"Review Form for Adult Day Care Center/Facility - Adult Care Food Program" - Florida

This "Review Form for Adult Day Care Center/Facility - Adult Care Food Program" is a document issued by the Florida Department of Elder Affairs specifically for Florida residents with its latest version released on December 1, 2017.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Florida Department of Elder Affairs.

ADVERTISEMENT

Download "Review Form for Adult Day Care Center/Facility - Adult Care Food Program" - Florida

1010 times
Rate
4.3(4.3 / 5) 51 votes
DATE(S) OF REVIEW:_________________
CENTER/INSTITUTION
____________________________________
NAME/ADDRESS/PHONE:
REVIEW TEAM LEADER:
____________________________________
____________________________________
____________________________________
Adult Care Food Program
REVIEW STAFF:______________________
____________________________________
REVIEW FORM for
____________________________________
____________________________________
ADULT DAY CARE Center/Facility
____________________________________
(For DOEA use only)
CENTER REPRESENTATIVE(S):
____________________________________
*Indicates questions that are more likely to result in reclaims
____________________________________
and/or serious deficiencies if answered NO.
____________________________________
Indicates sponsors with multiple facilities
____________________________________
REVIEW
CONTRACT #
CHECK TYPE OF INSTITUTION
APPROVED MEAL TYPES
MONTH/YEAR
B MS L AS S
ADULT DAY CARE:
DAY MENTAL HEALTH:
# of HOMES SAMPLED
PROCEDURE
PROGRAM ADMINISTRATION
YES
NO
N/A
COMMENTS
MANUAL
REFERENCE(S)
1. The center/facility uses current DOEA provided forms or alternate
All Chapters
forms approved by DOEA.
2. The center/facility has on file and utilizes all pertinent program
Policy Memo
information and documents from the USDA and DOEA.
Dissemination
3. The center/facility has written policies and procedures that assign
58A-6.006(2),
program responsibilities and duties as it pertains to ACFP.*
F.A.C
4. The ACFP is directly managed by the center/facility; no portion of the
Section 5.1,
program management is subcontracted.
6.1
Chapter 429,
5. The center/facility emergency preparedness plan is sufficient to
Part III &
ensure that providers are reimbursed and disruption of ACFP services is
Chapter 58A-
minimized during emergencies.
6.011, F.A.C.
6. Copies of all records pertaining to the ACFP in Florida are maintained
Section 5.1,
in an office located within the State of Florida at all times.
6.1
7. All ACFP records are maintained for at least the current fiscal year
Section 5.1,
and the six prior fiscal years.*
6.1
8. All records pertaining to any unresolved audits or reviews are
Section 5.1,
maintained for a minimum of the current fiscal year and six prior fiscal
6.1
years or until all outstanding issues are resolved.*
9. Meal types and times submitted by the center/facility meet all DOEA
Section 3.1
requirements. Any exceptions have been approved in writing by DOEA.
7.1, 7.5
10. A written individual plan of care is developed and maintained for
Section 2.5
every functionally impaired participant.
Revised 12/2017
Page 1 of 5
DATE(S) OF REVIEW:_________________
CENTER/INSTITUTION
____________________________________
NAME/ADDRESS/PHONE:
REVIEW TEAM LEADER:
____________________________________
____________________________________
____________________________________
Adult Care Food Program
REVIEW STAFF:______________________
____________________________________
REVIEW FORM for
____________________________________
____________________________________
ADULT DAY CARE Center/Facility
____________________________________
(For DOEA use only)
CENTER REPRESENTATIVE(S):
____________________________________
*Indicates questions that are more likely to result in reclaims
____________________________________
and/or serious deficiencies if answered NO.
____________________________________
Indicates sponsors with multiple facilities
____________________________________
REVIEW
CONTRACT #
CHECK TYPE OF INSTITUTION
APPROVED MEAL TYPES
MONTH/YEAR
B MS L AS S
ADULT DAY CARE:
DAY MENTAL HEALTH:
# of HOMES SAMPLED
PROCEDURE
PROGRAM ADMINISTRATION
YES
NO
N/A
COMMENTS
MANUAL
REFERENCE(S)
1. The center/facility uses current DOEA provided forms or alternate
All Chapters
forms approved by DOEA.
2. The center/facility has on file and utilizes all pertinent program
Policy Memo
information and documents from the USDA and DOEA.
Dissemination
3. The center/facility has written policies and procedures that assign
58A-6.006(2),
program responsibilities and duties as it pertains to ACFP.*
F.A.C
4. The ACFP is directly managed by the center/facility; no portion of the
Section 5.1,
program management is subcontracted.
6.1
Chapter 429,
5. The center/facility emergency preparedness plan is sufficient to
Part III &
ensure that providers are reimbursed and disruption of ACFP services is
Chapter 58A-
minimized during emergencies.
6.011, F.A.C.
6. Copies of all records pertaining to the ACFP in Florida are maintained
Section 5.1,
in an office located within the State of Florida at all times.
6.1
7. All ACFP records are maintained for at least the current fiscal year
Section 5.1,
and the six prior fiscal years.*
6.1
8. All records pertaining to any unresolved audits or reviews are
Section 5.1,
maintained for a minimum of the current fiscal year and six prior fiscal
6.1
years or until all outstanding issues are resolved.*
9. Meal types and times submitted by the center/facility meet all DOEA
Section 3.1
requirements. Any exceptions have been approved in writing by DOEA.
7.1, 7.5
10. A written individual plan of care is developed and maintained for
Section 2.5
every functionally impaired participant.
Revised 12/2017
Page 1 of 5
PROCEDURE
PROGRAM ADMINISTRATION (Cont.)
YES
NO
N/A
COMMENTS
MANUAL
REFERENCE(S)
11. The sponsor submits Change Forms and accompanying
documentation when any information changes on the center/facility’s
Section 3.2
application form.
12. Daily point of service meal count only includes ACFP eligible clients.
Section 8.15
*
13. The center/facility receives only ACFP funds for meals claimed.*
Section 6.12
PROCEDURE
ELIGIBILITY DETERMINATIONS
YES
NO
N/A
COMMENTS
MANUAL
REFERENCE(S)
Sections 2.1,
14. Each enrolled adult claimed resides in a nonresidential institution.*
2.2, 2.3
15. The center/facility ensures that each adult whose meals are claimed
Section 2.5
for reimbursement is age-eligible to participate in the ACFP.*
16. A disability determination from the Social Security Administration or
proof of Medicaid eligibility due to disability is on file for any person
Section 2.5
eligible for ACFP participation on the basis of a medical disability.
17. The center/facility accurately completed the Meal Benefit Income
Sections 2.5,
Eligibility Form. (See attached Participant Application & Roster Review
10.4
form).*
18. Participant and household income statements and certain other
information as required by law or requested by providers are kept
Section 10.7
confidential by the center/facility.
Sections,
19. Current and complete enrollment forms and daily attendance forms
8.14, 8.15,
are on file for all adults participating in the ACFP.*
10.7
PROCEDURE
CLAIM REVIEW AND EDITS
YES
NO
N/A
COMMENTS
MANUAL
REFERENCE(S)
20. The center/facility ensures the monthly claim information is accurate,
Sections 4.6,
the meals claimed are eligible for reimbursement, and that adequate
4.7, 4.8, 8.6,
documentation (meal count worksheets, daily attendance sheets, and
9.10
enrollment rosters) support the provider’s claim.*
21. The center/facility cost is not in excess of three months of operating
Section 9.6
budget.
22. The center/facility correctly designates the meal reimbursement.
Sections 4.6
23. The information on the Point of Service forms is accurate and
Sections 5.1,
supports the claim. (See Daily “Point of Service” Meal Count form).
9.10, 6.3
24. Claims for reimbursement are received by the 15th of the month
Section 4.3
following claim month from the center/facility.*
25. The center/facility has the one-time exception available for submitting
Sections 4.3
a claim.
Revised 12/2017
Page 2 of 5
PROCEDURE
CLAIM REVIEW AND EDITS (Cont.)
YES
NO
N/A
COMMENTS
MANUAL
REFERENCE(S)
26. Revised claims are filed when necessary and within the required time
Sections 4.3
frames.*
PROCEDURE
CIVIL RIGHTS COMPLIANCE
YES
NO
N/A
COMMENTS
MANUAL
REFERENCE(S)
27. The center/facility does not discriminate in employment or program
participation based on race, age, sex, color, disability, or national origin
Sections 5.1
and has written policies and procedures that ensure compliance with civil
6.1, 9.11
rights requirements.*
28. Racial and ethnic data is collected for all enrolled adults in a manner
Sections 5.1,
that does not bring attention to the adults. This information is recorded
5.6
and reported to DOEA as required.
29. The non-discrimination, “And Justice for All” poster, is posted in a
Section 5.1
prominent place in the center/facility.
5.7, 5.8, 6.1
30. Informational materials are provided in the appropriate language
Sections 5.1,
concerning the availability and nutritional benefits of the program, as
5.8, 6.8
needed.
Sections
31. Civil Rights training records for frontline staff are documented.
5.10, 6.11
PROCEDURE
TRAINING
YES
NO
N/A
COMMENTS
MANUAL
REFERENCE(S)
32. Mandatory training, which includes all required topics, is provided for
the center/facility new ACFP staff upon hire, and for all center/facility
Section 6.6
ACFP staff at least annually.*
Revised 12/2017
Page 3 of 5
PROCEDURE
MONITORING / OVERSIGHT
YES
NO
N/A
COMMENTS
MANUAL
REFERENCE(S)
33. Each adult day care has a current AHCA license or contract to
Sections 9.4,
administer mental health day services.*
3.2
34. The center/facility ensures that each facility meets applicable staff to
Section 3.5
adult ratios.
35. Observe meal preparation and meal service to assess the facility’s
Sections
food safety practices and to ensure that all meal components are served
7.10, 9.13
in the proper quantity. (Use Meal Service Review Form)
36. The center/facility’s prior programmatic review was without
DOEA Internal
deficiencies/serious deficiencies.
Check, 9.16
37. The center/facility’s deficiencies/serious deficiencies remain corrected
DOEA Internal
per the CAP submitted to DOEA. There are no repeat findings during
Check, 9.16
review.*
PROCEDURE
MEAL SERVICE MONITORING
YES
NO
N/A
COMMENTS
MANUAL
REFERENCE(S)
38. Dated menus are posted in full view of all participants. Dated facility
F.A.C 58A-6
menus are retained with the monthly records.
Section 8.12
F.A.C 58A-6
39. The current meal service contract is approved by the ACFP office.
Section 11.1
Sections 7.1,
40. Records indicate meals served meet the ACFP meal pattern.
8.10
41. Delivery slips for contracted meal service or central kitchen provide
Sections 5.1,
accurate and adequate
5.14, 8.7
42. The ACFP Adult Meal Pattern is being followed on day of review.
Section 9.9
43. Accurate daily menu production records with temperatures are
Sections11.2,
maintained for self-prep meal service.
12.3
44.The Monthly Food Service Performance Report is completed for
Sections 5.1,
current/previous month.
5.14, 8.6
45. Copies of medical statements are on file for any adult being served
Sections 5.3,
special meals that do not meet the ACFP meal pattern requirements.
6.3, 7.5
PROCEDURE
FINANCIAL MANAGEMENT
YES
NO
N/A
COMMENTS
MANUAL
REFERENCE(S)
46. The center/facility has adequate funding to meet financial obligations
due to any reclaims or unexpected expenses. If a line of credit is
Section 9.12
secured, ACFP funds and property are not used as collateral.
47. Administrative expenses are specified in the budget and are
Section 9.12
allowable, reasonable, necessary, and appropriately documented.
Revised 12/2017
Page 4 of 5
48. Monthly expenditure records are maintained and support claim(s)
reviewed regarding food costs, non-food supply costs, labor costs,
Sections 8.2,
administrative costs, and non-expendable costs. (See attached ACFP
8.3,9.6
Monthly Expenditures Worksheet).
49. Appropriate methods (bids, price quotes) and procedures are used
Section 11
when procuring goods and services.*
ADDITIONAL COMMENTS / REVIEW NOTES
ACFP Representative:
_____________________________/______________________________ Date: _________________
Signature
Print Name
Sponsor Representative: _____________________________/______________________________ Date: _________________
Signature
Print Name
ACFP Supervisor Review: _____________________________/______________________________ Date: _________________
Signature
Print Name
Revised 12/2017
Page 5 of 5
ADVERTISEMENT
Fill PDF online
Page of 5