# This monitoring template is not guidance nor legal advice provided by the Nutrition and Aging Resource Center or the Administration for Community Living.

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# Senior Nutrition Program 

# Local Home-Delivered Meal Monitoring Tool

**PROVIDER AGENCY:**

**ASSESSMENT DATE**:

**TIME OF MEAL:**

**NAME AND TITLE OF PERSON COMPLETING THIS FORM:**

**SIGNATURE:**

**AGENCY STAFF INTERVIEWED:**

The following checklists provide guidance for local nutrition service providers who are monitoring nutrition site(s). Those items required by the Older Americans Act (OAA) have been indicated with a parenthetical (OAA citation). Items that the OAA does not cover are highly recommended standards of practice. This tool provides examples of questions that could be asked during a site visit. Nutrition service providers are encouraged to modify this form to align with their specific program policies and procedures.

If food is not prepared onsite, name the current vendor for food preparation and delivery:

Document the current meal service process (e.g., the agency is providing frozen meal carry-out meal service to program participants in the senior center parking lot daily; home-delivered meals clients are delivered five frozen meals each Monday; meals continue to be prepared by a local hospital in compliance with a certified menu; participants are called once a week by staff/volunteers for a safety check and for socialization; consumer contributions are accepted):

Other comments:

# MEAL OPTIONS

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##  Menu Planned vs. Served

If the meal served is different than planned, is there a document signed by an RD approving the change?

☐	Yes

☐	No

Comments:

Menus are approved by an RDN, demonstrating compliance with the OAA and SUA nutrition requirements.

☐	Yes

☐	No

Comments:

Describe the arrangements for the dietitian/nutritionist's involvement in the nutrition program (for example, who employs the dietitian, does the dietitian develop the menus and recipes, how often does the dietitian review menus, how does the dietitian receive menu substitutions for approval, etc.).

Comments:

# Home-Delivered Meal Program Management

**Home-delivered meal site location & date:**

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# Home-Delivered Meal Service Audit

# Meal route name and date:

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# Food Temperatures

**Delivery start time:**

**Last meal delivered:**

# Home-Delivered Meal Observation Key Tips

· Note observations about food presentation and palatability based on direct experience or interactions with clients on day of site visit. 

· Note observations about the perceived eligibility of clients in attendance on day of site/route visit:      

· Are there any other observations you would like to make (e.g., things the site should work on, TA that is recommended for the site, etc.)?

· Identify the names of 3-5 individuals who received a meal on the day of the site visit:      

· Include 2 or more of these names in the client record reviews OR verify that these names are included in the agency's client database.

· Program Income Verification: The purpose of this item is to establish appropriate procedures to safeguard and account for all contributions. (OAA315(b)(D))

With assistance from nutrition/agency staff, trace one or more transactions from each program from the point of collecting program income through recording in the general ledger:

· Amount collected at nutrition site on (date): $

· Amount counted and recorded at location: $

· If the administrative offices are a different location from nutrition site: $

· Amount recorded on deposit slip for the sample date: $

· Amount recorded in general ledger or accounting records of the provider: $

There should be a clear audit trail from the point of counting program income to the point of deposit and recording in the general ledger. Explain any difference in these amounts:

**Document Review Checklist:**

_____ Procedures to follow in the event a participant becomes ill or injured

_____ Health department sanitation inspection and permits (must be posted in a visible location) (OAA 339 (2)(F))

_____ Provider notified AAA if the sanitation grade falls below "A" or 90% 

_____ Documentation for required drills (e.g., fire, tornado). Drills are conducted regularly on-site

_____ Current fire department inspection report or record of efforts to have an inspection completed

_____ Training documentation for site managers (e.g., site operations, record-keeping, referral process, food safety, and food portioning)

_____ Emergency plan for medical emergencies and evacuation in case of emergencies

_____ Policy for registered participants and receiving full payment/reimbursement for those who are ineligible

_____ Written procedures for reporting changes in the eligibility of meal clients (i.e., termination of services)

_____ Policy for serving people with accommodation needs and mobility challenges

_____ Site has a grievance policy and system for collection for HDM clients.

_____ Policy and procedures related to food safety and time/temperature control 

_____ Procedures to document eligible meal clients receive telephone reassessments routinely, per SUA/AAA policies

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# Home-Delivered Meal Records Review

# DATE OF ASSESSMENT:

# AGENCY:

# MONTH AND YEAR REVIEWED:

# FUNDING SOURCE:

Reviewer should select a random sample of clients from each site for home-delivered/route/worker code and include one or more special eligibility clients (if any).

· Attach to this worksheet the Units of Service Verification Report used to select the sample of clients and units. Identify the persons sampled and the month(s) reviewed in this report. Also, attach copies of other worksheets, such as copies of the Nutrition Site Monitoring Checklist or comparable documents.

· On the reverse side of this worksheet, list the clients and specific dates for which units could not be verified, if applicable.

· Provide a copy of both sides of this completed worksheet to the agency during the exit interview if unverified units are found.

TOTAL UNITS NOT VERIFIED:

Total units reported for all clients in the month reviewed:

THIS REPRESENTS  % OF TOTAL UNITS REPORTED FOR THE MONTH REVIEWED. If 10% or more, expand the sample and select another month to review.   

# Home-Delivered Exit Conference

**Suggested Corrective Action/Technical Assistance:SIGNATURE OF REVIEWER:**

**DATE COMPLETED:**

**SIGNATURE OF REVIEWER:**

**DATE COMPLETED:**

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**DATE COMMUNICATED WITH SITE/AGENCY:**

**COMMENTS OR DISCUSSION WITH AGENCY:**

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**MONITORING FOLLOW-UP (CORRECTIVE ACTIONS COMPLETED) note dates and corrective actions:**