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

(NEW 7/1/19 ML #3552)

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Legal References:

1. North Dakota Administrative Code Chapter 33-33-04.1, Food Code
2. North Dakota Century Code Chapter 50-06, Department of Human Services
3. Public Law 114-144, Older Americans Act (OAA) of 1965, as amended in 2016
4. 45 CFR part 1321, Grants for State and Community Programs
5. 2 CFR Part 200 Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, as applicable
6. Older Americans Act Policies and Procedure Manual 650-25

 

Other References:

North Dakota Department of Human Services Contract

 

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

• Licensed registered dietitians or individuals with comparable expertise, including a licensed nutritionist, a dietary technician or a certified dietary manager;
• Meal participants; and
• Individuals who are knowledgeable of the needs of older individuals.

The contract entity must publicly display the menus at each congregate site as well as provide a copy of the menu to home-delivered meal participants.

 

A participant must be offered all the required menu components; however, the participant may choose not to take a specific menu component. A specific menu component should not be served or delivered if the participant has chosen not to receive it. A meal is considered eligible based on nutritional content and not on how much is eaten.

 

New congregate meal participants must complete the Congregate Meal Program Registration (SFN 479). The contract entity may choose to allow a first-time guest to dine at the meal site without completing the Congregate Meals Program Registration form and Nutrition Screening Checklist; however, the meal cannot be counted as an eligible meal and cannot be submitted for reimbursement.

 

Home-Delivered Meal Assessment must be completed when the participant changes from congregate meals to home-delivered meals.

 

Eligibility for home-delivered meals must be determined using the Home-Delivered Meal Program Registration (SFN 480) form. Initial determination of eligibility may be accomplished by telephone and an in-home assessment must be completed prior to or within ten working days after beginning meal delivery.

 

Home-delivered meal reassessments must be completed annually (minimum) through a home visit; however, may occur more frequently if needed. Documentation must include verification of continued eligibility for participants under the age of 60.

 

Participants who are no longer eligible to receive home-delivered meals, should be directed to the nearest congregate site or other appropriate food assistance services.

 

Individuals records must be:

• In its own individualized file.
• Secured in a locked file cabinet, in a locked area, or in
• A secure computer that requires an access code.

 

There is no provision in the Older Americans Act for carry-out or take-out meals and cannot be submitted for reimbursement.

 

Nutrition Counseling

Nutrition counseling defined by the Administration for Community Living, Administration on Aging, is:

“the provision of individualized advice and guidance to individuals, who are at nutritional risk, because of their health or nutritional history, dietary intake, medication use or chronic illness, about options and methods for improving nutritional status, performed by a health professional in accordance with state law and policy.”

 

Congregate and home-delivered meal participants must be screened for nutritional risk using the Nutrition Screening Checklist which is part of the Congregate Meals Registration form and the Home-Delivered Meals Registration form.

• For congregate meals, the screenings must be conducted at initial registration.
• For home-delivered meals, the screening must be conducted on an annual basis or sooner if needed.
• Participants who:

• Score six or more are considered a 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 participants must be recorded in the narrative section of the web-based data collection system.

 

Home-delivered participants that score six or more must be reassessed annually using the Nutrition Screening Checklist.

 

Nutrition Education

Nutrition education must be provided to both congregate meal and home-delivered meal participants. 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 on an annual basis (minimum). Some acceptable formats are, but not limited to:

• Nutrition presentations.
• Nutrition printed materials.
• Nutrition videos.
• Food demonstrations.
• Cooking classes.

 

Congregate site nutrition education documentation must include:

• Meal site.
• Date of distribution.
• Presenter (as applicable) and topic.
• Number of participants.
• Number of service units.

 

Nutrition education must be provided to home-delivered meal individuals on an annual basis (minimum). Some acceptable formats are, but not limited to:

• Printed materials.

 

Home-delivered nutrition education documentation must include:

• A copy of the printed nutrition education material.
• Date of distribution.
• Number of participants receiving the material.
• Number of service units.

 

The nutrition education service delivery must be documented in the web-based data collection system. A separate consumer group should be created for each meal site, and in the comment, section is where the site would indicate how many congregate and home-delivered individuals received the nutrition education. Each participant attending the presentation or receiving printed materials equals one unit of service. Expenses for the provision of nutrition education are included in the unit cost of a congregate and home-delivered meal and 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 participants with available medical information approved by healthcare professionals, such as informational brochures and information on how to get vaccines such as influenza, pneumonia, and shingles, in the participant’s community.

 

Menus and Menu Planning

Established by the Food and Nutrition Board of the Institute of Medicine of the National Academy of Sciences, all meals provided must:

• Comply with the most recent Dietary Guidelines for American’s (DGAs), published by its Secretary and the Secretary of Agriculture.
• Provide a minimum of 33 1/3 percent of the dietary reference intakes (DRIs) if the program only provides one meal per day.
• Provide a minimum of 66 2/3 percent of the allowances if the program provides two meals per day.
• Provide 100 percent of the allowances if the program provides three meals per day.

 

Recipes and menus that meet the current dietary guidelines and DRI requirements have been developed by the South Dakota Division of Adult Services and Aging. The recipes and menus are available to North Dakota contract entities. The recipes and menus can be accessed at: Menus and Recipes

 

Contract entities that do not use the menus developed by the South Dakota must address the following:

• Develop menus that comply with the most recent DGAs and meet current DRI recommendations. Guidelines for nutrient values are listed in below.
• Use a cycle menu format (minimum of four weeks) that is rotated at set intervals and reflects seasonal availability of foods.
• To the maximum extent practicable, consider the special dietary needs arising from health requirements, religious requirements, or ethnic backgrounds of eligible individuals.
• The cycle menus, recipes, and nutritional analysis must be submitted to Aging Services Division for approval.

 

The following guidelines for nutrient values must be used in developing menus:

 

Meals Program Nutrient Goals (2015 Dietary Guidelines)

For Planning and Analyzing Menus

1 meal per day

Calorie goal +/- 10% of Value below

Macronutrients (protein, carbohydrate, fat) balanced

(Fat can be lower if calories are met)

Micronutrient (vitamins & minerals) 80-100% or more daily except sodium

 

Contract entities should strive to meet nutrient values daily. Averaging the nutrient values over a five or seven-day period is allowable.

 

A meal pattern is a menu-planning tool that ensures the number of servings per food group are met at each meal. Meal patterns do not ensure that nutrient requirements are met; therefore, computer-assisted nutrient analysis must be run. Component meal patterns may be used to design menus; however, a specific menu pattern is not required.

 

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 - Meats, Fish, Poultry, Legumes, Eggs, Nuts, and Cheese: Each meal should contain a minimum of two ounces of cooked, edible portions of meat, seafood, poultry, cheese, eggs, beans and peas, or unsalted nuts and seeds (or a combination thereof). Providers may serve a larger portion of meat than the required two ounces.

• Vegetables – Choose a variety, especially dark green, red and orange vegetables. Serving sizes: ½ cup cooked legumes; ½ cup cooked vegetables; 1 cup raw leafy green vegetables, such as, lettuce or salad.
• Fruits – Choose fresh, frozen or canned fruit packed in water or juice, light syrup or without sugar. If the fruit is packed in heavy sugar, rinse before serving. Serving sizes: 1 medium sized whole fruit; ½ cup fresh, chopped, cooked, frozen or canned fruit; or ½ cup 100 percent fruit juice. The 2015 DGA encourage the consumption of whole fruit rather than 100 percent fruit juice.
• Breads/Grains – ½ of the daily grain intakes should be from whole grains. Serving sizes: 1 slice bread or ½ cup cooked rice, pasta or cereal.
• Milk/Orange Juice – Each meal should include 8 ounces of fat-free, low-fat, 1%, buttermilk or calcium fortified soymilk or orange juice.

 

Other menu planning considerations include:

• Fat: Replace solid fats with plant-based oils that have high percentage of beneficial monounsaturated and polyunsaturated fatty acids without added calories.
• Dessert: Fruit is encouraged to use as a dessert. Desserts can be provided occasionally as an optional element of the meal to satisfy caloric requirements or to deliver additional nutrients. Avoid serving desserts that are high in sugar, refined grains and solid fats.
• Sodium: Focus on a stepwise reduction of sodium over time. Prepare foods without adding salt in the cooking process. Use herbal seasonings to replace salt.
• 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. 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 older individuals. (North Dakota Administrative Code (NDAC) Chapter 33-33-04.1):

• Congregate Meals:

• Hot food must be served at 135 degrees Fahrenheit or higher.
• Hot food temperature checks must be taken daily, and documentation must be kept on file at each meal site.
• Hot food that is prepared off-site, the temperature must be taken when the food leaves the production area and prior to the food being served only if delivered in bulk at the arrival of the meal site.
• Cold food must be served 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 packaged 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.
• Hot food that is prepared off-site, the temperature must be taken when the food leaves the production area and prior to the food being served only if delivered in bulk 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 potentially hazardous must remain at 41 degrees Fahrenheit or less.
• Cold food temperature checks must be taken daily prior to be being placed in the salad bar and every two hours. 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 served 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.

• Shelf Stable:

• Label must include entrée selection and the expiration date.

• 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 35-41 degrees Fahrenheit.
• Freezers must be maintained at zero degrees Fahrenheit or below.
• 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.