"Review Form for Adult Day Care Sponsoring Organization - Adult Care Food Program" - Florida

This "Review Form for Adult Day Care Sponsoring Organization - 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.

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Download "Review Form for Adult Day Care Sponsoring Organization - Adult Care Food Program" - Florida

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DATE(S) OF REVIEW:_________________
SPONSOR/INSTITUTION
____________________________________
NAME/ADDRESS/PHONE:
REVIEW TEAM LEADER:
____________________________________
____________________________________
____________________________________
Adult Care Food Program
REVIEW STAFF:______________________
____________________________________
REVIEW FORM for
____________________________________
____________________________________
ADULT DAY CARE Sponsoring Organization
____________________________________
(For DOEA use only)
SPONSOR REPRESENTATIVE(S):
____________________________________
*Indicates questions that are more likely to result in reclaims
____________________________________
and/or serious deficiencies if answered NO.
____________________________________
____________________________________
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 Sponsor Uses and insures centers use current DOEA provided
All Chapters
forms or alternate forms approved by the DOEA.
2. The sponsor has on file and utilizes all pertinent program information
Policy Memo
and documents from the USDA and DOEA.
Dissemination
3. The sponsor has written policies and procedures that assign program
58A-6.006(2),
responsibilities and duties as pertaining to the ACFP.
F.A.C
4. The ACFP is directly managed by the sponsor; no portion of the
Section 5.1,
program management is subcontracted.
6.1
Chapter 429,
5. The sponsor’s emergency preparedness plan is sufficient to ensure
Part III &
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 approved by the sponsor meet all DOEA
Section 3.1
requirements. Any exceptions have been approved in writing by DOEA.
10. A written individual plan of care is developed and maintained for
Section 2.5
every functionally impaired participant.
Revised 12/17
Page 1 of 6
DATE(S) OF REVIEW:_________________
SPONSOR/INSTITUTION
____________________________________
NAME/ADDRESS/PHONE:
REVIEW TEAM LEADER:
____________________________________
____________________________________
____________________________________
Adult Care Food Program
REVIEW STAFF:______________________
____________________________________
REVIEW FORM for
____________________________________
____________________________________
ADULT DAY CARE Sponsoring Organization
____________________________________
(For DOEA use only)
SPONSOR REPRESENTATIVE(S):
____________________________________
*Indicates questions that are more likely to result in reclaims
____________________________________
and/or serious deficiencies if answered NO.
____________________________________
____________________________________
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 Sponsor Uses and insures centers use current DOEA provided
All Chapters
forms or alternate forms approved by the DOEA.
2. The sponsor has on file and utilizes all pertinent program information
Policy Memo
and documents from the USDA and DOEA.
Dissemination
3. The sponsor has written policies and procedures that assign program
58A-6.006(2),
responsibilities and duties as pertaining to the ACFP.
F.A.C
4. The ACFP is directly managed by the sponsor; no portion of the
Section 5.1,
program management is subcontracted.
6.1
Chapter 429,
5. The sponsor’s emergency preparedness plan is sufficient to ensure
Part III &
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 approved by the sponsor meet all DOEA
Section 3.1
requirements. Any exceptions have been approved in writing by DOEA.
10. A written individual plan of care is developed and maintained for
Section 2.5
every functionally impaired participant.
Revised 12/17
Page 1 of 6
PROCEDURE
PROGRAM ADMINISTRATION (Cont.)
YES
NO
N/A
COMMENTS
MANUAL
REFERENCE(S)
11. The sponsor submits Change Forms and accompanying
Section 3.2,
documentation when any information changes on the sponsor’s
5.2
application or providers’ information form.
12. Daily point of service meal count only includes ACFP eligible clients.*
Section 8.15
13. The sponsor receives only ACFP funds for meals claimed.*
Section 6.12
PROCEDURE
ELIGIBILITY DETERMINATIONS
YES
NO
N/A
COMMENTS
MANUAL
REFERENCE(S)
Sections 1.2,
14. Each enrolled adult claimed resides in a nonresidential institution.*
2.12
15. The sponsor ensures that each adult whose meals are claimed for
Section 2.5
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 sponsor accurately completed the Meal Benefit Income Eligibility
Sections 2.6
Form. (See attached Participant Application & Roster Review form).*
10.4
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 sponsor ensures monthly claim information form the
center/facility is accurate, the meals claimed are eligible for
Sections 4.6,
reimbursement, and that adequate documentation (meal count
4.7, 4.8, 8.6,
worksheets, daily attendance sheets, etc.) to support the provider’s claim
9.10
has been submitted.*
21. The center/facility cost is not in excess of three months of operating
Section 9.6
budget
22. The Sponsor 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)
24. The total number of meals for each facility has been accurately
Sections 9.10,
compiled. (See attached “Point of Service” Meal Count form).
6.3
25. Only allowable meals were claimed following the Sponsor review.
Sections 9.16
Revised 12/17
Page 2 of 6
PROCEDURE
CLAIM REVIEW AND EDITS (Cont.)
YES
NO
N/A
COMMENTS
MANUAL
REFERENCE(S)
26. Claims for reimbursement are received by the 15th of the month
Section 4.3
following claim month from the center/facility.*
27. The sponsor has the one-time exception available for submitting a
Sections 4.3
claim
28. Meal disallowances are issued when there is evidence of
Sections 4.3
noncompliance with ACFP regulations.
29. Revised claims are filed when necessary and within the required time
Sections 9.16
frames.
30. Copies of medical statements are on file for any adult being served
Section 4.3,
special meals that do not meet the ACFP meal pattern requirements.
12.4
PROCEDURE
CIVIL RIGHTS COMPLIANCE
YES
NO
N/A
COMMENTS
MANUAL
REFERENCE(S)
31. The sponsor 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.*
32. 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.*
33. 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
34. 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
35. Civil Rights training records for frontline staff are documented.
5.10, 6.11
PROCEDURE
TRAINING
YES
NO
N/A
COMMENTS
MANUAL
REFERENCE(S)
36. The sponsor provides mandatory training, which includes all required
Sections 6.6
topics, for all institutions and staff at least annually.*
37. The sponsor’s pre-approval process and training for prospective
Sections 6.6
institutions and staff covers all required information.
38. Mandatory training, which includes all required topics, is provided for
the sponsor’s new ACFP staff upon hire, and for all center/facility ACFP
staff at least annually.*
Section 6.6
Revised 12/17
Page 3 of 6
PROCEDURE
MONITORING / OVERSIGHT
YES
NO
N/A
COMMENTS
MANUAL
REFERENCE(S)
39. An adequate number and type of qualified staff are employed to
ensure proper operation of the ACFP and to monitor the facilities
Section 3.5
participating under the sponsorship.*
40. Each adult day care has a current AHCA license or contract to
Sections 9.4,
administer mental health day services.*
3.2
41. The sponsor ensures that each facility meets applicable staff to adult
Section 6.6
ratios.
42. The sponsor has an accurate and effective method to schedule and
Section 6.6
track reviews and follow-up reviews to ensure requirements are met
43. The required number of monitoring visits is performed within the
Section 6.6
required time frames and are not conducted in a predictable manner.*
44. The sponsor has conducted the required number of unannounced
Section 6.6
reviews.
45. The sponsor conducts some monitoring reviews on weekends,
evenings, and/or holidays for those institutions approved to claim meals
Section 6.6
during these times.
46. The sponsor has conducted monthly edit checks on each center’s
Section 6.1
meal claim to ensure accuracy.
47. The sponsor’s monitor(s) properly conducted the Five-Day
Sections 6.6
Reconciliation. (The meal counts were completed).
48. The sponsor completed the reconciliation of the facility’s meal counts
Sections 6.1,
with enrollment and attendance records for five-days using the Five-Day
9.10
Reconciliation form. (The meal counts were determined accurate).
49. Observe meal preparation and meal service to assess the facilities’
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)
50. Sponsor monitor forms are completed accurately and in their entirety
Section 6.6
51. Meal disallowances are issued when appropriate and the monitor
Section 9.16
follows proper disallowance procedures.
52. Corrective Action Plans (CAPs) are required when necessary and are
submitted to the sponsor in a timely manner. The sponsor ensures that
Sections 6.6
CAPs reflect appropriate actions to correct the deficiency(s) identified.
53. Follow-up reviews are performed when necessary and in a timely
Sections 6.6
manner.*
54. The sponsor utilizes the Serious Deficiency Process as required by
Sections
DOEA and has a system in place to track the process.*
9.16, 12.3
Revised 12/17
Page 4 of 6
PROCEDURE
MONITORING / OVERSIGHT (Cont.)
YES
NO
N/A
COMMENTS
MANUAL
REFERENCE(S)
55. The sponsor maintains copies of all correspondence related to the
Sections,
Serious Deficiency Process and provides DOEA with copies of all such
9.16
correspondence at each step of the process.
DOEA
56. The sponsor’s prior programmatic review was without
Internal
deficiencies/serious deficiencies.
Check, 9.16
57. The sponsor’s deficiencies/serious deficiencies remain corrected per
DOEA
the CAP submitted to DOEA. There are no repeat findings during
Internal
review.*
Check, 9.16
PROCEDURE
MEAL SERVICE MONITORING
YES
NO
N/A
COMMENTS
MANUAL
REFERENCE(S)
58. 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
59. The current meal service contract is approved by the ACFP office.
Section 8.12
Sections 7.1,
60. Records indicate meals served meet the ACFP meal pattern.
8.10
61. Delivery slips for contracted meal service or central kitchen provide
Sections 5.1,
accurate and adequate meal production information and are maintained
5.14, 8.7
with monthly records.
62. The ACFP Adult Meal Pattern is being followed on day of review.
Section 9.9
63. The Monthly Food Service Performance Report was completed
Sections 5.1,
for previous month.
5.14, 8.6
64. Accurate daily menu production records with temperatures are
Sections11.2,
maintained for self-prep meal service.
12.3
PROCEDURE
FINANCIAL MANAGEMENT
YES
NO
N/A
COMMENTS
MANUAL
REFERENCE(S)
65. The sponsor has a financial system with management controls (i.e.,
policies that govern administrative/operational budgets,
Sections 8.2,
costing/procurement standards, revenue/property management,
9.12
expense/asset tracking systems, and fiscal audit systems) in order to
ensure fiscal integrity and accountability.*
66. Internal controls have been established to safeguard assets from loss
or misappropriation and ensure that financial transactions are executed in
Section 9.12
accordance with management's general or specific authorization. (See
attached Internal Controls Worksheet).*
67. The sponsor’s internal control system includes an adequate
separation of duties regarding the authorization and processing of
Section 9.12
financial transactions.
68. The sponsor follows DOEA prescribed internal controls for the receipt
Section 9.12
and disbursement of ACFP funds.
Revised 12/17
Page 5 of 6
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