary Solutions, Inc. must address the following before the menu/recipe can be implemented:

• A named dietician must develop the cycle menus (minimum of 4-week intervals) and recipes that comply with the 2020-2025 DGAs and meet or exceed the current DRI recommendations, and nutritional analysis must be submitted to Aging Services for approval.

• Menu items/recipes must provide a complete breakdown of the nutrition analysis by using appropriate computerized nutrition software (will show the nutrient values per meal or per recipe). Computer-assisted nutrient analysis ensures menus meet the nutritional requirements of the DGAs and DRIs.

• Submit the cycle menus, recipes, and nutritional analysis four (4) weeks in advance before being implemented.

The goal of healthy eating is a balanced diet including all food groups. The following five dietary components must be included in each meal when planning menus:

• Protein – One (1) serving of 3 oz. (after being cooked) equivalent per meal requirement.

• Fruits/Vegetables –One (1) serving per meal requirement.

  • One (1) serving is equivalent to:

    • ½ cup cooked, canned, or chopped raw fruits.

    • One (1) medium whole fruit (apple, orange, banana, etc.).

    • Half (1/2) grapefruit

    • 1/8 Melon

    • ¼ cup dried fruit

    • Four (4) ounces 100 percent vitamin C fruit

• Vegetables –Two (2) servings per meal requirement.

  • One (1) serving is equivalent to:

  • ½ cup cooked, canned, or chopped raw vegetables.

  • One (1) cup leafy raw vegetable (lettuce, spinach, etc.).

  • Four (4) ounces 100 percent vitamin C fruit or vegetable juice.

  • One (1) small potato or ½ large potato

  • Half (1/2) cup sweet potato, yams, corn kernels, squash, peas, or lima beans.

• Grains – Two (2) serving per meal requirement. Grains should be whole grain rich

  • One (1) serving is equivalent to:

  • One (1) slice of bread

  • One (1) small roll (1oz)

  • Half (1/2) cup whole grain pasta.

• Half (1/2) cup rice.

• Milk and Milk Alternatives – Each meal should include one (1) serving (8 oz) per meal. Milk alternative must contain at least 250 mg of calcium per serving and be low or reduced fat.

Other menu planning considerations include:

• Sugar: Choose packaged foods that have less added sugar such as canned fruit packed in 100% juice or unsweetened applesauce. Limit sugary beverages such as lemonade or fruit drinks. Limit adding sugar in the cooking process.

• Fat: Choose foods which are higher in unsaturated fats such as nuts, seeds and fatty fish like tuna or salmon. Choose canola oil, olive oil, or other vegetable oils for cooking and use in limited amounts.

• Dessert: Fruit is encouraged to be used as a dessert. Desserts can be provided occasionally but is not a requirement. If your site chooses to provide a dessert(s) avoid serving desserts that are high in sugar, refined grains, and solid fats. Fruit based desserts may be counted toward a fruit serving one time per week if they are made with fresh, frozen, or canned fruits but not with fruit fillings.

• Sodium: Choose foods with less sodium. Canned and processed foods have more sodium than fresh or frozen products. Use herbs, spices, lemon, lime, and vinegar to add flavor to foods.

• Vitamins and Mineral Supplements: Vitamin and mineral supplements are prohibited.

All menu changes/substitutions must be documented and saved at each meal site for review. Dietary compliance must be met when there are substitutions with substitutes for like items (i.e., vegetable for another vegetable). It is recommended that a list of approved substitutions be maintained at each meal site.

 

Sanitation/Safety Requirements

 

Contract entities must meet all applicable state and local laws and regulations regarding the safe and sanitary handling of food, equipment, supplies, and materials used in the storage, preparation, and delivery of meals and services to eligible individuals. ND Food and Lodging has created, “The Food Establishment Plan Review Manual” (Food Establishment Plan Review Manual_2016.pdf (nd.gov)):

• Congregate Meals:

  • Hot food must be maintained at 135 degrees Fahrenheit or higher.

  • Hot food temperature checks must be taken daily right before being served, and documentation must be kept on file at each meal site.

  • If the hot food is prepared off-site, the temperature must be taken when the food leaves the production area and prior to the food being served at the arrival of the meal site if it is served in bulk and not individually packaged.

  • Cold food must be maintained at 41 degrees Fahrenheit or less.

  • Cold food temperature checks must be taken daily, and documentation must be kept on file at each meal site.

• Salad Bars & Soup:

  • Hot food must be maintained at 135 degrees Fahrenheit or higher.

  • Hot food temperature check must be taken daily, and documentation must be kept on file at each meal site.

  • If the hot food is prepared off-site, the temperature must be taken when the food leaves the production area and prior to the food being served at the arrival of the meal site.

  • Cold food must be placed in the salad bar at 41 degrees Fahrenheit or less.

  • Cold food considered to be “Time and Temperature Control for Safety” (TCS) must remain at 41 degrees Fahrenheit or less.

  • Cold food temperature checks must be taken prior to be placed in the salad bar daily, and documentation must be kept on file at each site

• Home-Delivered Meals:

  • Hot food must be packaged at 135 degrees Fahrenheit or higher.

  • Hot food must be delivered within a two-hour time frame.

  • Cold food must be maintained at 41 degrees Fahrenheit or less.

  • Cold food must be delivered within a two-hour time frame.

• Frozen Meals:

  • If commercially frozen meals are not used, frozen meals must be produced using rapid/blast freeze equipment and technology.

  • The label must include entrée selection, instructions for storage and reheating, and the expiration date. The expiration date should be no longer than three months after the meal was rapid/blast frozen.

  • The provider must ensure the client has the ability to store and prepare the frozen meal.

  • Frozen meals must be recorded as a sub-service of home-delivered meals.

• Mail Order:

  • Food items/Meals may require refrigeration and/or are non-perishable.

  • Label must include entrée selection and the expiration date.

• Emergency Meals:

  • Meals that are provided on a temporary basis when regular meal services are not possible.

  • Emergency meals “such as weather-related closure” provided to otherwise congregate eligible individuals are to be recorded in the web-based data collection system as congregate meals.

  • Emergency meals “such as weather-related closure” provided to home-delivered eligible individuals are to be recorded in the web-based data collection system as home-delivered meals.

  • Emergency meals “such as weather-related closure” provided to take-out eligible individuals are to be recorded in the web-based data collection system as Take Out Meal - Home Delivered meals.

• Working thermometers must be in place in all refrigerators/walk-in coolers and freezers utilized by the nutrition program.

  • Refrigeration/walk-in coolers temperatures must be maintained between 41 degrees Fahrenheit or less.

  • All sites must have readily available an accurate and easily readable thermometer(s).

  • All thermometers must be calibrated per the manufacture guidelines and/or after being dropped.

  • Freezers must be maintained at 32 degrees Fahrenheit or below (“Stored frozen food shall be maintained frozen.”).

  • All sites must document weekly monitoring of temperatures refrigerators/walk-in coolers and freezers. Records of these temperatures’ checks must be kept on file at the meal site.

• Insulated containers or other appropriate materials must be used to maintain temperatures during the transport of bulk foods to serving sites and for home-delivered meals.

• Handwashing sinks:

  • Sites where food is prepared/cooked must have a separate plumbed handwashing sink. The handwashing sink(s) should be easily accessible and cannot be used for purposes other than handwashing.

  • Each handwashing sink(s) must have hot and cold water with a water temperature of 100 degrees Fahrenheit.

  • A splash guard must be use if the handwashing sink is located next to a food preparation area, utensil or equipment storage, or food-contact surface. The splashguard shall be required when the sink is located next to clean utensils or equipment.

  • There must be soap and paper towels located at the handwashing sink(s)

  • Handwashing sinks must have proper hand washing signage (Handwashing Poster.pdf) displayed above the sink(s).