Depafiment  of Health and Human Setices 
ADMINISTUTION  ON  AGING
AND 
OFFICE  OF 
INSPECTOR  GENERAL 
~RIL  1993 
- ADMINISTRATION  ON AGING 
The Administration  on Aging (AoA) is the principal Federal  agency designed to carry out the 
provisions of the Older Americans Act (OAA).  It advises the Secretary of Health  and Human 
Services and other  Federal  agencies on the characteristics, circumstances and needs of older 
individuals.  Further,  it develops policies, plans, and programs designed to promote  their 
welfare. 
AoA administers three grant programs under the Older Americans Act.  The largest program -
- Title III of the Act -- consist of formula grants to States to establish State and community-
based programs for older individuals with the purpose of preventing the premature 
institutionalization  of older individuals.  The second program --Title VI -- consists of 
discretionary grants with the same purpose as Title III, but to meet the unique needs of older 
Native Americans.  The third program --Title IV -- is also discretionary.  Its purpose is to fund 
research, demonstration.  and training activities to elicit knowledge and techniques  to impr~vc 
the circumstances of older Americans.  (The 1992 Amendments to the OAA created  a fourth 
program --Title VII -- which provides funds for State activities to protect  the rights of 
vulnerable older people.  Prior to the  1992 Amendments. Title III of the OAA provided the 
funds for these activities.) 
OFFICE  OF INSPECXOR GENERAL 
The mission of the Office of Inspector General  (OIG), as mandated by Public Law 95-452. :]s 
amended, is to protect  the integrity of the Department  of Health  and Human Services (HHS) 
programs as well as the health and welfare of benetlciaries served by those programs.  This 
statutory mission is carried out through a nationwide  network  of audits. investigations, and 
inspections conducted  by three OIG operating components:  the Office of Audit Smwices.the 
O[fice of Investigations, and the Office of Evaluation and Inspections.  The OIG also informs 
the Secretary of HHS of program and management problems  and recommends courses tO 
correct them. 
The OIGS Office of Evaluation and Inspections (OEI) conducts short-term  management  and 
program evaluations  (called inspections) that focus on issues of concern to the Department. 
the Congress, and the public.  The findings and recommendations  contained  in these inspection 
reports generate  rapid, accurate, and up-to-date  information on the efficiency, vulnerability, 
and effectiveness of departmental  programs. 
THIS REPORT 
This report  is the result of a joint effort between AoAi  and OIG/OEI  to assess the 
implementation  of Title 111of the Older Americans Act.  OIG staff in the New York and 
Dallas regional offices provided technical support to the joint project.  AoA staff in New York 
and Dallas directed  the project with all regional offices participating in the development  of 
instruments and data collection. 
For additional information, please contact: 
AoA  John DiaL Regional Program Director-Dallas 
OIG  Jack Molnar, Project Leader-New York 
_- .  Department of  Health and Human Services 
ADMINISTRATION  ON  AGING

AND

OFFICE  OF 
INSPECTOR  GENERAL 
STATE  IMPLEMENTA~ON  OF= 
NUTRITION  REQUIREMENTS  OF  THE 
OLDER  AMERICANS  ACT 
APRIL  1993  OEI-02-91-01515
 EXECUTIVE  SUMMARY 
PURPOSE 
To review  State  Units  on Aging  (SUA)  implementation  of the  nutrition  requirements 
of Title  III of the  Older  Americans  Act  (OAA). 
BACKGROUND 
In an effort  to strengthen  its stewardship  of the  O*  the  Commissioner  of the 
Administration  of Aging  (AoA)  requested  technical  assistance  from  the  Office  of 
Inspector  General  (OIG)  in designing  a review  of their  primary  Title  III grantees  --
SUAS.  After  reviewing  traditional  and  current  stewardship  activities,  and  discussing 
potential  approaches  for future  efforts,  we agreed  that  a review  of individual  States 
would  be  instituted  in such  a way as to provide  the  Commissioner  with  an overview  of 
how States  are  implementing  key components  of Title  III.  In order  to conserve 
limited  travel  funds  the  reviews would  be  conducted  on a sample  of States  and would 
focus on only five programmatic  areas  -- stewardship,  targeting,  ombudsman,  nutrition, 
and  financial  management. 
This  report  on nutrition  addresses  congregate  and  home-delivered  meal  programs,  and 
related  services,  such  as nutrition  education.  It focuses  on issuing guidance  on and 
monitoring  implementation  of the  key nutrition  requirements  of Title  III of the  OAA, 
including  the  area  planning  process. 
METHODOLOGY 
The  reviews  were  conducted  in a stratified,  random  sample  of 20 States  based  upon 
the  population  of individuals  over  60 years  of age in each  State.  In the  first step  of 
the  sampling  process,  States  were  divided  into  four  strata  based  upon  the  number  of 
older  individuals  in each  State.  In the  second  step,  five States  were  selected  from 
each  stratum.  This  stratified,  random  sample  permits  a generalization  of findings  from
   
the  20 sample  States  to the  Nation. 
FINDINGS 
States  Address  A  Majority  Of  The Nutrition  Requirements,  However  El&ibiWy  And 
Related  Semces Standards  Need  Attention 
About  one  fifth of States  do not  assess  some  of the  requirement  eligibility  for 
 
congregate  home-delivered  meals 
Guidance  and  assessment  of the  use  of USDA  cash  and  commodities  is often 
 
weak 
i  States  Seek  To Control  N-n  l?ogram  COSB 
Most  established  cost factors  (i.e., cost of raw food,  supplies,  labor/personnel, 
 
transportation,  etc.)  for meals 
Many  States  report  cost saving initiatives 
 
States  Use A  Va&ty  QfMetho&  And  Staff  To Assess  Nidion  J%grams 
Nutrition  project  monitoring  staff vary greatly,  with only 40 percent  requiring 
 
registered  dietitians 
About  half  assess  area  agencies  annually 
 
States  Bovi&  llaihing  And  Technical  Ass&ance  To Address  D~ 
85 percent  of States  provide  training  and  technical  assistance  to area  agencies 
 
60 percent  establish  training  standards 
 
ii  TABLE  OF  CONTENTS 
EXECUTIVE  SUMMARY  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..i 
INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . ...1 
AMajority  Of The  Nutrition  Requirements  AreMet  . . . . . . . . . . . . . . . . . . . .  4 
States  Seek  To  Control  Nutrition  Program  Costs  . . . . . . . . . . . . . . . . . . . . . . . .  6 
Assessment  Of Nutrition  Programs  Varies  . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  7 
States  Provide  Nutrition  Training  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  9 
APPENDICES 
A  Appendix  A  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..A-l  INTRODUCTION 
PURPOSE 
To review  State  Units  on Aging  (SUA)  implementation  of the  nutrition  requirements  of 
Title  III of the  Older  Americans  Act  (OAA).  In this report,  the  term  nutrition  refers  to 
congregate  and  home-delivered  meal  programs,  and  related  services,  such  as nutrition 
education.  It focuses  on issuing guidance  on and  monitoring  implementation  of the  key 
nutrition  requirements  of Title  III of the  O- including  the  area  planning  process. 
BACKGROUND 
Under  the  0~  the  Administration  on Aging  (AoA)  serves  as the  principal  Federal 
advocate  for  older  individuals,  providing  national  leadership  in the  development  of 
programs  to  address  their  needs.  Through  Title  III of OAA  (Grants  for State  and 
Community  Programs  on Aging),  AoA  encourages  and  assists WAS  and  area  agencies  on 
aging (AAAs)  to implement  a system  of coordinated  community-based  services  to prevent 
the  premature  institutionalization  of older  individuals  by allowing  them  to remain  in their 
own community. 
Under  Title  III, AoA  distributes  approximately  $765 million  in formula  grants  to States 
based  on the  age  60+  population  within  each  State.  The  SUAS use  about  5 percent of 
the  grant  on administration,  and  then  fund  AAAs  who then  contract  for the  supportive 
services,  nutrition  services  and  multipurpose  senior  centers.  The  single largest 
component  of Title  111,the  nutrition  program,  provides  approximately  $450 million  for 
congregate  and  home-delivered  meals.  Other  key program  components  include 
supportive  services  (i.e., access  services,  in-home  services  and  legal  assistance)  and  the 
Ombudsman  program  which  serves  as an advocate  for residents  in long term  care 
facilities. 
One  of AoAs major  administrative  responsibilities  is to provide  stewardship  over  the 
States  implementation  of the  Title  III program.  However,  AoAs capacity  to carry  out  its 
stewardship  responsibilities  declined  substantially  during  the  1980s due  to a significant 
reduction  in resources.  More  specifically,  AoA  sustained  a 47 percent  reduction  in staff 
and  75 percent  reduction  in travel  funds.  Each  regional  office  had  only $2,000annually 
for travel.  Because  they  could  not  monitor  SUAS, AoA  became  further  and  further 
removed  from  the  activities  of the  SUAS and  their  area  agencies  on aging. 
In an effort  to strengthen  its stewardship  of the  OAA,  the  Commissioner  of AoA 
requested  technical  assistance  from  the  Office  of Inspector  General  (OIG)  in designing  a 
review  of their  primary  Title  III grantees  -- SUAS.  In response  to the  Commissioners 
request,  OIG  staff met  with  key AoA  headquarters  and  regional  staff to identify 
traditional  and  current  stewardship  activities,  and  to discuss potential  approaches  for 
future  efforts.  As a result,  we agreed  that  the  review  of individual  States  would  be 
instituted  in such  a way as to provide  the  Commissioner  with  an overview  of how States 
are  implementing  key components  of Title  III.  The  OIG  agreed  to assist AoA  in 
1  developing  national,  standardized  review  instruments  for key components  of Title  III and 
in writing  a report  summarizing  States  implementation  of the  Act.  We  also  agreed  that 
in order  to conserve  limited  travel  funds  the  reviews would  be  conducted  on a sample  of 
States  and  would  focus  on only five programmatic  areas  -- stewardship,  targeting, 
ombudsman,  nutrition,  and  financial  management. 
Designing  the  review  began  with the  meeting  of a review  team  of OIG  and  selected  AoA 
regional  staff.  They  brainstormed  approaches,  identified  Federal  reporting  and  operating 
requirements  for SUAS and  AA&  and  drafted  instruments  containing  the  review 
questions  and  criteria.  The  draft  instruments  were  shared  with AoA  headquarters  staff 
and  each  regional  office  for comments,  and  then  revised  to reflect  comments. 
The  OIG/AoA  review  teams  pre-tested  the  instruments  and  data  collection  methodology 
by conducting  reviews  for each  of the  five instruments  in six States  located  in four 
different  Federal  regions.  The  pre-test  identified  that  a great  deal  of time  was lost 
explaining  criteria  (interpreting  law and  regulation)  and  searching  for documentation. 
Accordingly,  the  review  team  modified  each  of the  instruments  and  changed  the  data 
collection  methodology.  The  most  significant  change  to the  methodology  required  the 
sharing  of the  review  instruments  with the  States  prior  to the  site visit in the  belief  that  if 
States  are  aware  of and  understand  the  review  criteria  being  used  during  the  review,  they 
will be better  prepared  to provide  required  documentation  and  to discuss  specific  issues. 
METHODOLOGY 
The  reviews were  conducted  in a stratified,  random  sample  of 20 States  based  upon  the 
population  of individuals  over  60 years  of age in each  State.  These  are  the  same  data 
used  to allocate  Title  III funds  among  States.  In the  first step  of the  sampling  process, 
States  were  divided  into  four  strata  based  upon  the  number  of older  individuals  in each 
State.  In the  second  step,  we selected  five States  from  each  stratum.  This  stratified, 
random  sample  permits  us to generalize  findings  from  the  20 sample  States  to the  Nation. 
Table  I indicates  those  States  selected  for the  review  process  (See  Table  I). 
We  also used  sampling  techniques  during  site visits to each  State  for the  reviews  of 
specific  area  plans  and  assessments.  In these  instances,  we selected  a simple,  random 
sample  of 10 AAAs  prior  to the  visit to review  on-site.  For  those  States  with less than  10 
AA&,  all AAAs  were  included  in the  review. 
2  TABLE  I 
SAMPLE  STATES 
Stratum  1  Stratum  2  Stratum  3  Stratum  4 
California  Michigan  Wisconsin  New Hampshire 
Pennsylvania  Indiana  Colorado  North  Dakota 
New York  Massachusetts  Oklahoma  Nevada 
Texas  Georgia  Maine  District 
Florida  North  Oregon  of Columbia 
Carolina  Montana 
The  data  collection  was conducted  in two phases  -- an AoA  regional  office  desk  review 
and  an  on-site  review  at the  SUA.  During  the  desk review  phase,  we looked  at  area  plan 
guidance  and  program  instructions,  as well as the  States  assessment  instruments  for 
AAAs  to determine  if they  are  consistent  with Federal  law and  regulations.  We  also 
reviewed  priority  services  waivers  and  targeted  populations  participation  data  from  the 
State  Program  Report  for Title  III. 
Following  the  desk  review,  each  State  was sent  a proposed  agenda  for the  site visit, a 
listing of the  AAAs  whose  area  plans  and  assessment  reports  will be  reviewed,  a copy of 
the  nutrition  review  instrument  (Appendix  A), and  the  findings  from  the  desk  review  to 
be  discussed  during  the  site visit. 
The  review  instrument  focused  on the  guidance  SUAS issued  to AAAs,  on key 
requirements  of Title  111,and  on the  instruments  and  procedures  they  use  to assess 
AAAs  with those  requirements.  A review  of area  plans  and  assessment  reports 
determine  whether,  and  to what  extent,  they reflect  OAA  requirements.  The  instruments 
also focus  on the  issues  of SUA  operating  procedures,  and  on training  and  technical 
assistance  activities. 
We  entered  data  from  the  nutrition  review  instruments  into  three  databases.  One 
database  contained  the  responses  to the  open- and  closed-ended  questions  on the 
instrument  and  the  other  two contained  the  reviews  of 183 area  plans  and  assessments. 
The  number  of responses  to questions  vary because  some  questions  did not  apply  to the 
four  States  in Stratum  4-- NH,  ND,  NV,  & DC  -- which  are  single planning  and  service 
area  (SPSA)  States. 
The  percentages  cited  in this report  are  based  on the  responses  to specific  questions 
contained  in the  review  instrument.  The  responses  are  weighted  to reflect  the  sampling 
plan  and  are  projected  to the  Nation.  The  precision  at the  90-percent  confidence 
intervals  vary for  each  question  from  plus or minus  6 to 21 percent  based  upon  the 
nature  of the  question  (categorical  or continuous)  and  the  number  of respondents  to each 
question. 
3  FINDINGS 
STATES  ADDRESS  A MAJORITY  OF  THE  NUTRITION  Requirement% 
HOWEVER  ELIGIBILITY  AND  RELATED  SERVICES  STANDARDS  NEED 
ATIENTION 
The  single largest  component  of the  Older  Americans  Act  (OAA)  is nutrition  services. 
Title  III-C  requires  States  to establish  and  operate  nutrition  projects  which  are  required 
to provide  nutrition  services  to individuals  age  60 and  older  and  for  selected  other 
individuals.  Congregate  and  home-delivered  meals  are  the  most  common  nutrition 
services  provided.  Title  III-C  provides  about  $450 million  annually  for meals  in both 
congregate  and  in-home  settings.  About  3.5 million  individuals  are  served  by nutrition 
projects  annually.  The  OAA  and  related  laws and  regulations  establish  eligibility  criteria 
and  guidance  for  creating  and  operating  nutrition  projects. 
Congregate  Meal  El&ibiZi~ 
Virtually  all States  (95 percent)  provide  guidance  to their  Area  Agencies  on Aging 
(AAAs)  concerning  eligibility  criteria  for congregate  meals.  However,  some  States  have 
no criteria  to assess  AAAs  implementation  of eligibility  criteria  for congregate  meals. 
Regarding  these  eligibility  criteria  we found  that: 
1)  21 percent  have  no assessment  criteria  for ensuring  that  each  AAA  has 
procedures  allowing  the  option  to offer  a meal  to individuals  providing 
volunteer  services  during  the  meal  hours; 
2)  20 percent  have  no criteria  for ensuring  each  AAA  shall  establish 
procedures  allowing  the  option  to offer  a meal  to individuals  with 
disabilities  who reside  at home  with and  accompany  older  eligible 
individuals; 
3)  although  each  nutrition  services  project  may make  nutrition  services 
available  to disabled  individuals  who have  not  attained  60 years  of age but 
who reside  in housing  facilities  occupied  primarily  by the  elderly  at which 
congregate  nutrition  services  are  provided,  12 percent  of the  States  have 
no criteria  to review  this stipulation;  and 
4)  12 percent  have  no criteria  for ensuring  that  nutrition  services  will be 
available  to spouses  of eligible  individuals. 
Homeddivered  Meal  Eligibility 
States  guidance  on and  assessment  of eligibility  criteria  for home-delivered  meals  is 
weaker  than  that  for  congregate  meals.  Three  requirements  were  missing  most 
frequently. 
4  1)  27 percent  of States  have  not  issued  guidance  on eligibility  for home 
delivered  meals  for volunteer  workers  under  age  60, and  36 percent  do 
not  assess  the  implementation  of this eligibility  criteria. 
2)  18 percent  of States  have  not  issued  guidance  on eligibility  for home-
delivered  meals  for handicapped  individuals  under  age  60 living with  a 
participant,  and  22 percent  do not  assess  the  implementation  of this 
eligibility criteria. 
3)  9 percent  of States  have  not  issued  guidance  on participants  spouse  under 
60 years  of age  and  12 percent  do not  assess the  implementation  of this 
eligibility  criteria. 
Use of the  USDA  Cash  and  Commodities  Option 
Since  the  implementation  of the  OAA  nutrition  program,  United  States  Department  of 
Agriculture  (USDA)  legislation  made  available  surplus  commodities  to expand  the 
resources  and  meals  available  through  the  nutrition  program.  In the  late  1970s, Federal 
legislation  provided  States  the  option  of also choosing  cash reimbursements  in-lieu  of 
commodities  based  on the  number  of meals  served.  Commodities  are  surplus  food  items 
sold by USDA  at a discount. 
Our  review  of nutrition  programs  found  that  49 percent  of States  elect  to use the  USDA 
cash only option,  while  51 percent  use  a combination  of cash  and  commodities.  Many 
reasons  were  given for options  selected  by the  States.  The  more  common  reasons  for 
using cash  only were  problems  with the  commodities.  These  problems  included  lack of 
variety  (31 percent),  storage  space  and  costs  (17 percent),  and  transportation  costs  (17 
percent).  The  primary  reason  given for using the  commodities  option  was the  availability 
of bonus  items  (18 percent).  Seven  percent  of States  reported  that  they  left the  choice 
option  up  to a vote  of their  AAAs. 
A number  of AoA  and  USDA  requirements  for the  use  of USDA  cash  and  commodities 
were  frequently  not  addressed  in guidance  or assessments.  We  found  that: 
1)  32 percent  of the  States  have  not  issued  guidance  saying that  food  service 
management  companies  receiving  donated  foods  must  have  contracts  with 
the  nutrition  service  provider.  Further,  46 percent  of the  States  do not 
assess whether  food  service  management  companies  receiving  donated 
foods  have  such contracts; 
2)  27 percent  of States  have  not  issued  guidance  on prompt  reporting  to 
USDA,  and  26 percent  of the  States  do not  assess whether  prompt 
reporting  occurs; 
3)  35 percent  of States  do not  assess whether  there  are  established  procedures 
for the  prompt  and  equitable  disbursement  of USDA  cash  received; 
5  4)  30 percent  of the  States  do not  assess whether  only Title  III-C  grantees  get 
USDA  reimbursement;  and 
5)  24 percent  of the  States  do not  assess whether  records  are  maintained  for  3 
years  on cash receipts  and  disbursements. 
Other  N&n  Requirements  of  Ofi 
Requirements  for the  collection  of voluntary  contributions  are  fully addressed  by all 
States  in their  guidance  to AAAs  and virtually  all assess  their  AAAs  in these  areas. 
However,  25 percent  do not  assess the  collection  of food  stamps  which  can be  used  as 
contributions. 
Health  and  safety  requirements  of the  OAA  are  more  consistently  addressed  and 
assessed  by States  than  many  other  nutrition  services  criteria.  All of the  States  have 
issued  guidance  to AAAs  regarding  both  State  and  local  licensing  requirements,  as well as 
health  department  inspections.  Further,  only 6 percent  have  no criteria  for which  to 
monitor  AAAs  for these  requirements.  We  did find, however,  that  8 percent  have  not 
issued  guidance  in the  area  of fire  department  inspections  and  9 percent  have  no criteria 
assessing  these  inspections. 
Almost  half  of the  States  (48 percent)  do not  monitor  the  AAAs  provision  of other 
nutrition  services.  This  may be because  such services  are  allowed  at State  option  and  not 
all States  call for them.  These  can include  nutrition  education  and  other  appropriate 
nutrition  services  for  older  individuals  such as shopping  assistance. 
STATES  SEEK  TO  CONTROL  NUTRITION  PROGRAM  COSTS 
Congregate  and  Home-delivered  Meal  Cost 
The  reported  cost to provide  meals  varies  among  nutrition  providers  due,  in large  part,  to 
the  use  of different  factors  to calculate  these  costs.  The  factors  used  to determine  meal 
costs included  any number  of combinations  of raw food,  labor,  transportation,  supplies, 
rent,  equipment,  and  other  miscellaneous  costs. The  key issue with  cost factors  is which 
are  used  in what  combinations  to develop  budgets  and  do planning.  While  most  States 
use factors  to calculate  the  cost to provide  meals,  the  other  States  either  used  a set price 
that  AAAs  could  allow for the  cost of a meal  or they  did not  figure  these  costs. 
Many  of the  States  (70 percent)  have  identified  specific  cost factors  for congregate  meals. 
They  include: 
1)  raw food  (52 percent  of States), 
2)  supplies  (46 percent), 
3)  labor/personnel  (43 percent), 
4)  transportation  (34 percent), 
6  5)  operations  (30 percent), 
6)  space/rent  (24 percent),  and 
7)  equipment  (14 percent). 
Many  States  (65 percent)  also specify  cost factors  for  home-delivered  meals  that  include 
the  following  factors: 
1)  raw food  (48 percent  of States), 
2)  supplies  (46 percent), 
3)  transportation  (39 percent), 
4)  labor/personnel  (34 percent), 
5)  space/rent  (24 percent), 
6)  operations  (19 percent),  and 
7)  equipment  (10 percent). 
In addition  to reviewing  cost factors,  many  of the  States  (61 percent)  have  reported 
utilizing  a variety  of m~thods  to help  reduce  the  costs  of required  or  necessary  services, 
to imp~ove  access  to semices,  or to improve  or increase  services.  Among  the  methods 
used  are: 
1)  identifying  non-aging  sources  of funds  for transportation/services 
(20 percent); 
2)  joint  consortium  purchasing  (17 percent), 
3)  changes  in food  preparation  to meet  ethnic,  religious,  or therapeutic  needs 
(14 percent); 
4)  inter-generational  programs  (13 percent); 
5)  nutrition  education  (12 percent); 
6)  obtaining  surplus  or donated  equipment  (9 percent); 
8)  commodity  usage  (9 percent);  and 
9)  eligibility  and  nutrition  status  screening  tool  (8 percent). 
STATES  USE  A  VARIETY  OF  METHODS  AND  STAFF  TO  ASSESS  NUTRITION 
PROGRAMS 
The  nutrition  program  is a multi-faceted  food  service  program  requiring  a number  of 
professional  skills.  In order  to appropriately  assess the  efficacy  and  quality  of the 
delivery  of these  services,  individuals  trained  in food  service,  nutrition,  and  dietetics 
should  provide  a more  thorough  review  of the  status  of such services.  We  found  that 
those  staff who  routinely  perform  assessments  of the  nutrition  program  have  a range  of 
expertise  and  qualifications.  We  found  that  13 percent  of the  States  require  that 
registered  dietitians  conduct  the  assessments.  Another  26 percent  specify using  registered 
dietitians  as part  of an assessment  team.  Eighteen  percent  require  staff with  dietetic 
qualifications  or education;  19 percent  allow qualifications  other  than  in the  field of 
nutrition  but  with working  experience  in the  nutrition  program.  Twenty-two  percent 
permit  the  use  of staff such  as field representatives,  fiscal specialists  and  program 
7  evaluators  (with no nutrition  qualifications  and  expertise)  to conduct  the  nutrition  service 
assessments. 
While  most  States  attempt  to provide  guidance  concerning  a majority  of the  requirements 
for nutrition  services  as outlined  in the  OAA  and  related  laws and  regulations,  they  do 
not  always address  them  through  the  assessment  instruments  or the  actual  assessments. 
In addition  to the  areas  discussed  earlier,  criteria  most  frequently  not  addressed  in the 
assessment  instruments  are:  provision  of canned,  frozen  or supplemental  meals  in the 
home-delivered  meals  program  (40 percent  of States);  nutrition  education  services  (25 
percent);  meals  in weather  emergency  (18 percent);  and  provision  of at least  one  meal, 
five or more  days per  week  (12 percent). 
Generally,  the  criteria  States  include  in their  assessment  instruments  concentrate  on 
specific  programmatic  areas  and  issues.  These  are  usually  considered  State  priorities  and 
what  they  believe  are  the  priorities  of the  Administration  on Aging.  Additional  criteria, 
not  required  by Federal  law or regulation,  have  been  developed  by 79 percent  of States. 
Of these,  57 percent  include  criteria  for menu  development,  and  28 percent  have  specific 
monitoring  and  reporting  criteria. 
Ninety-eight  percent  of the  States  perform  assessments  of AAAs;  56 percent  of these 
States  report  that  they  conduct  them  at least  annually.  The  44 percent  who  reported 
other  than  an annual  assessment  responded  with  a variety  of time  frames.  Responses  in 
our  sample  range  from  we (State  Agency)  dont  assess  the  area  agencies,  we require  the 
AAAs  to monitor  the  nutrition  program,  the last formal  assessment  was done  in the 
1988-1990 cycle, and  several  States  responded  that  they  do them  every  2 to 3 years.  The 
last  completed  cycle of on-site  assessments  was completed  by 37 percent  of States  in 
1992; 42 percent  in 1991; 11 percent  in  1990; and  by 5 percent  prior  to  1990. 
All States  have  procedures  to act  on deficiencies  identified  through  assessments.  Sixty 
percent  of States  utilize  follow-up  letters  or visits; 50 percent  employ  corrective  action 
plans;  42 percent  provide  technical  assistance;  and  14 percent  perform  a subsequent 
evaluation. 
In addition  to the  on-site  assessments,  States  use  a variety  of activities  to monitor  the 
performance  of the  Title  III-funded  nutrition  program.  All of the  States  routinely  review 
United  States  Department  of Agriculture  (USDA)  program  performance  and  other  State 
reports,  such as those  regarding  the  planned  number  of meals  to be  served  contrasted 
with the  actual  number  of meals  served.  Many  of the  States  also review  USDA  cash 
disbursements  (80 percent)  and  commodity  withdrawals  (44 percent). 
In reviewing  the  most  common  problems  faced  by the  nutrition  program,  as identified 
through  the  assessment  and  monitoring  processes,  the  States  have  identified  the 
following: 
1)  inadequate  staff  (49 percent),  (i.e., numbers  of and  qualified  personnel  with 
dietetic/nutrition  educational  background  and  experience); 
8  2)  lack  of resources  (35 percent),  (e.g., funding  and  equipment); 
3)  sanitation  problems  (31 percent); 
4)  meals-related  issues  (14 percent),  (e.g., menu  development,  vendors, 
purchasing,  waiting  lists);  and 
5)  inadequate  provider  assessments  (6 percent)  (i.e., documentation  and 
follow up of AAAs assessment  and  monitoring  of nutrition  service 
providers). 
In further  examining  the  problem  of inadequate  numbers  of qualified  staff, we noted  that 
73 percent  of States  report  having  hiring  standards  for the  staffing  of the  Title  III funded 
nutrition  programs.  These  standards  range  from  general  guidelines  for adequate  and 
qualified  staff  to requirements  outlining  specific  staff positions,  training  requirements 
(e.g.,  15 hours  in food  protection),  and  minimum  hours  of employment  (e.g., full time 
director,  8 hours  per  month  for a registered  dietitian). 
Although  there  are  standards  for the  staffing  of the  program  with qualified  individuals, 
almost  half  of the  States  report  this as a problem.  Several  of our  States  in the  sample 
commented  on this  concern.  One  State  reported  on the  difficulties  in hiring  and  keeping 
qualified  staff  due  to low salaries.  Another  State  reported  the  dilemma  where  whenever 
there  is a cut in budgets,  the  registered  dietitian  position  is usually  the  first  eliminated. 
Another  State  recommended  the  need  for AoA  to address  this concern  in policy  or 
regulations  by outlining  stronger  staffing  standards/requirements;  since  the  lack  of 
enforcement  power  makes  it difficult  for the  network  to justify  and  maintain  adequate 
and  qualified  positions  in the  nutrition  program. 
STATES  PROVIDE  TRAINING  AND  TECHNICAL  ASSISTANCE  TO  ADDRESS 
DEFICIENCIES 
Eighty-five  percent  of States  report  that  they  provide  technical  assistance  or training  to 
address  deficiencies  identified  in AAA  assessments.  They  usually  provide  the  training  on 
a regular  basis  to nutrition  staff or as needed  to others,  such as managers.  A common 
example  of the  latter  is new manager  training  or site manager  training.  When  training 
for nutrition  staff occurs,  it is often  done  at regularly  scheduled  (e.g., quarterly)  meetings. 
The  technical  assistance  provided  by SUAS to their  AAAs  covers  a broad  range  of areas 
and  topics.  Some  deal  directly  with  meal  related  issues such temperature  control, 
sanitary  standards,  menus,  and  the  efficient  delivery  of meals.  Other  commonly 
mentioned  topics  include  nutrition  education,  meal-related  services,  and  managing 
commodities.  A significant  proportion  of nutrition  training  and  technical  assistance 
addresses  administrative  concerns,  such  as, cost controls,  client  screening  and  tracking, 
targeting,  and  reporting. 
We  also found  that  many  States  (59 percent)  have  established  standards  for the  training 
of Title  III-funded  nutrition  program  staff.  Among  these  States,  78 percent  specify the 
training  topics  for  staff functions,  17 percent  specify the  frequency  of training,  and  25 
percent  identify  the  specific  training  sponsors  or agencies. 
9  APPENDIX  A 
Review  Instrument  For  Nutrition  NUTRITION  COMPLIANCE  REVIEW 
Department  of Health  and  Human  Services 
Administration  on  Aging 
State  Date 
Primary  Respondent  Telephone 
Review  Team  Leader  Telephone 
---------------------------------- ---------------- ---------
1.  Prior  to the  on-site  visit,  obtain  copies  of policies,  procedures,  and  other  guidance  to Area 
Agencies  on A~ng  (IL&is)  on  nutrition  services  j%om the  Sttie  Agency  on Aging  (State 
Agency).  Review  and  determine  whether  or not  these  issuances  address  the  cnte~ia 
identified  in the following  table.  Indictie  your  responses  with  an  X in the  appropnate 
column  reflecting  these  codes: 
Y (Yes)  =  Total  Compliance  with  Criteria 
P  (Patial)  =  Pa~al  Compliance  with  Criteria 
,V (No)  = 
L~d  h  Complhn  Cf?  with  Cnten-a 
Dunng the  desk  review,  if the policy  m~erials  do  include  those  items  necessary  to 
make  a determin~on  of  compliance  (1(, P,  or N),  mark  NA  (Not  Available)  in the 
Comments  section  of the  table. 
CRITER1~  Y  P  N  CONIMENTS 
a.  1.  Eligibility  for Congregate  }Ieals 
60+ 
OA~ 307(a)f13)(A) 
b.  Handicapped(< 60) livingwith 
participant 
OAA307(a)(13)(1) 
c.  Handicapped( < 60) living  at meal  site 
OAA307(a)(13)(A) 
d.  Spousef < 60) of participant 
OAA307(a)(13)(A) 
e.  Volunteer  ( < 60)  worker 
OAA  307(a)(  13)(1) 
f.  2.  Eligibility  for  Home  Delivered  %leals 
60+ 
OAA  307(a)(  13)(A)(B) 
ii- 1  CRITERIA  Y  P  N  COMMENTS 
~  Handicapped  ( <60)  living  with 
participant 
OAA  307(a)(  13)(1): 45  CFR 
1321. 17( f)(12);  AOA-PI-89-02 
h.  Spouse  ( <60)  of participant 
OAA  307  (a)(13)(A);  45  CFR  1321.69B 
i.  Volunteer  ( < 60)  worker 
OAA  307  (a)(ls)(r) 
j.  I&R  for  other  participant  needs 
45  CFR  132 1.65(d)(f) 
k.  Provide  canned,  frozen.  or supplemental 
meals 
OAA  Part  C-2.  Section  336 
1.  Meals  in weather  emergency 
45  CFR  1321.65(e) 
m.  3.  USDA  Cash/Commodities 
Used  by Title  III-C  finded  providers  for 
the  provision  of eligible  meals  regardless 
of the  finding  source 
OAA  311(a)(l)  & (2) 
n.  Cash  purchases  only  U.S. -grown  food 
OAA  31 l(b)(2) 
:,,..,,:,.:. 
0.  Prompt  reporting  to USDA	 .,,.. .......... ,.:.,,....,.,...,.,,,,,.,...:,
:,:,::::::::::::::::
OAA  31 l(c)(l)(B),  31 l(b)(2);  :. ._,,.:.,..,,,:,,,,: ..:.x,:,..:,,:..:,:.:,:,:,:.:::
UPaSrDt A2 50F.4o2o(dC )(D5)is(it)r ibution  Regulations,  ..,.:.:......,.,,,...,,,,:...,...,,,x....,,., ..,.,..,,,.:..,,,.,...,.,..,..,...:,. .,....,:....,,..,...,,,.,...,.:...,..,......:..,.,.,,.,,, ,..,.:,.,,:,,,..,,,,,,,.,:.,,,,:...::,,:
..... .... ...
P.  Food  service  management  companies  ,...:,..,:: .,.....,..,., ::,.:,..,:.,::::.:....,,:.,. ,:.
receiving  donated  foods  have  contract  ...:,...,.: .:,,:.:,.....,.,../,.,.:: ,:,:,.....,....:.:.,...,...:.:.
with  the  nutrition  service  provider  ,,.,..,,,.,,..:., .:...., .,.,.:,,.,Y:,:...,.,....,.,::, ,.,..:.::,,
UBS( D12A)( c)R egulations,  Part  250,  Subpart  ....,,.,.:......:..,,:..:, ,.:..,.:..,,.:...,:,.:.,.. .:...,,,.....:,:, ,,,.::::::,
...:...., , .,,,..,,,.. 
q.  Only  IHC  grantees  get  USDA  ::,,.:.:::.:
reimbursement  ..,,.::,.: ...,. ..,.}:.. .:..,,...,.,.:.,,.,,.,.,,...:.,,., :,,,,
OAA  311(a)(l)  .,..,...,,....,. .,.::,:
r.	 Maintain  for 3 years  records  of cash  .......... .,.,.:.,....::.:... ..
received  and  distributed  .:,:.: .,,.,.::.
:..,.., 
UPaSrDt A2 50F.4o2o d (c)D(iiisit)r ibution  Regulations.  ..:,,,.:.,..,., .,.:..., . 
s.  Establish  procedures  for  the  prompt 
and  equitable  disbursement  of USDA 
cash  received 
OAA  31 l(b)(2) 
A-2  CRITERIA  Y  P  N  COMMENTS 
t.  4.  Nutrition  Services 
Location  of nutrition  sites 
OAA  307(a)(  13)(D) 
u.  Outreach  to eligible  individuals 
OAA  307(a)(  13)(E) 
v.  Each  meal  provides  a minimum  of  1/3 
RDA 
OAA  Part  C - Section  331(1) 
w.  Provide  at least  one  meal,  5 or  more 
days  per  week 
OAA  Part  C - Section  331(1) 
x.  Nutrition  education  services 
OAA  Part  C - Section  33 1(3) 
y.  Other  nutrition  services 
OAA  Part  C - Section  33 1(3) 
List  other  nutrition  services  in State: 
z.  Special  menus 
OAA  307(a)(  12)(G) 
List  special  menus  in State: 
aa.  Assure  competition  in provider  selection 
OAA  Sec.  501 (b),  Comprehensive  Older 
Americans  Act  Amendments  of  1984: 
45 CFR  Part  92,  36(8)  Procurement 
bb.  5.  Voluntary  Contributions 
Collect  and  safeguard  cash 
OAA  307(a)(  13)(C)(i) 
cc.  Collection  of  food  stamps 
45  CFR  1321 .65(c) 
dd.  Confidentiality 
45 CFR  1321.67(a)(2) 
W.  6.  Health  and  Safety 
State  and  local  licensing  requirements 
45  cm  1321.75 
ff.  Health  department  inspections 
45 cm  1321.75 
A-3  CRITERIA  Y  P  N  COMMENTS 
i  i 
%?l  Fire  department  inspections 
45  cm  1321.75 
At  this  point,  you  should  have  completed  the  in-house  compliance  review  of the policies, 
procedures,  and  other  guidance  provided  to AAAs  on  nutrition  services.  For  each  cnteria la
lgg  indi~~ng an entry of .~(),p~T~,  or NOT  Av~~LE,  listitin the ~rst cohunn  of 
question  2 prior  to the  on-site  interview.  NOTE:  For those  items  marked  iVA as  a result  of the 
desk  review,  St&e  Agency  responses  may  indictie  conveting  the  NA  to  Y, P,  N,  CMSL  (Cntena 
met  al  State  level),  or NSC  (State  Agency  does  not  address  this  applicable  Federal  cntena).  Ask 
question  2 during  the  on-site  visit following  the  brief  explan~on  initi~ng  the  intemiew. 
7-.  A few weeks ago.  we requested  copies of the policies,  procedures,  and other  guidance 
provided  to the Area  .~gencies on Aging concerning  nutrition  services.  These  were 
reviewed  against  specific  nutrition  criteria  contained  in the Older Americans  Act and the 
Title  III regulations.  During  this review,  we identified  issuances  which only partially 
addressed  specific  criteria.  or we were unable to identify  issuances  addressing  specific 
criteria.  For these.  I need to understand  how the State Agency  directs  and guides the 
AAAs 
to ensure  that nutrition  services  requirements  are met for those criteria  not addressed  or 
partially  addressed. 
Criteria  # with 
No,  Partial,  or 
Not ..Availableentrv  Asencv  Response 
A-4  (If additional  space  is required,  use  the  back  of the previous  page) 
3.	 Beyond  that  required  by  Federal  law  or  regulation.  what  guidance  have  you  provided  to 
AA/M  on nutrition  services? 
a. 
b.  Dont Know  (Check  if applicable)  4.	 Prior  to  the  on-site  visit,  obtain  a copy  of the  instrument  used  by the  State  Agency  to 
assess  compliance  and  performance  of A&is  with  nutrition  service  law  and  regultions. 
If the  questions  on  nutrition  service  are part  of a lizrger  review  instrument,  ask  the  Sttie 
Agency  to  identi!  or  highlight  those  items  pertaining  to  the  review  of nutrition  service 
efforts.  Have  the  St&e  Agency  mark  the  instrument  with  the  applicable  cntena(e.g., 
a,  b,  c,  etc.)  using  a provided  copy  of the  cntena.  17tis infonn~onal  request  should  be 
included  in the  letter  thti  is sent  to the  State  Agency  outlining  the  Compliance  Review. 
Review  and  determine  whether  or not  the  assessment  instruments  address  the  nutrition 
service  criteria  identified  in the follo wing  table.  Indicate  your  responses  with  an  X in the 
approptie  column  reflecting  these  codes: 
Y ~es)  =  Total  Compliance  with  Criteria 
P  (Patial)  =  Pa&al  Compliance  with  Crttena 
N  (No)  =  Not  in  Compliance  with  Cntena 
Dun-ng  the  desk  review,  if the  assessment  instrument  and  related  materials  do  w  include 
those  items  necessary  to make  a determination  of  compliance  (Y,  P,  or  mark  NA  (Not 
iV), 
Available)  in the  Comments  section  of the  table. 
CRITERIA  Y  P  N  COMNIENTS 
a.	 1.  Eligibility  for  Congregate  Meals 
60+ 
OAA  307(a)(  13)(A) 
b.	 Handicapped  ( < 60)  living  with 
participant 
OAA  307(a)(  13)(1) 
c.	 Handicapped  ( < 60)  living  at meal  site 
OAA  307(a) (13)(A) 
d.	 Spouse  ( < 60)  of participant 
OAA  307(a)(  13)(A) 
e.	 Volunteer  ( < 60)  worker 
OAA  307(a)(  13)(I) 
f.	 2.  Eligibility  for  Home  Delivered  Meals 
60+ 
OAA  307(a)(  13)(A)(B) 
&?.  Handicapped  ( < 60)  living  with 
participant 
OAA  307(a)(  13)(1); 45  CFR 
1321. 17(f)( 12); 40#4.pI.g94)~ 
h.	 Spouse  ( < 60)  of participant 
OAA  307  (a)( 13)(A);  -$5 CFR  1321 .69B 
I 
A-6  CRITERIA  Y  P 
Volunteer  (<60)  worker 
OAA  307  (a)( 13)(1) 
.  I&R  for other  participant  needs  I 
45CFR  1321.65(d)(f) 
c.  Provide  canned,  frozen,  or supplemental 
meals 
OAA  Part  C-2.  Section  336 
1.  Meals  in weather  emergency 
45CFR  1321.65(e) 
m.  3.  USDA  Cash/Commodities 
Used  by Title  HI-C  fimded  providers  for 
the provision  of eligible  meals  regardless 
of the funding  source 
OAA  31 l(a)(l)  & (2) 
n.  Cash  purchases  only  U.S. -g,rown  food 
OAA  31 l(b)(2) 
Prompt  reporting  to USDA 
D. 
OAA  31 I(c)(1)(B),  31 l(b)(2); 
USDA  Food  Distribution  Regulations. 
Part  250.42(C)(5)(i) 
I 
P  Food  service  management  companies 
receiving  donated  foods  have  contract 
with  the nutrition  service  provider 
USDA  Regulations,  Part  250,  Subpart 
B(12)(c) 
q.  Only  IIIC  grtantees  get  USDA 
reimbursement 
OAA  311(a)(l) 
r.  Maintain  for 3 years  records  of cash 
received  and  distributed 
USDA  Food  Distribution  Regulations. 
Part  250.42 (c)(iii) 
s.  Establish  procedures  for the  prompt 
and  equitable  disbursement  of USDA 
cash  received 
OAA  31 l(b)(2) 
t.  4.  Nutrition  Services 
Location  of nutrition  sites 
OAA  307(a)(  13)(D) 
u.  Outreach  to eligible  individuals 
OAA  307(a)(  13)(E) 
A-7  CRITERIA  Y  P  N  COMMENTS 
v.  Each  meal  provides  a minimum  of  1/3 
RDA 
OAA  Part  C - Section  331(1) 
w.  Provide  at least  one  meal.  5 or  more 
days  per  week 
OAA  Part  C - Section  531(1) 
x.  Nutrition  education  services 
OAA  Part  C - Section  33 1(3) 
Y  Other  nutrition  services 
OAA  Part  C - Section  331(3) 
List  other  nutntion  services  in State: 
z.  Special  menus 
OAA  307(a)(  12)(G) 
List  speciai  menus  in State: 
aa.  Assure  competition  in provider  selection 
OAA  Sec.  50 l(b),  Comprehensive  Older 
Americans  Act  Amendment  of  1984: 
45  CFR  Part  92,  36(8)  Procurement 
bb.  5.  Voluntary  Contributions 
Collect  and  safeguard  cash 
OAA  307(a)(  13)(C)(i) 
cc.  Collection  of food  stamps 
45  CFR  1321.65(c) 
dd.  Confidentiality 
45  CFR  1321.67(a)(2) 
ee.  6.  Health  and  Safety 
State  and  local  licensing  requirements 
45  cm  1321.75 
ff.  Health  department  inspections 
45  CFR  1321.75 
W   Fire  department  inspections 
45  cm  1321.75 
For  each  cdeti  4a-4gg  indicaing  WI entry  Of NO,  plWTLU,  or NOT  A VMLABLE,  list  it in  the Jimt  column  of  question  5 prior  to the  on-site  interview.  NOTE:  For  those  items  marked 
NA  as  a result  of the  desk  review,  State  Agency  responses  may  indictie  conve~ng  the  NA  to  Y, 
P,  N,  CMSL  (Critezia  met  at St&e  level),  or NSC  (Stae  Agency  does  not  address  this  applicable 
Federal  critena).  Ask  question  5 during  the  on-site  visit. 
5.  A few  weeks  ago,  we also  requested  a copy  of the  assessment  instrument  and  any  applicable 
tools  used  by the  State  Agency  to assess  compliance  and  performance  of  AAAs  with 
nutrition  service  law  and  regulations.  These  were  reviewed  against  specific  nutrition  service 
criteria  contained  in the  Older  Americans  Act  and  the  Title  III  regulations.  During  this 
review,  we  identified  issuances  which  only  partially  addressed  specific  criteria,  or we were 
unable  to  identify  issuances  addressing  specific  criteria.  For  these,  I need  to understand 
how  the  State  Agency  assesses  the  AAAs  to  ensure  that  nutrition  services  requirements  are 
met  for  those  criteria  not  addressed  or partially  addressed. 
Criteria  # with 
No,  Partial,  or 
Not  Available  entw  (If additional  space  is required,  use  the  back  of the previous  page) 
6.  What  criteria,  not  required  by Federal  law  or  regulation,  has  the  State  Agent  y included  in 
its assessment  instrument  for  nutrition  programs? 
a. 
b.  Dont Know  (Check  if applicable)  7.  Howoften  does the State Agency  assess the Title 111-fimdednutrition  programs? 
a.  Annually 
b.  Semi-annually 
c.  Quarterly 
d.  Monthly 
e.  Other  (Specijj  time  period) 
f.  Dont K. IOW (Check  if applicable) 
8.  What  are  the  start  ; nd end  dates  for the  last  completed  cycle  of on-site  assessments? 
a.  Start date -
b.  End date  -
9.  Who  routinelv  conducts  these assessments?  (Probe:  #,  qualificalzons) 
L 
individual/JOB  TITLE  QUALIFICATIONS 
a. 
b. 
c. 
d. 
e. 
f.  Dont Know  (Circle  if applicable) 
10.  What  are used to follow-up  on 
a. 
b.  Dont Know  (Check  if applicable) 
A-11  11.  Which  of  the  following  activities  does  the  State  Agency  use  to  monitor  the  Title  III-funded 
nutrition  programs?  (Read  the following  list  and  check  responses.) 
a.  Review of  reports  (USDA.  Program  Performance.  or  other  State  reports 
regarding  the  planned  number  of  meals  to be  served  contrasted  with  the 
number  of meals  actually  served). 
b.  Commodity  withdrawals 
c.  USDA  cash  disbursements 
d.  Other  (ExpZain): 
e.  (Check  if applicable) 
12.  What  are the most  common  detlciencies  in the  nutrition  program  in this  State? 
a. 
b. 
c. 
d. 
e. 
f.  Dont  Know  (Check  if applicable) 
13.  What technical  assistance  or training  has  the  State  provided  to address  these  deficiencies? 
a. 
. 
b.  Dont Know  (Check  if applicable)  14.  Has  the  State agency  established  hiring  standards  for  staffing Title 111-fimded nutrition 
programs? 
a.  Yes,  Please  explain: 
b.  No 
c.  Dont  Know  (Check  if applicable) 
15.  Has the State agency  established  standards  for the training  of Title III-funded  nutrition 
program  staff? 
a.  Yes,  Please  explain: 
b.  No 
c.  Dont  Know  (Check  if applicable) 
16.  Some of the factors  that might be used in calculating  the  cost  of  meals  would  include:  raw 
food,  labor,  space,  supplies,  transportation  and  utilities.  In order  to ensure  a degree  of 
uniformity  in the  calculation  of  meal  costs,  what  cost  factors  does  the  State  Agency  allow 
when  the  cost  of  meals  is being  calculated? 
* 
FACTORS 
CONGREGATE  MEALS  HOME  DELIVERED  MEALS 
a.  aa.
b 
A-13  b.  bb. 
c.  cc. 
d.  dd. 
e.  ee. 
f.  State Agency  does  not  specify  ff.  State Agency  does not specify allowable 
allowable  cost  factors  cost factors 
(Circle  if applicable)  (Circle  if applicable) 
Dont  Know  gg.  Dont  Know 
(Circle  if applicable)  (Circle  if applicable) 
17.  Of the  following,  which USDA option  did the State choose? 
a.  Cash 
b.  Commodities 
c.  Cash and Commodities 
d.  Dont Know  (Check  if applicable) 
18.  Why  was this option chosen? 
a. 
b.  Dont  Know  (Check  if applicable) 
A-14  19.	 Does  the  State  have  any  innovative  programs  that  reduce  costs,  improve  access,  or 
improve/increase  services? 
a.  Yes,  Please  explain: 
b.  No 
c.  Dont  Know  (Check  if applicable) 
20.	 The preselected  sample  of  10 Area  Agencies  on  Aging  were  identified  prior  to the  on-site 
visit.  IWis sample  is to be  used  throughout  the  compliance  review  process  for  all jive 
areas,  the jirst  compliance  review  being  Stewardship. 
For  the  sample  AAAs,  obtain  the  most  currently  completed  annual  cycle  of  Stale  Agency 
assessment  instruments  and  con-esponding  assessment  repotis  (if any).  Review  the 
assessment  jindings  and  detenrtine  the  extent  to  which  each  of the  sample  AAAs  were  in 
compliance  with  each  of the  ctieti  identi!ed  in Attachment  A.  Record  your  responses 
on  the following  table  using  these  codes: 
Y (les)  =  Total  Compliance  with  Ctiteria 
P  (Pati)  =  Pati  Compliance  with  Criteti 
N  (No)  =  Not  in  Compliance  wilh  Cdena 
ivsc  =  No  State  C&eria  (State  Agency  does  not  assess  this 
Federal  criteria  - identified  through  in-house  review  of 
State  Agencys  assessment  tool  and  related  m~enak) 
CMSL4 =  Ctieti  met  al State  level 
o	 =  Other  Finding  (@wide  explan~on  and  indicate  by 
repoti  number  and  criteti  number  in the  Comments 
sec~on follo  wing  the  table) 
A-15  Name 
10 
Sample  1  2  3  4  5  6  7  8  9 
Number 
Criteria 
a. 
b. 
c. 
d. 
e. 
f. 
: 
h. 
i. 
j. 
k. 
1. 
m. 
n. 
o. 
A-16  I 
~,   
,. 
Name ,  
10 
Sample  1  2  3  4  5  6  7  8  9 
Number 
P. 
q. 
r. 
s. 
t. 
u. 
v. 
w. 
x. 
Y. 
z. 
aa. 
bb. 
cc. 
dd. 
A-17  I 
10 
2  3  4  5  6  7  8  9 
COMMEN:T S
[INTERVIEW  COMPLETED] 
A-18