Administrative Requirements 650-25-60-15

(Revised 07/01/23 ML #3733)

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The contract entity must adhere to the following:

 

Confidentiality of Records:

• The contract entity must develop and maintain records on eligible individual(s):

  • The congregate and/or home-delivered meal assessment.

  • Emergency contact

• All information obtained is to be maintained in a manner that is confidential and will not be violated.

• A signed release of information must be obtained from the older individual or legal representative prior to sharing records.

• The contract entity cannot deny any older individual(s) nutrition service(s) if the older individual refuses to provide written informed consent.

• The contract entity must provide training on confidentially of records to staff and volunteers.

 

Non-Discrimination and Grievance:

• The contract entity must have a non-discrimination policy for eligible individuals.
• The contract entity must have a grievance procedure for eligible individuals who are dissatisfied with or denied services. Procedure must include:

  • The contract entity has five (5) business days to acknowledge the complaint.

  • If the eligible individual does not feel comfortable submitting a grievance directly to the contract entity, the eligible individual can file the grievance directly to Aging Services.

  • The contract entity has 10 business days to provide a written response regarding the grievance to the eligible individual and a copy to Aging Services. The written response must include a decision that was made for the grievance that was filed.

  • All notifications to the complainant must include a statement that the complainant may reach out/appeal the results of the review to Aging Services.

  • The contract entity must submit a copy of all grievances/complaints to Aging Services.

• The sites must have documentation posted that any older individual has a right to contact Aging Services with any concerns/complaints.

• The contract entity must have a process that includes confidentiality provisions to protect the complainant’s right to privacy. Only information relevant to the complaint may be released to the responding party without the consent of the older individual/complainant. The older individual/complaint has a right to remain anonymous but will need to provide an address for written correspondences. An email address is also acceptable.

• Individuals that file grievances must be assured there will be no retaliation.

 

Service Contributions (Program Income):

• Eligible individuals may not be coerced into suggested contributions.

• Nutrition Providers/Programs must not use misleading language implying there is a specific price or cost to receive a meal.

• Eligible individuals must be provided the opportunity to voluntarily contribute toward the cost of services.

• Eligible individuals must clearly be informed there is no obligation to contribute, and the contribution is purely voluntary.

• Eligible individuals must not be denied service due to inability or unwillingness to contribute.

• Means testing shall not be used; however, a suggested contribution based on the contract entity’s actual cost of the meal may be developed and used.

• Eligible individuals cannot be billed for the number of services received.

• Measures must be taken to protect the privacy and confidentiality of the eligible individual’s contribution or lack of contribution.

• Service contributions must be protected from loss, mishandling, and theft.

  • Acceptable methods of receiving contributions for congregate meals include the following:

    • A locked box with a slit located on top in a private area for cash and/or sealed envelope.

    • A mailed check.

    • Self-punch meal ticket.

    • Supplemental Nutrition Assistance Program (SNAP) benefits.

    • Debit and/or Credit Card.

  • Acceptable methods of receiving contributions for home-delivered include the following:

    • A mailed check.

    • Self-punch meal ticket.

    • Supplemental Nutrition Assistance Program (SNAP) benefits.

    • Debit and/or Credit Card.

• Service contribution must be placed with a contribution sign and box away from the sign-in area.

• Service contributions must be secured in a safe location until time of deposit.

• Service contributions must be reviewed by two individuals (site manager, cook, volunteer, etc.) and documented each day.

  • Deposit slips must be maintained on file for assessment(s)/audit purposes.

• The full cost and the suggested contribution for the service must be publicly displayed at site location(s) and provided to all eligible individuals that receive services.

• Service contributions received for congregate meals must be used to expand congregate meals, and service contributions received for home-delivered must be used to expand home-delivered meals.

• Aging Services may request a review of service contribution communications that contract entities utilize to solicit contributions from individuals.

 

Web-based Data Collection System:

• The contract entity will be responsible for entering the data in the web-based data collection system along with processing required reports.

• All assessments and reassessments must be documented in the web-based data collection system.

• Documentation relating to the assessments and reassessments must be in the narrative section of the web-based data collection system.

 

Fiscal Procedures:

• Measures must be established to safeguard and account for receipt of all contract-related funds (including service contributions) and for the payment process. The following must be included:

• Contributions must be counted, recorded, and signed daily by two individuals.
• Procedure for verification of receipt of funds.
• Procedure for deposit of funds.
• Location of funds prior to deposit.
• List of staff who have access to funds.
• Payment process.

 

Congregate Meal Sites:

• Meal sites must:

  • Allow individuals to have the option of taking home any part of a meal that was prepared and served to them. Nutrition Service Providers are required to develop or adapt a current ‘leftovers’ policy to incorporate this option to allow individuals to take leftovers. In addition, there must be signs placed throughout the meal site that clearly state once the meal is taken from the site, food safety is the responsibility of the older individual(s).

  • Meet state and local fire safety, safety and sanitation codes, and standards.

  • Be accessible to older individuals and/or individuals with disabilities.

  • Be in close proximity to the majority of eligible individuals.

  • Have a landline phone and/or cellphone.

    • Cellphone must be accessible to the individuals and located in a commonly known area for everyone to use in case of an emergency.

  • Have emergency numbers posted by each phone.

  • Have the address of the site posted by each phone.

  • Have a fire evacuation and weather-related plan posted.

  • Have adaptive equipment available for individuals with special needs.

Home-Delivered Meals when the Individual is not home:

• The contract entity must have a policy in place that describes what happens in the event that a home-delivered meal individual(s) is not at home.

• Leaving a meal unattended is not considered “delivery to the individual.”

  • Leaving a meal in a cooler, bag, or on a chair by the door must be approved by the contract entity and Aging Services.

  • If approval is granted it must be documented in the older individual’s record.

• Delivery provider must document missed meals and provide it back to the site manager to keep on file. It is highly encouraged that site manager reach out to the older individual’s emergency contact if the individual didn’t inform you, they would not be home.

• Drivers are encouraged not to enter an older individual’s home unless it has been approved by the contract entity. The approval must be documented in the older individual’s record.

• If an older individual requests the meal to be delivered to the neighbor this can only occur if approved by the contract entity. It must be documented in the older individual’s record.

 

Suspension and/or Termination of Older Individual from Nutrition Program:

• The contract entity, staff, and volunteers serving eligible individuals in the community have the right to work in a safe environment and to be treated with courtesy and respect.

• The contract entity is expected to make every effort possible to resolve situations that might occur before suspending and/or terminating an older individual from the nutrition program.

• The contract entity must have a policy in place regarding proper procedure when suspending/terminating an older individual.

• Meal participants can be suspended and/or terminated from congregate and/or home-delivered meal program for any of the following reasons but not limited to:

  • Death;

  • Admitted to a long-term care facility, hospital, swing bed, etc.;

  • Older individual requests for the services to be discontinued;

  • Older individual threatens the health or safety of an individual at a congregate meal site;

  • Older individual or another individual living in the home threatens, the health and safety of the individual delivering meals;

  • Older individual racially discriminates against an individual at a congregate meal site;

  • Older individual or another individual living in the home racially discriminates against the individual delivering the meals;

  • Older individual sexually harasses an individual at the congregate meal site;

  • Older individual or another individual living in the home sexually harasses the individual delivering the meals;

  • Older individual making unreasonable demands for services.

  • Repeated inappropriate behavior from the individual served and/or other individuals living in the home.

• It must be documented in the eligible individuals record if they are suspended and/or terminated from a meal program.

  • Documentation must include but not limited to:

  • Date of suspension and/or termination of services;

  • Reason for the suspension and/or termination;

  • How was the action leading to suspension and/or termination was confirmed; and

  • Date if the delivery of meals to the eligible older individual are reinstated.

• If an older individual that is being suspended and/or terminated from a meal program, they must receive a suspension/termination letter with the grievance form along with providing a copy to Aging Services.

 

Safety Checks/Emergency Contacts:

• The contract entity must have a policy in place that describes what happens in the event that a home-delivered meal individual(s) is found ill and/or injured when a meal is delivered.

• The policy must describe procedures to follow if the individual is ill, injured, or cannot be located when a meal is delivered. The plan must be incorporated in staff and volunteer training.

   

Emergency Preparedness Plans:

• The contract entity must have emergency preparedness plans in place for unplanned events (public health emergencies, inclement weather, power outage, natural disasters, facility issues, threat of harm, etc.) The plans must include:

• Contingent service delivery.
• How to contact staff, volunteers, caterers, etc., through phone or other means.
• Notification to eligible individuals of program closings (radio, phone, etc.)

 

Emergency Disaster Plan:

• The contract entity must have a written emergency disaster preparedness plan to assure coordination of activities with local and state governments, emergency response agencies, relief organizations, and other entities that are responsible for disaster relief service delivery.

 

Holiday(s) or Site Closures:

• The contract entity must assure service delivery to congregate and home-delivered eligible individuals during holidays and/or planned site closures. This may include providing hot/cold, frozen, and mail order meals.

  • Holiday and planned site closures must be identified in the contract entity’s menus, newsletter if applicable, posted in a visible location at the meal sites and provided to home-delivered eligible individuals.

  • For congregate eligible individuals receiving home-delivered meals during holidays and planned site closures, the meal provided must be recorded in the web-based data collection system as a congregate meal.

 

Information and Referral:

• Either with a Release of Information or verbal consent from the older individual, the contract entity shall provide and/or make referrals for older individual(s) to Aging Services, Aging & Disability Resource Link (ADRL) for resources. Contract entities and/or the older individual can reach the ADRL through the following means:

  • Telephone: 855.462.5465

  • Email: carechoice@nd.gov

  • Web Intake: https://carechoice.nd.assistguide.net

 

Mandated Reporter:

• The contract entity is considered a mandated reporter and must have a policy in place to report suspected abuse, neglect, or exploitation to Adult Protective Services (APS) within Aging Services. Contract entities and/or any individual(s) can reach APS through the following means:

  • Online via Option 1: North Dakota APS Web Intake Report (wellsky.com);

  • Online via Option 2: https://www.hhs.nd.gov/sites/www/files/documents/featured-area/sfn01607.pdf. Please note send the completed form by emailing it to dhsvaps@nd.gov or faxing to 701.328.8744.

  • Telephone via Option 3: 855.462.5465, then press 2.

 

Advocacy:

• Provide leadership relative to aging issues on behalf of all eligible individuals in the defined service area.

 

Planning/Evaluation Requirements:

• Services must be coordinated within the community to avoid duplication.
• Participate in Department of Health and Human Services(DHHS)/Aging Services Section evaluation activities as requested.

 

Training:

• Training must be provided to all paid staff and volunteers initially when onboarding. All paid staff and volunteers must have annual training thereafter.
• The training must include, but is not limited to the following:

• Overview of the OAA including but not limited to:
  • Polices and Procedures
• Requirements/expectations of the contract entity with ND Department of Health and Human Services (DHHS).
• Emergency procedures and protocols.
• Reporting/data entry requirements.
• Service contribution.
• Code of Conduct/Ethics.
• Health Insurance Portability and Accountability Act (HIPAA).
• Serv Safe
  • Individual employee training, or
  • Groups of employees trained by "train the trainer."
• Volunteer Training
  • Proper Handwashing
  • Food Safety
    • Temping Food
    • Hairnets
    • Gloves
• Portion Control

• Staff training records must be maintained in the personnel files at the contract entity’s office.