304 Nutrition Service Program Guidelines and Requirements | HCBS-5300-MANUAL

This section establishes requirements for Area Agencies on Aging and their subcontractors in the administration and provision of a comprehensive program of nutrition services to older adults.

These requirements apply to all congregate and home delivered nutrition services contracted and provided through or by the Area Agency on Aging, supported by any and all non-Medicaid sources of funding.

Each nutrition service program site shall be operated in compliance with all federal, state, and local laws and codes that govern facility operations, specifically related to fire safety, sanitation, insurance coverage, and wage requirements.

The congregate nutrition program promotes better physical and mental health for older adults through the provision of nutritious meals and opportunities for social contact.

The home delivered meal program promotes better health for older adults and eligible members of their households through the provision of nutritious meals; nutrition screening, education and counseling; and opportunities for social contact.

Both types of nutrition services shall be part of a system of services that promotes independent living for older adults.

At a minimum:

Eligible persons are:

AAAs shall give priority to those:

Providers may offer a meal to the spouse/caregiver(s) of a homebound eligible person if the provision of the meal supports maintaining the person at home. Providers may also offer meals to the non-elderly or persons with disabilities who reside in the household of an older adult (60 years or older) and are dependent on them for care.

Each meal shall comply with provisions in the Older Americans Act, Title III, Subpart 3, Section 339, concerning compliance with Dietary Guidelines for Americans.

Meals will focus not only on the nutrition content, but also color, texture and flavor.

Variety in the meal pattern is important to meal satisfaction. Therefore, there are no requirements that any specific food be served (example: milk), or any requirements that a meal pattern be followed (example: 3oz meat, 2 ½-cup vegetables, dessert, roll).

Standardized recipes will be used to analyze and prepare meals. The food that is served will be the same as analyzed, to the fullest extent possible.

A caffeine free and sugar free beverage must be offered as part of a complete meal.

Providers will develop a plan to offer choice in meals.

Providers will be capable of serving a therapeutic diet based on a doctor’s recommendation. See 304.3k for further explanation.

Providers shall follow at a minimum a twenty day (four week) menu cycle, which can be repeated during the quarter.

Nutrient content of meals is determined by the application of the Dietary Reference Intakes (DRI) guidelines and the Dietary Guidelines for Americans.

To allow for regional preferences, the nutrient content of meals must:

The provider shall obtain and maintain documentation of nutrient analysis for each meal per menu cycle. If the AAA allows the use of alternative protein sources, the procurement documents must clearly state how frequently alternative protein may be used on a monthly basis and to what degree.

Hot, frozen, dehydrated, chilled, and shelf-stable meals shall be prepared and served in accordance with Division of Aging Services requirements. The AAA or provider will be responsible for assessing the ability of the home delivered meal recipient to store and prepare meals. Appendix 304-A contains instructions to determine appropriate meal type.

A hot meal is not required for congregate or home delivered programs. However, each individual should be assessed and given the type of meal that is determined to be the most appropriate, or that the individual requests.

Therapeutic diets shall be provided as required by the participant’s special needs and medical condition, providing:

A qualified dietitian shall certify menus in each cycle as meeting the dietary guidelines and providing recommended dietary allowances. The AAA shall submit copies of certified menus and nutrition analyses to the Division of Aging Services’ Chief Nutritionist on a quarterly basis, at least two weeks before implementation.

The AAA shall assure that the services of a registered dietitian are available for menu review and certification. This dietitian shall not be employed by the commercial food vendor that provides meals for the planning and service area, if the provider subcontracts meal preparation.

The certified menus are subject to the audit process and are to be retained for a minimum of six years, according to state record retention requirements.

The AAA is responsible for assuring compliance with the Older Americans Act, which states that the nutrition program be administered with the advice of dietitians or individuals with comparable expertise. The AAA may employ directly the dietitian(s) or contract for consultation services.

Nutrition service providers may also employ or contract the services of a dietitian in fulfillment of this requirement.

Duties of the dietitian include, but are not limited to:

Nutrition service providers shall use procedures that provide for the safety, sanitation, accessibility and convenience of participants, and efficiency of service, and shall include the following:

Picnic, special occasion, holiday and weekend meals must meet the nutrient targets outlined in Appendix 304-B Georgia Nutrition Program Nutrient Targets for Meals; meet temperature requirements for hot and cold foods; and must be prepared in a commercial food service or on-site kitchen.

Shelf-stable, dehydrated, chilled, and frozen meals must meet the nutrient targets outlined in Appendix 304-B Georgia Nutrition Program Nutrient Targets for Meals; and applicable temperature standards.

Package labeling must be legible and show:

All rules and regulations governing food service stated by the Georgia Department of Public Health (511-6-1) shall apply for congregate and home delivered meal programs.

Refer to references section for web link.

Providers shall assure that holding times for hot foods do not exceed four (4) hours from the final stage of food preparation until the meal is served to the participants, including delivery to the homes of home delivered meal participants.

Providers shall develop and implement procedures for assuring safe meal delivery in accordance with applicable food service and safety rules and DAS requirements for holding times. Meals shall not be left in coolers or other containers outside the house or dwelling as proper temperatures may not be possible in this environment.

Nutrition screening begins at the AAA with the administration of the Nutrition Screening Initiative DETERMINE (NSI-D) Checklist as part of the intake and screening process.

The AAA may allow congregate meal sites with no waiting lists to perform initial applicant intake and screening directly. Congregate meal providers shall complete the checklist thirty (30) days after services begin, and at a minimum, annually thereafter, or at any time a change in the participant’s condition or circumstances warrants.

The AAA and provider(s) jointly (or case management, if used) shall develop protocols to assure that applicants/recipients whose NSI-D score is 6 or greater receive or are referred for:

Area Agencies and nutrition service providers are to work collaboratively to identify or develop resources for the provision of nutrition assessments for persons at high nutrition risk and/or those with low food security. Registered Dietitians and other qualified professional (example: Dietetic Technician, Registered) may conduct nutrition assessments.

Each provider shall develop written nutrition education programming, including a calendar, documentation of subject matter, presenters, and materials to be used, in accordance with requirements below.

The RD may develop a single educational curriculum that may be used by multiple sites. The provider may develop curriculum, however the RD will review and approve all nutrition education content and materials. The RD is not required to approve nutrition education from reliable sources (USDA, Universities, etc.)

Providers shall assure that nutrition education content and materials are developed to be consistent with the nutritional needs, literacy levels, and vision and hearing capabilities, as well as the multi-cultural composition of participating older adults. Providers shall make available print materials that are sufficiently large (14 point or larger), use clear and common typefaces (such as Arial, Verdana, Georgia, or Times New Roman), and in language that is appropriate for the educational levels and cultural backgrounds of the participants.

The AAA or provider (or case management, if used) shall develop protocols to determine those participants with special nutrition needs who would benefit from individual counseling and assure that such counseling is made available by qualified professionals.

Individual counseling may not be indicated, regardless of the level of nutritional risk if the person would not benefit from the counseling due to:

In addition to identifying, assessing and referring individuals to a nutrition program, the following service activities are meant to enhance the core services and allow individuals to remain independent in the community.

The service provider shall provide home delivered meals as proscribed by contract and in accordance with the frequency requirements in the Older Americans Act Section 336 (42 U.S.C. §3030f). Individual meal service and frequency shall be based on the determined needs of each individual.

Temporary home delivered meal service may be provided to registered congregate meal site participants who are ill, incapacitated, or temporarily homebound, at the discretion of the AAA. An additional provider assessment for home delivered eligibility is not required for this service. Funding for these temporary home delivered meals should be charged to the congregate meal program. When providing this service, only the meal cost and cost of delivery are to be included. An eligible homebound congregate meal participant may receive up to twenty (20) consecutive home delivered meals.

Receipt of more than 20 consecutive home delivered meals shall require:

The provider agency shall make facilities, equipment, and services available to the fullest extent possible in emergencies and disasters, according to the AAA regional emergency/disaster plan.

The provider agency shall develop and implement written procedures to provide for the availability of food to participants in anticipation of and during emergencies and disasters, including contingency planning for delivery vehicle breakdowns, inclement weather, shortages in deliveries, food contamination, spoilage, etc.

Minimum implementation guidelines include:

The guidelines and sample plan from Meals On Wheels Association of America can be used. www.mealsonwheelsamerica.org/docs/default-source/conference/2019-session-materials-handouts/tuesday/200/meals-on-wheels-america-ep-standards.pdf?sfvrsn=f82ab93b_2

All nutrition sites shall comply with the Americans with Disabilities Act requirements, and with any other relevant DAS standards or program requirements relating to access and safety. Facility requirements for senior centers which house congregate meal programs are found in DAS Manual 5300 Section 200, Chapter 206.

Each nutrition service provider shall retain on file each menu with meals as served, for monitoring purposes. If providing services at multiple sites, each site must have a copy of the menus with meals as served.

Providers shall conduct outreach activities with emphasis on identifying potential program participants who are among those in greatest social and economic need. Providers shall refer potential participants to the Area Agency for intake and screening, when appropriate, according to the procedures developed by the AAA. Outreach strategies and contacts will be documented.

When appropriate, service providers shall work with the AAA (or case management, if available) to refer participants to other service resources that may be able to assist with remaining independent and safe in the home, and/or to assist caregivers with maintaining their own health and well-being.

All providers shall comply with all provisions for nutrition services contained in the Older Americans Act, as amended.

Each provider agency shall use procedures that comply with all applicable state and local fire, health, sanitation, and safety laws and regulations. All food preparation, handling and serving activities shall comply with applicable requirements as found at 290-5-14 of the Administrative Rules and Regulations of the State of Georgia (website in References).

The provider shall report to local health authorities within 24 hours of receiving complaints involving two or more persons with symptoms of foodborne illness within a similar time frame after consuming food supplied through the nutrition service program. Providers shall report any complaints regarding foodborne illness to the contracting AAA within two business days of receipt.

The provider shall identify an individual who is responsible for the overall management of nutrition services and compliance with performance standards, requirements, and procedures. This person, and any other employee(s) responsible to food service management, shall be ServSafe certified, as required by the state.

www.servsafe.com

The service provider shall assure that orientation and ongoing training for administrative and direct service staff and volunteers shall be adequate to5 provide safe, appropriate, and efficient services to older adults, and compliance with all applicable requirements and procedures. Providers shall document and maintain records of all content and dates of orientation and training for monitoring purposes. Providers may offer additional topics.

It is the responsibility of the nutrition service provider to obtain required health inspections and certificates from the appropriate local health authorities, and post the annual certificates in each facility. Any facility that handles food in any capacity (cooking, warming, plating, etc.) must have a current health inspection.

Providers shall comply with all record keeping and reporting and retention requirements as prescribed by DAS in MAN5600, Section 3012. Documentation requirements specific to food service include, but are not limited to:

Providers shall allow participants the opportunity to make voluntary contributions in support of the program, in a manner that protects their confidentiality.

Refer to Manual 5600, Sections 2025, 2026, 2027, and 2028 for full guidance.

The purpose of NSIP in part, is to reduce hunger and food insecurity, promote socialization, promote health and well-being, and delay adverse health conditions for older individuals.

NSIP funding is to be used exclusively to purchase domestically produced food.

AAAs shall use the raw food cost from the uniform cost methodology for reimbursement.

Meals eligible for NSIP funding are those that:

Each nutrition program provider shall develop and implement an annual plan to evaluate and improve the effectiveness of operations and services to ensure continuous improvement in service delivery.

The evaluation process shall include:

Each provider shall prepare and submit to the AAA annually (no later than September 30^th) a written report that summarizes the evaluation findings, improvement goals, and implementation plan for each site.

Providers that also operate senior centers shall incorporate the evaluation of the nutrition program into the annual senior center program evaluation.

Each provider will monitor and document daily that temperatures of hot or cold food received from vendors are within acceptable ranges upon delivery to the site. Providers will monitor no less than twice per month and document the temperature of the last meal delivered on a given delivery route to assure that holding times, safe temperatures, and quality of meals are maintained.

Providers shall select routes randomly for monitoring. Providers will maintain this documentation in accordance with DAS policy, MAN 5600, 3015 Area Agency on Aging Monitoring and Evaluation of Service Providers.

Nutrition service providers, including AAAs, if applicable, shall assure that participants, or their caregivers/representatives, receive written notice of their rights and responsibilities upon admission to the program, according to Manual 5300, 202 Program Guidelines and Requirements. For ongoing participants, the information may be provided at the next re-assessment.

The AAA shall develop and implement any necessary additional policies and procedures for the following:

AAAs are responsible for:

The AAA shall designate one or more staff to manage the nutrition service contracts or obtain the services of consultants to coordinate with staff for the management of nutrition service contracts. The minimum qualifications for staff or consultants shall be:

Refer to Manual 5600, 3014 Area Agency on Aging Contract Management Requirements.

The AAA shall monitor each nutrition service provider and individual provider site at least once annually within the first six months of the contract year, placing additional emphasis on monitoring more often those sites that continue to demonstrate substantial non-compliance for the previous year, or new provider(s)/site(s).

Monitoring forms provided from DAS are the preferred tool. If an AAA uses its own forms, all information on the DAS forms must be included.

Refer to Manual 5600, 3015 Area Agency on Aging Monitoring and Evaluation of Service Providers.

Using the Uniform Cost Methodology and principles or performance-based contracting to procure congregate and home delivered meal services, AAAs shall assure that potential subcontractors establish a base meal cost. AAAs shall base reimbursement rates on actual cash costs, excluding estimates of volunteer time, and the value of contributed goods and services. The base meal cost shall be the basis for negotiation between the AAA and any respondents to requests for proposals.

Area Agencies may waive the use of the Uniform Cost Methodology by food vendors if the vendor provides a meal unit cost with similar food cost categories.

Costs of services other than the base meal rate must be accounted for in other service categories.

The AAA has the authority to renegotiate reimbursement rates during the contract period, based on documentation from the provider that identifies additional costs and the rationale for including any additional costs as necessary and reasonable to the provision of meals.

Refer to Manual 5600, 3014 Area Agency on Aging Contract Management Requirements.

On an annual basis, the AAA shall analyze individual and cost data, in addition to compliance monitoring results, to identify necessary program improvements. The AAA shall involve the provider(s) in the evaluation process and provide written feedback regarding required corrective actions or program improvement initiatives.

Area Agencies shall assure that each nutrition program provider develops and implements an annual plan to evaluate and improve the effectiveness of operations and services to ensure continuous improvement in service delivery.

The evaluation process shall include:

Each provider shall prepare and submit to the AAA annually (no later than September 30^th) a written report that summarizes the evaluation findings, improvement goals, and implementation plan for each site.

Providers that also operate senior centers shall incorporate the evaluation of the nutrition program into the annual senior center program evaluation.

Contractors providing nutrition services shall practice sound and effective fiscal management and planning, financial and administrative record keeping and reporting. Contractors will use the Uniform Cost Methodology to analyze, evaluate and manage the costs of the program on an annual basis.

Refer to MAN 5600, Appendix G

www.nal.usda.gov/human-nutrition-and-food-safety, maintained by the USDA Food and Nutrition Service for information and resources on food safety.

Websites which may assist in the development of nutrition education materials include extension.uga.edu/food/

Georgia Department of Public Health Rules and Regulations Governing Food Service dph.georgia.gov/environmental-health/food-service

ServSafe www.servsafe.com

MOWAA Disaster Planning Sample and Guide www.mealsonwheelsamerica.org/docs/default-source/conference/2019-session-materials-handouts/tuesday/200/meals-on-wheels-america-ep-standards.pdf?sfvrsn=f82ab93b_2

Dietary Guidelines for Americans 2015-2020 odphp.health.gov/our-work/nutrition-physical-activity/dietary-guidelines/previous-dietary-guidelines/2015