Adult Care Food Program Provider of Multiple Sites Long Monitoring Form Review Date: Site: General Information

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Lesley McCarthy
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1 Adult Care Food Program Provider of Multiple Sites Long Monitoring Form General Information Contract # Review Date: Is this review: announced unannounced Site Reviewed: Time Arrived: Address: Time Departed: Zip Tele # Day Program representative: Title: (Completed at each administered site during the first 6 weeks of provider participation each contract year.) A. Participant Applications and Enrollment Rosters 1. All current contract year ACFP Enrollment Rosters and Free & Reduced-Price meal applications were reviewed during visit by monitor? 2. All non-residential *participants enrolled in the day program are enrolled on ACFP Enrollment Roster? * Residential - an institution defined as hospitals, nursing homes, asylums for the mentally ill or for persons with mental or physical disabilities, convalescent homes, apartment complexes designed only for the functionally impaired that provided meals and full-time care, hospices, and assisted living retirement facilities. 3. All Free & Reduced-Price applications were appropriately categorized? 4. All information transferred correctly from the Free & Reduced-Price meal application to the enrollment roster? 5. Participants whose eligibility category has changed have information revised correctly on Enrollment Roster? 6. Zero income participant applications have been followed up monthly? 7. All applications currently on file were signed by applicant within the past 364 days? 8. All applications currently on file are approved with dated signature of provider s determining official? 9. Number of ACFP participants enrolled, by eligibility category, on day of review: FREE: REDUCED-PRICE: NON-NEEDY: TOTAL: 1

2 Adult Care Food Program Provider of Multiple Sites Long Monitoring Form B. Civil Rights Compliance 1. And Justice For All poster displayed in view of all enrolled participants? 2. Center offers all ACFP participants the same meal at no separate charge, regardless of race, color, national origin, sex, age, or disability? 3. Number of enrolled participants in attendance on day of review: By racial identities: American Indian/Alaskan Native: Asian: Black or African American: Native Hawaiian or Other Pacific Islander: White: By ethnic identities: Hispanic or Latino: Not Hispanic or Latino: C. Adult Meal Pattern for Self Prep or Central Kitchen Meals (Skip this section if not applicable to this site) 1. Monitor reviewed all dated menus for meals claimed for reimbursement during month reviewed? 2. All menus for month reviewed met or exceeded the required ACFP Meal Pattern? 3. All menu substitutions were in compliance with the USDA Food Crediting Guide? 4. Current posted, dated menu with substitutions indicated is in view of all enrolled participants? D. From Food Service Management Company or Central Kitchen (Skip this section if not applicable to this site) 1. Daily delivery slips for the month reviewed were correct regarding: a. Date of delivery? b. # meals ordered? c. # meals delivered? d. Menu items listed with individual portion sizes? e. Meals delivered met or exceeded the ACFP Meal Pattern? f. Delivery slip menus matched approved cycle menu? 2

3 Adult Care Food Program Provider of Multiple Sites Long Monitoring Form D. From Food Service Management Company or Central Kitchen, continued (Skip this section if not applicable to this site) g. Menu substitutions pre-approved by provider representative and documented by vendor? h. Appropriate menu substitutions regarding meal component and serving size? i. Adequate quantities received to serve a reimbursable meal to all enrolled participants in attendance on delivery date? j. Temperatures recorded for potentially hazardous hot foods were 140 degrees Fahrenheit or higher? k. Temperatures recorded for potentially hazardous cold foods were 41Ε degrees Fahrenheit or lower? 2. Menus checked for the month reviewed included foods rich in vitamins A and C several times each week? 3. Menus checked for the month reviewed included a variety of food items diverse in color, texture, flavor, serving temperature, etc.? 4. One or more of enrolled participants requires substitutions or omissions of certain food/beverage items due to medical reasons? (leave blank if N/A) a. If Yes, how many participants? b. Do these participants have a current (within last 12 months) medical statement in their participant chart/file, from a Physician, ordering a special diet? 5. Meal Review conducted by monitor for all meals claimed for reimbursement on day of review? (Attached) 6. Food Service Performance Report completed monthly? (leave blank if Central Kitchen) 3

4 Adult Care Food Program Provider of Multiple Sites Long Monitoring Form MEAL SERVICE REVIEW Date: Contract #: Meal Observed: Breakfast Lunch Supper Center: (Check one) A.M. Supplement P.M. Supplement Time : AM PM (Circle one) Meat/Alternate Vegetable/Fruit Bread/Alternate Milk Per Posted or Approved Menu Actual Meal Observed by Viewer Number of Reimbursable meals recorded by staff: Potentially Hazardous Food Temps: Number of Reimbursable meals recorded by reviewer: F Meat (Circle one) F Vegetable Is Point of Service meal count taken? Yes No F Vegetable Did meal reviewed meet or exceed ACFP meal pattern requirements? Yes No F Cold Side Did meal reviewed appear appetizing? Yes No F Other Was meal reviewed served in a sanitary manner? Yes No F Other Family Style Dining provided? Yes No F Other If Yes, provided correctly re: portion sizes available & served? Yes No F Milk Was the Offer vs Serve option used? Yes No Reviewer: Title:

5 Provider of Multiple Sites Long Monitoring Form E. RECORD KEEPING 1. Point of Service meal count conducted during all meal services observed by monitor on day of review? a. Offer vs. Serve option used correctly? (Leave blank if N/A) 2. Review administrative documentation for each meal/snack reimbursed for the previous five business days before current date. List enrollment, attendance and meal count records for previous five operating days: Day ACFP Enrollment Program Attendance Daily breakfast meal count Daily am snack count Daily Daily Lunch meal count Daily pm snack meal count Daily supper Meal Count 3. Review chart against licensed capacity. Are there any days where the meal counts exceed licensed capacity? 4. Is there more than a 10% difference between today s enrollment, attendance or meal count and any of the previous five operating days? If yes to either question #3 or #4: indicate the reason for the difference, if the difference indicates there is an error in record keeping (i.e. inaccurate records, missing enrollment forms), revise the monthly claim and document the required corrective action. 3. For the calendar month reviewed, the following site records were completed and submitted, as necessary to the ACFP point of contact, by the 5 th of the month: Adult Day Program s daily attendance record Dated menus for all dates in operation Point of Service Meal Count Sheets Monthly Expenditures Worksheet 5

6 Provider of Multiple Sites Long Monitoring Form Daily Delivery slips for catered meals (if applicable) Food vendor invoice for all meals during month Monthly invoice from central kitchen (if applicable) All new Free & Reduced-Price meal applications Calendar month s purchase receipts for food service (if applicable) Monthly time logs/time sheets (if applicable) Prorated utility cost, rent, etc. (if applicable) Title XIX Monthly eligibility certification (if applicable) Food Service Program income (if applicable) License/contract updated? (ADC license, DCF contract, etc.) F. FOOD SERVICE SANITATION 1. Monitor reviewed the kitchen area and equipment? 2. All refrigeration units are in good condition and free from spills and odors? a. Each refrigeration unit contains a functioning, calibrated thermometer and is free from spills and odors? b. Temperature(s) of each refrigeration unit recorded by monitor on day of review: degrees F degrees F, degrees F c. All refrigeration units registered the cold storage holding temperature of 41 degrees Fahrenheit or below? d. All previously opened food items are sealed, labeled with date of opening and appear fresh? e. Potentially hazardous food items, such as milk and eggs, have not exceeded their expiration date? f. Meats and eggs are stored on bottom shelf or away from ready to serve foods to prevent cross-contamination? 3. All freezer units are in good condition and free from spills and odors? a. Each freezer unit contains a functioning, calibrated thermometer and is free from spills and odors? b. Temperature(s) of each freezer unit recorded by monitor on day of review: degrees F, degrees F, degrees F c. All freezer units registered the proper frozen storage holding temperature of 0 degree Fahrenheit or below? 4. Adequate refrigeration and freezer space available to meet the needs of the daily food service operation? a. If No, what additional storage is needed? 6

7 Provider of Multiple Sites Long Monitoring Form 5. Trash receptacles used in all areas of food service are lined with disposable liners? a. Each receptacle has a tight fitting lid? b. All food service trash is emptied at the end of each day? 6. Microwave oven(s) is/are in good condition and cooking area is free or crumbs, spills, odors and the wall seams are free of build-up? (Leave blank If no microwave present) 7. On day of review, a probe thermometer was used to check all potentially hazardous foods temperatures prior to serving? a. Thermometer cleaned using alcohol swab or hot soapy water between checking temperature of different food items? b. All hot foods held at 140 degrees Fahrenheit or higher prior to serving? c. All cold foods held at 41 degrees Fahrenheit or lower prior to serving? 8. Adequate dry/pantry storage available for the needs of the daily food service operations? a. All items are stored at least 6" off floor? b. All items stored 18" or more from light fixture/heat source? c. All canned food items are free from rust, dented seams and leakage of contents? d. All pesticides, cleaning products, toxic chemicals or other non-food service items are stored in separate area from food service items? e. All pesticides, cleaning products and toxic chemicals are stored out of reach of day program participants? f. Items removed from original container are stored in clean, dry, covered containers to protect from dust and other sources of contamination? Container labeled with date of opening? 9. All areas of the program site are free from signs of insect and/or rodent infestation? a. Describe pest control method used: 10. During day of review; food service gloves/or hand washing techniques were used appropriately by staff serving meals? a. Food service staff use effective hair restraints during delivery of meal services? 7

8 Provider of Multiple Sites Long Monitoring Form 11. Site is compliant with Florida Administrative Code, Chapter 64E - 11 which does not allow live birds or animals in any area used to conduct a food service operation? 12. On day of review, monitor observed the dishwashing techniques to clean/sanitize re-usable food service dinnerware, cookware, eating and serving utensils? a. Dishes/utensils are scraped or flushed to remove food particles prior to using a commercial dishwasher or washing by hand? b. If commercial dishwasher is used; it sanitizes at a water temperature of a minimum of 180 degrees Fahrenheit or uses an approved amount of liquid sanitizing agent? c. (Leave blank if no re-usable food service items are hand washed) If dishes/utensils are hand washed, at least a two (2) compartment sink is used? The following manual dishwashing steps are used: Scrape/flush dishes Wash with hot soapy water Rinse with clear hot water Sanitize with approved sanitizing agent (If bleach, use in cool water 75 degree F or cooler) Air dry and store appropriately? G. STAFF TRAINING 1. Facility staff has participated in current fiscal year ACFP training? 2.Facility staff has participated in current fiscal year Civil Right Training? END OF REVIEW Reviewer Signature of Person in Charge of Site Attach Completed Review Findings Form N:\\acfp\forms\ Long Monitoring Form Rev. 8/08 8

Florida Department of Agriculture and Consumer Services Division of Food, Nutrition and Wellness SFSP SPONSOR MONITOR SITE VISIT OR REVIEW FORM

ADAM H. PUTNAM COMMISSIONER Florida Department of Agriculture and Consumer Services Division of Food, Nutrition and Wellness SFSP SPONSOR MONITOR SITE VISIT OR REVIEW FORM Sponsor Name: Agreement #: 04-