Sample Program & Personnel Management Policies and Procedures

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

<Name of Agency>

# ****Nutrition ServicesProgram & Personnel ManagementPolicies and Procedures

< Additional agency information>

<Date created/last updated><Agency disclaimer, if applicable>

# Eligibility

Congregate Meal ProgramCongregate meals are available on a contribution basis to the following persons:

Participants 60 and older — regardless of sex, national origin, or residency — are eligible for the elderly meals and nutrition program.

The spouse of an eligible participant — regardless of sex, nation of origin, or residency — is also eligible for the nutrition program meals and nutrition education for a donation.

Individuals with disabilities who reside in the home of a participant who is eligible for the nutrition program and nutrition education and attend with the participant are eligible for the congregate meals and nutrition education on the same basis as the eligible participant.

Individuals with disabilities who reside in a senior housing facility at which congregate meals and nutrition services are provided are also eligible for meals and the nutrition program.

Individuals who are under 60 years of age and provide volunteer services during meal hours shall be offered a meal on the same basis as meals provided to eligible participants.

Volunteer service means that a minimum of one hour of volunteer service is given on the day the meal is consumed.

The volunteer is eligible for the senior contribution rate only on the days that volunteer services are performed. On these days, volunteers are encouraged to make a voluntary, confidential contribution to the meal.

Staff and volunteers who are 60 and older may participate in the meals and nutrition program on the same basis as an eligible senior.

People under 60 years of age (50-60) not covered by the Older Americans Act (OAA) and employees under 60 years of age may choose to purchase an entire meal at the full contracted cost of the meal. Reservations must be made and paid for at the time of reservation.

People under 60 years of age (50-60) not covered by the OAA that have not made a reservation and paid in advance will only get a meal if the center has extras.

Persons who cannot function independently must be accompanied by a constant companion (this does not include persons who need help only to get their meal).

Individuals who exhibit inappropriate behavior that is potentially dangerous to others or creates situations that impede socialization may be denied participation in the congregate program. Persons who repeatedly abuse the reservation system may be asked not to participate. However, this should be a last resort, and staff should work closely with the client services office to ensure the participant does not go hungry (i.e., set them up for a home-delivered meal, have a family member pick up a meal, coordinate services through local food banks, etc.).

Home-Delivered Meals

Home-delivered nutrition services shall be available to any person 60 and older who:

Is homebound by reason of illness or otherwise isolated. The term “otherwise isolated" may be interpreted as isolation related to not being comfortable with dining in a group setting.

Is unable to participate in the congregate dining program due to the inability to travel to a congregate meal site. (This does not include participants who may not be allowed to attend centers due to inappropriate behavior.)

Is at nutritional risk.

Has limited or no in-home care provider(s) — such as a relative, friend, or fee-for-service aide — available to obtain food and/or prepare meals on a regular basis.

Cannot safely prepare meals due to physical disability or mobility limitations, dementia, or other documented psychological impairment.

Needs temporary support following discharge from a hospital or other health care facility.

The spouse of the home-delivered participant, regardless of age, may receive a home-delivered meal if, according to the criteria determined by the <agency>, receipt of the meal is in the best interest of the participant.

Home-delivered meals may be offered to persons with disabilities regardless of age when the individual with disabilities resides at home with an eligible older person.

Home-delivered meals may be offered to persons of any age when they meet the eligibility criteria listed above. Persons under 60 will be asked to pay for the full cost of the meal.

# Cost/Donations

1.  Congregate Program All program income from the congregate program shall be used to increase the number of meals served, facilitate access to meals, and provide supportive services directly related to the nutrition program.

For a meal provided through the nutrition program, there shall be no mandatory fee to any participant, volunteer, or staff who meets the eligibility requirements.

Voluntary contributions shall be allowed and may be solicited if the method of solicitation is noncoercive.

Eligible participants shall determine for themselves what they are able to contribute toward the cost of the service.

Contributions shall be voluntary and confidential for all eligible participants, including volunteers. This is accomplished using an envelope system. Each eligible person receives an unmarked envelope for their donation, which is collected after the meal is delivered or placed in the locked drop box during meal time.

No eligible participant shall be denied a nutrition service because of failure to contribute.

Cost sharing and means testing shall not be conducted. Participants cannot be asked to pay a certain amount based on their income level.

<Appropriate staff> have a system to identify eligible vs. non-eligible participants. Non-eligible persons should be marked with an asterisk on the reservation list with a check under the non-senior column.

<Appropriate staff> require payment at the time of registration for meals for ineligible persons who participate in the senior dining meal program.

Non-eligible participants are any persons under 60 years of age who do not fall into any of the participant eligibility criteria listed above.

Non-eligible participants will pay the full cost of the meal.

Ineligible meals are reported as Title III income but are recorded in the database as ineligible so they are not counted as eligible meals for state reporting purposes.

Ineligible participants will pay the <appropriate staff> directly.

Employees or volunteers who are under 60 years of age may purchase individual meal items instead of a complete meal, but only when it is assured that no senior has been denied a meal or a second serving.

A sign listing individual meal items and the cost of each item shall be posted at each site.

Employees or volunteers shall pay the <appropriate staff> for the cost of items selected prior to consumption.

Individuals may select to pay for meals on a daily, weekly, or monthly basis.

Employees or volunteers shall not select any “leftover” items until all patrons have been offered the opportunity for second servings. These second servings shall only be counted as an additional eligible meal if the eligible person receives a full second meal.

Staff-selected meal item income shall be counted as Title III income and will be recorded in the database as ineligible meals.

<Appropriate staff> will place all staff members/volunteers under 60 years of age on the reservation sheet, and they shall be noted with a check in the non-senior column.

When publishing financial requests for meals in <agency> publications, the “cost” of a meal shall be referred to as a suggested donation.

All persons receiving a meal, along with the number of meals ordered, should be recorded on a reservation sheet which must be submitted weekly to the <appropriate staff>.

Home-Delivered Meals

Voluntary contributions are solicited from program participants for meals; however, the method is not coercive. Clients receive a letter monthly from the <agency> outlining the number of meals received and the cost per meal to aid in considering their contribution.

Collection and handling of funds is a <agency> function. <Describe process>.

Services are not denied to any eligible individual who does not contribute to the cost of the service. Donations are kept confidential and protected from loss, mishandling, and theft.

Contributions received are reported as program income and as a <agency> cash contribution. Program income and cash contributions are used to increase the number of meals served, facilitate access to meals, and provide supportive services directly related to the home-delivered program.

# Confidentiality

Staff and volunteers will ensure the confidentiality of all participants receiving nutrition services through the congregate program and home-delivered meals.

Information about or obtained from a participant served by the nutrition program shall not be disclosed without the individual’s written consent.

Exception: Participant information shall be shared, as the need arises, between the <appropriate parties>.

No participant data is shared with any agency or person seeking information through questionnaires, polls, assessments, surveys, etc. without prior written approval of <agency>.

Pictures of individuals taken during congregate, home-delivered, and senior activities shall not be published without a signed participant photo release form. 

# Grievance/Complaint Procedure

Follow the requirements for a grievance procedure as established by the <agency> in accordance with the Older Americans Act (Section 307.a.43).

If an individual feels they have been treated unfairly by staff or volunteers, the participant has a right to an appeal meeting which will be arranged as outlined in the following grievance procedure:

Older individuals who express their dissatisfaction or the desire for an appeal meeting to <agency> staff will be given a copy of the grievance procedure. Or, find information on filing a civil rights complaint (HHS).

The complainant will have <number> days in which to submit a written appeal letter to the attention of <name and address>. The appeal letter must include all the following:

Complainant’s full name, address, and telephone number.

Complainant’s signature.

Clear description of the issue(s).

Statement of the complainant’s position on the issue(s).

Pertinent facts in support of the complainant’s position.

The program will acknowledge, in writing to the complainant, its receipt of the letter within <number> days of receiving the appeal letter.

The program will conduct an agency review of the action, which is the basis for the complainant’s appeal.

Within <number> days of receiving the appeal letter, the program will notify the complainant, by certified/return receipt mail, of the results of the review. The review may support, modify, reverse, or let stand the original decision.

If the original decision is unchanged, the certified letter will also inform the complainant of the date, time, and place of an appeal meeting to provide the complainant an opportunity to present a statement of facts and additional pertinent information. This meeting shall be scheduled to occur within <number> days of the complainant’s receipt of the review letter. If there is no further communication from the complainant within <number> working days, the issue will be considered resolved and closed.

Within <number> days after the appeal meeting, the <agency> will issue a written final decision to the complainant via certified mail.

# Monitoring and Inspection Procedures

All staff members shall follow applicable federal, state, local, and <agency> food service and health requirements, policies, and procedures.

Periodic Dining Facility/Delivery Inspections

Congregate Program

The <appropriate staff> shall perform periodic inspections of the dining facility and the delivery method in conjunction with daily oversight.

The <appropriate staff> will conduct an unannounced site visit/inspection of the nutrition sites at least <frequency>. These visits will be documented.

During health department or <agency> inspections, <appropriate staff> shall take immediate corrective action to improve any practices found out of compliance or not economical for the operation.

Documentation of all self-monitoring/inspections and all corrective actions shall be kept on file for a minimum of <number> years.

Inspector should verify that the following items are posted in the dining room:

Current license.

MyPlate nutrition education.

Food temperatures.

Material safety datasheets for chemicals.

HACCP manual.

Current menu with substitutions.

The <appropriate staff> will conduct unannounced site/visit inspection of the program at least <frequency>.

Health Department Inspections

The kitchen may be monitored annually by the health department. On-site kitchen/food production and serving facilities shall receive a good to excellent rating from the local health department.

<Designated staff> shall immediately notify their supervisor when a health inspection occurs. The supervisor will notify the <appropriate parties>. Furnish a copy of each inspection report to the <appropriate staff> within <number> working days of receipt from the inspecting agent.

<Designated staff> will make sure that any necessary corrective actions are completed immediately.

Corrective action shall be taken. 

<Designated Staff> shall submit a full report on findings and corrective actions taken to the <appropriate manager> within <time period> of the inspection.

# Participant Input/Satisfaction

Congregate Program

The <agency> takes a proactive approach to ensure customer satisfaction by regularly soliciting client input, asking questions, paying attention to the daily meal program statistics, noting verbal and non-verbal feedback on the weekly menu logs, plate waste, responses to written surveys, and feedback from focus groups.

Survey results shall be reported to the <agency>. Findings will be used to make changes as applicable to the menu. The summary of survey responses must be kept on file for <time period>.

<Appropriate staff> can determine food likes or dislikes by using non-verbal feedback, such as monitoring food consumption. Estimating the number of people who ate approximately half or less of their meals and identifying which items were not eaten often provides a more objective picture of customer satisfaction than comments obtained through other means.

Home-Delivered MealsThe <agency> will provide a written survey to home-delivered meal recipients <frequency> by mail with a self-addressed stamped envelope to ensure a response. Prior to sending out the survey, participants will be sent a notice indicating when the survey will be mailed and that their input is important to evaluate the service and identify areas of improvement. Client comments reported to the <agency> are also taken into consideration when evaluating the program.

# Supervision/Person in Charge

The <agency> shall designate a person or persons in charge (PIC) of each site and shall ensure that the PIC has the appropriate food service training and is present at the site(s) during all hours of meal operation.

In consideration of the risks of foodborne illness inherent to food service operations, the PIC shall, at all times, be able to demonstrate the applicable knowledge of foodborne disease prevention and application of Hazard Analysis Critical Control Points (HACCP) principles.

The PIC shall ensure that:

The food service operation is maintained in a clean, safe condition and the facility and equipment are in good repair.

Employees/volunteers are effectively cleaning their hands by routinely monitoring the staff/volunteers handwashing.

Employees are properly receiving, storing, and preparing food, especially potentially hazardous foods.

Employees are preventing cross-contamination of foods.

Employees do not have direct hand contact with ready-to-eat foods.

All employees/staff/volunteers report disease or medical conditions that are transmissible through food. 

# Training

Staff members in a food service management position, designated PICs (responsible for directing home-delivered meals and/or congregate programs), or those responsible for food service monitoring/inspections shall have successfully completed a <required class name> class either through the health department, local college, university, technical school, or other <agency> approved class/workshop.

The <appropriate staff> shall ensure all the required staff has current food safety course certification.

The <appropriate staff> shall develop, implement, and document a training plan — in addition to the orientation — for all new employees, staff, and volunteers who participate in food preparation, service, or delivery. The training, at minimum, must develop skills and abilities as it relates to their assigned duties.

All supervisors/PICs shall be required to complete the course recertification at least every <number> years.

The <appropriate staff> shall ensure that all required staff members receive nutrition program training throughout the year.

# Employee/Volunteer Health and Hygiene

The following employee/volunteer cleanliness, health, and hygienic practices shall be enforced:

Food service employees shall wear clean clothing to prevent contamination of food, equipment, utensils, linens, or single-use articles.

Food service employees shall keep their fingernails trimmed, filed, and maintained so the edges and surfaces are cleanable. Unless wearing intact gloves in good repair, a food service employee may not wear fingernail polish or artificial fingernails when working with exposed food.

While preparing food, food service employees should limit jewelry on their arms or hands, especially jewelry that has dangling parts. Plain rings such as a wedding band are acceptable. Wristbands and watches must be removed.

Food service employees shall wear hair restraints such as hats, hair coverings, or nets designed and worn to effectively keep their hair from contacting exposed food, equipment, or utensils. This applies to all staff involved in preparation or serving, whether in front or behind the counter areas.

# Employee/Volunteer Hand-Washing

All individuals who are involved in the preparation and service of food must wash their hands and exposed portions of their arms using the proper hand-washing technique:

Apply vigorous friction on the surfaces of the lathered fingers, fingertips, areas between the fingers, hands, and exposed areas of the arms, or by vigorously rubbing the surrogate prosthetic devices for hands or arms, for at least 20 seconds.

Thoroughly rinse under clean, running warm water.

Immediately follow the cleaning procedure with thorough drying of cleaned hands and exposed areas of the arms or surrogate prosthetic devices.

Pay particular attention to the areas underneath the fingernails during handwashing. Use a nail brush as available.

Hand washing must occur in a sink designated for such use. Do not use food preparation and service sinks for hand washing.

Employees involved in food preparation must wash their hands regularly, but especially under the following conditions:

Before starting to work.

After using restroom facilities.

After touching dirty objects including trash cans, telephones, or cell phones.

After coughing, sneezing, using a handkerchief or tissue, or touching other exposed portions of the body (i.e., the arm, face, hair, eyes, nose, or mouth).

After smoking, eating, or drinking.

After touching their face, other skin areas, or clothing.

After handling soiled equipment or utensils.

Before and after using gloves.

# Employee/Volunteer Illnesses/Medical Conditions

Employees and volunteers who work in preparing or serving food should report to the person in charge if they have any of the following:

Vomiting, diarrhea, fever, or sore throat with fever. The person must be symptom-free for at least 24 hours before returning to work or provide written medical documentation from a health care practitioner that states symptoms are from a noninfectious condition.

Salmonella, Shigella, Shiga-toxin-producing E. coli, hepatitis A, botulism, or other intestinal illness diagnosed by a doctor.

Suspected exposure to a confirmed disease outbreak caused by S. Typhi, Shigella, Shiga-toxin-producing E. coli, botulism, COVID-19, or hepatitis A virus.

Open, blistered, or infected burns, boils, cuts, etc. on the hands or forearms.

Jaundice (yellowing of the skin or eyes).

Persistent sneezing, coughing, or a runny nose.

If a food employee is diagnosed with any of the above-listed bacteria or viruses, the PIC shall report this to a manager. They should not provide employee name(s). It is only necessary to report that a food employee at the facility has been infected with one of the above pathogens.

The PIC shall exclude a food employee from food service operation who:

Is experiencing vomiting, diarrhea, fever, or sore throat with fever.

Has a been diagnosed with salmonella, S. typhi, Shigella, COVID-19, botulism, or Shiga toxin-producing E. coli.

Food handlers should not consume food, chew gum, or use tobacco in any form while engaged in food preparation, service, or cleaning and sanitizing.

All individuals who are involved in the preparation and service of food should not keep or store personal items, such as glasses, cell phones, prescriptions, etc., in the food production area or on themselves, like in a top pocket, where these items could possibly fall out and contaminate food. Personal items shall be stored in an office area or around an employee’s desk.

All employees and volunteers engaged in the preparation and service of food shall be instructed in, and monitored to, employ good sanitary work practices.

# Money Handling 

Donations

Contributions to the nutrition program are program revenue to be used by the agency to fund the senior nutrition program. The contributions are to be safeguarded until deposited.

Each eligible participant will be provided an envelope in which to contribute to the congregate meal.

Each person under age 60 will pay the full meal cost directly to the nutrition site’s <appropriate staff> without using a contribution envelope. This shall be done no later than the day before the meal is ordered.

Immediately following the daily meal program, two persons, which can include nutrition staff and/or a volunteer, will calculate the day’s meals and count the money collected. The total will be verified by the nutrition staff.

All money will be placed in a brown transport envelope identified with the site’s name. Enter the required information on the face of the envelope: date of collection, amount, and counters’ names. To prevent loss, loose coins may be placed in an envelope before placing them with dollar bills into the transport envelope.

The <appropriate staff> will log the required information from the transport envelope onto the nutrition monies log. The <appropriate staff> will present the transport envelope and the log to <appropriate staff> who will sign the log and place the transport envelope into the safe.

Outside sites will place the transport envelope into the metal lock box, which is provided daily by the <appropriate staff>.

Each outside site’s locked box and other interoffice mail will be given daily to the <appropriate staff> for transport.

The <appropriate staff> will deliver the locked box to <appropriate staff> by <X> p.m. each day.

The <designated staff> will remove the daily transport envelope from the locked box to the safe, making appropriate entries on the nutrition monies log. Transport envelopes will remain in the safe until a deposit is prepared.

The <designated staff> will prepare all nutrition deposits.

Coffee/Breakfast Fund Monies

All monies collected from the coffee/breakfast fund should be counted by two persons, which can include nutrition staff/volunteers, who will calculate the day’s meals and count the money collected. The total will be verified by nutrition staff and placed in the safe daily.

A journal entry shall be kept in the safe of the amount of money in the coffee/breakfast fund.

When coffee supplies are low, staff can use this money to replace coffee/breakfast supplies.

All receipts shall be kept, and the journal updated.

Monies should not be used to purchase any other kitchen supplies.

If coffee/breakfast monies do not generate enough money to cover the coffee expense, the coffee fund money should be counted and handled as listed below. 

Safekeeping of Monies

All money collected by and entrusted to <agency> staff will be placed in the safe, deposited, forwarded, or returned as appropriate as outlined below:

Place all money in a sealed envelope labeled with the following information:

Date collected.

Source of money.

Intended purpose.

Signature of person who collected money.

<Designated staff> deposit money on <designated days of the week>.

Access to Safe

The contents of the safe(s) will be accessible every day by only <appropriate staff>. <Assigned staff> are responsible for opening/closing safe.

<Agency> staff authorized to access safe include: <list authorized staff>

Opening/closing procedure is as follows:

Open safe every morning: <list authorized staff>

Close safe every evening: <list authorized staff>

Alternate for opening/closing: <list authorized staff>

# Recordkeeping

All <Agency> staff members are held responsible for recordkeeping duties as assigned. Employees and substitutes will be trained in recordkeeping.

1. Congregate Meals

a. The <agency> shall verify accurate and appropriate billing of units of service and ensure that the units of service are:

(1) Actually provided to eligible participants.

(2) Not paid in excess of units delivered.

(3) Not paid in excess of the contracted number of units of service.

b. Projected meal numbers are submitted to the caterer at least one week prior to the request week. If changes are required, the <appropriate staff> updates the caterer’s online system no later than <time> the day before to make changes to the meal count. Print a copy of original request and changes entered for your records.

c. <Appropriate staff> shall maintain all site meal sign-in sheets and other sufficient documentation to support services provided.

d. <Appropriate staff> sends a weekly monitoring report stating all findings, deficiencies, and concerns to caterer. Depending on the circumstances, the <agency> may request credits for meals or items.

e. The <appropriate staff> receives the billing units monthly and compares them to the data <agency> has on file.

f. Daily financial and meal count records shall be kept ensuring the complete, accurate, and prompt recording of all necessary local monthly, quarterly, and annual reports.

g. The <appropriate staff> shall ensure a method of reporting units of service that is within the specifications for the specific unit of service.

h. The <appropriate staff> shall ensure daily meal service is documented per site and maintained in the database.

2. Home-Delivered Meals

a. Delivery sheets for each route are prepared on <day> of the week prior to delivery by the <appropriate staff>. Meal counts are submitted to the caterer on <day> for the following week. On <day>, the <appropriate staff> places a route copy in the delivery notebook at each pick-up site. The <appropriate staff> carries one copy, and one copy is kept at the <agency>.

b. A daily count of home-delivered meals is tallied by the <appropriate staff> taken from the delivery sheets, and any changes are submitted to the caterer by <time> the day prior to the service date to capture any changes, cancellations, or additions.

c. Clients and client representatives are instructed during the interview process to contact the <agency> if meal service needs to be canceled, changed, or discontinued.

d. Weekly, the <appropriate staff> uses delivery sheets to enter home-delivered meals received into the database. Monthly, the appropriate staff will compare contractor’s home-delivered meal spreadsheet counts with the <appropriate staff>’s monthly tally to ensure the accuracy of meal charges. After the monthly tally is verified, the tally report is emailed to <agency> for reimbursement.

3. General RecordkeepingCurrent, complete, and accurate records for nutrition services shall be kept ensuring the complete, accurate, and prompt reporting of the following activities:

a. Congregate Program

(1) Dining site records, participant reservations, and registration systems, maintained by PIC.

(2) Nutrition education programs prepared and presented to site participants, maintained by appropriate staff. These records shall be retained for <number> years.

(3) Training programs for employees and volunteers, maintained by the <appropriate staff>. These records shall be retained for <number> years.

(4) Facility inspection reports and corrective action follow-up reports, kept at each site by the <appropriate staff>. The original is kept by the <appropriate staff>. <Appropriate staff> are responsible for sending the reports to the <appropriate staff>. These records shall be retained for <number> years.

(5) Original incident and/or grievance reports are maintained by the <appropriate staff>. A copy should be kept on file at the site. These records shall be retained for <number> years.

(6) All pertinent information on temperatures, times, and actions taken to correct problems is kept by <appropriate staff> daily. Weekly logs shall be sent to the <appropriate staff> for filing. A copy should be maintained on-site. These records shall be retained for <number> years. A copy of site temperature logs, as well as caterer temperature logs, are kept on file with the <appropriate staff>.

(7) In-kind contributions and/or copies of food supply receipts shall be kept by the <appropriate staff>. These records shall be retained for <number> years.

(8) All applicable forms for daily meals are kept by the <appropriate staff>. These records shall be retained for <number> years.

(9) Food purchase and inventory reports are kept on-site by the PIC. These records shall be retained for <number> years.

(10) Equipment purchases and inventory reports, kept on site by PIC.

b. Home-Delivered Meals

(1) Client delivery sheets for each route and client delivery intake and participant forms are maintained by the <appropriate staff>.

(2) Nutrition education is provided monthly to home-delivered meal clients with records maintained by <appropriate staff> and kept for <number> years.

(3) Training for home-delivered meal staff/volunteers and <agency> agendas and minutes of monthly board meetings are maintained by the <appropriate staff>.

(4) A copy of site temperature logs, as well as temperature log taken at the caterer, are on file with the <appropriate staff>.

(5) Home-delivered meal incident reports are reported to <appropriate staff> of <agency>. Records are kept on file with the <appropriate staff> for <number> years.

(6) <Agency> volunteer applications and background checks are maintained by the <appropriate staff>.

(7) Caterers shall cooperate to the best of their ability in any additional programmatic and fiscal reporting or surveying deemed necessary by the <agency> to effectively and efficiently administer all meal programs funded through this program.

# Monthly, Quarterly, and Annual Reporting

The <appropriate staff> shall ensure all data sheets are completed and statistics are entered into the computer monthly. <Appropriate staff> enter number of congregate meals served into the database weekly/monthly. <Appropriate staff> enters number of home-delivered meals into the database weekly/monthly.

The <appropriate staff> receives a monthly production report from the caterer outlining meals ordered in both congregate and home-delivered programs.

The <appropriate staff> prepares a quarterly home-delivered and congregate nutrition program report utilizing the database.

The <appropriate staff> prepares the financial reports for each nutrition grant and program and required year-end close-out reports.