Home-Delivered Meals Durham County Department of Social Services & Durham Meals on Wheels Monitoring Visit FY 13/14 Purpose A monitoring visit was made to Durham County Department of Social Services (DSS) and to Durham Meals on Wheels (MOW) on 11/13/13 and 11/14/13 by Mary K. Warren, Assistant Director and Ellison Jones, Family Caregiver Resource Specialist for Triangle J Area Agency on Aging (TJAAA). Ms. Warren and Mr. Jones conducted this interview by pre-arrangement with primary informants Gale Adland, Meals on Wheels Executive Director and Tammie Tate, Supervisor in the Adult Home Care Unit at Durham Social Services. The purpose of the visit was to review the use of Title III-C and NSIP (USDA) funds in providing nutrition services in accordance with the terms of the Older Americans Act of 1965 and subsequent amendments, OMB Circular A-133, Audits of States, Local Governments and Non-Profit Organizations, and compliance with the requirements of the NC Division of Aging and Adult Services. Additionally, the visit provided the opportunity to identify best practices or notable achievement in service provision, as well as to offer recommendations for improvement or to identify the need for more intensive assistance. For FY 13/14, $197,345 is appropriated for the provision of HCCBG-funded home-delivered meals. The home-delivered service total is comprised of $143,410 in federal and state funds, $38,001in NSIP (USDA) funds and $15,934 in local matching resources. At the end of September 2013 (25% of the fiscal year), approximately 29% of the homedelivered funds had been reimbursed. However, a budget revision is currently in process and will increase the budget to a total of $200,168. Authority Older Americans Act of 1965 as amended (as codified in Title 42 of the United States Code, Chapter 35, sec. 3001 et. seq.) Title 45, Code of Federal Regulations, Part 1321 NC General Statutes, Chapter 143B, 143-B-181.1 NC Administrative Code, Title 10A, Chapter 6 and Subchapter K US Office of Budget and Management (OMB) Circular A-133 1
Indicators Durham County Department of Social Services receives HCCBG funding for the provision of home-delivered meals throughout Durham County. Durham DSS sub-contracts with Meals on Wheels of Durham, Inc. to manage the distribution of up to 200 meals per day (funded and privately funded) and the volunteer recruitment process for delivery of those meals. Meals on Wheels, in turn, contracts with Food Runner s Collaborative in Raleigh, NC to provide catered food Meals on Wheels of Durham is a private, non-profit organization that has been in operation since 1975. The current Executive Director, Gale Adland, joined the organization in March of 2010. Other key staff members are new since the last monitoring visit and include Sharon Lawson, Operation Director, Phillip Roof, Outreach Coordinator and Michael Chilton, Accounting Specialist. Primary hours of operation are weekdays from 8:00 a.m. until 4:30 p.m., with the meal service activity taking place primarily in the morning hours. The program office and main meal distribution site relocated into a renovated shop building in June 2009, leaving its previous site at the Center for Senior Life. This site provided Meals on Wheels expanded office space, better parking for volunteers and more autonomy over its operations. Further renovations and improvements were made in 2011, resulting in a brighter, cheerier and more functional workspace. There is also an improved lobby area for receiving visitors and volunteers. The program operates approximately 22-25 meal delivery routes from this location, depending on current route configurations, and the program serves approximately 260-280 hot meals per day. Another 25 clients receive frozen meals each week, mostly those who are outside of a route or who must go to dialysis or other medical appointments. In addition to HCCBG funding, the program also provides meals to Medicaid Community Alternative Program (CAP) participants, Social Services Block Grant clients, private paying individuals and they provide other meals through donations and fund-raising efforts. For instance, Individuals who have just been discharged from the hospital may receive emergency meals on a short-term basis to assist in their recuperation and to help prevent re-hospitalization during the recovery period. Meals on Wheels has also partnered with the Food Bank of NC to provide weekend food assistance to approximately 60 needy individuals. Additionally, they are now an affiliate organization of United Way. Volunteers are at the heart of the Meals on Wheels program. The agency relies on approximately 150 dedicated volunteers to deliver a nutritious noon meal to their homebound clients. Recruitment of volunteers is an ongoing process and their aim is to reach both individuals and businesses that will encourage employees to deliver meals. Most volunteers will run a route once or twice per week, but a few dedicated volunteers deliver on a full time basis. They also rely on about six to ten volunteers daily to help pack the meals and any other items to be distributed. New volunteers are oriented to their duties by Ms. Lawson and Mr. Roof and they receive a volunteer handbook. All new volunteer drivers are accompanied on their first 2
route by another veteran driver. Volunteers are recognized throughout the year, in various ways and they try to hold one big event for all volunteers annually. Typically, the need for volunteers is publicized through the local newspaper, the Meals on Wheels website, public service announcements on cable television, through the Volunteer Center and Retired Senior Volunteer Program (RSVP), public speaking opportunities and through donor mailings. The program tries to participate in community events and fairs for additional publicity and visibility. However the best publicity remains through word of mouth and volunteers are encouraged to bring friends with them to see the program and services in action. Once volunteers are assigned to a specific route, they pick up the meals in cooler bags, along with a daily newspaper for each recipient, provided courtesy of the Herald-Sun. Directions for each stop along the route along with other pertinent details are printed daily and provided in a folder for each volunteer, which they are asked to check before they leave each day. When they return to the office, volunteers document any undelivered meals and report any problems that were encountered on the route. Staff members can then follow-up on any concerns. The delivery records are then keyed into SERVtracker software on a daily basis. There is also a custom mobile app available for volunteers that prefer to use their smart phone to make delivery reports. Meals are prepared and plated by Food Runners Collaborative in Raleigh and delivered daily. Cases of frozen meals are also provided by Food Runners. Meals on Wheels can also provide shelf stable meals for emergencies, such as inclement weather. Menus are changed quarterly and dietician services are provided through the contract with Food Runners. There is a menu planning session held for provider agencies each quarter, facilitated by Food Runners staff. MOW periodically conducts satisfaction surveys with clients and the most recent survey was distributed in October of this year. In addition to asking about food satisfaction and preferences, the survey also seeks to capture the impact of the daily volunteer visit on the individual s overall well-being. Temperatures are taken on each route monthly by a trained volunteer or staff member. The program has a warming oven to help hold or boost arrival temperatures. However, temperatures are noted to still be below the minimum of 135 degrees for hot items on some of the routes. It is not clear at this time exactly what may be causing the sub-par temperatures and further investigation of this is needed. Eligibility for HCCBG service is determined by Durham County DSS s social workers, under the direction of Bob Wallace, Adult Services Coordinator and Tammie Tate, Home Care Supervisor and assigned liaison to the program. Referrals for the HCCBG-funded meals are for those aged 60 and over who are homebound because of medical conditions or functional limitations. The workers document eligibility on the required Client Registration Form and enter the registration data into ARMS. Once a client is referred and accepted for service, case assignments are made 3
and the individual social worker is responsible for completing the client assessment updates and other required paperwork, as well as for following up on any clients who are not home when meals are delivered. DSS social workers also inform the client about the opportunity to contribute towards the cost of the service. After meals have been provided by MOW, information is transferred monthly back to DSS, where a staff member, Deborah Williams, enters the data into the Aging Resources Management System (ARMS) for reimbursement. Subcontractor Performance Monitoring DSS provides ongoing oversight of the performance of the Meals on Wheels program, mostly by reviewing temperatures, training and client service records on a monthly basis. The performance of Meals on Wheels is formally monitored by the AAA, as a part of the monitoring of Durham DSS s funded nutrition services. Food Runner s Collaborative, a subcontractor of Meals on Wheels is formally reviewed on an annual basis by Meals on Wheels of Wake County and this information is shared with other provider agencies utilizing this same caterer, as well as with the AAA representative. Unit Verification A sample of 15 HDM client records was reviewed for the month of September 2013. All of the clients in the sample were eligible for the service and had the required Client Registration Form in the client record. Reassessments were updated appropriately and in a timely manner for all clients, with the exception of two clients who were not yet due for a reassessment. The units sampled for the month of September 2013 were not consistent with the number of units reimbursed. In exploring the reason for the difference, it was discovered that two emergency meals for each HCCBG-funded client had been ordered and reimbursed, but not yet distributed. This was the result of an apparent misunderstanding between DSS and the Meals on Wheels staff, but these meals are not reimbursable until clients have actually received them. One other reimbursement error was noted for client, S.G., was discovered and corrected during the review period. Consumer Contributions Policy Implementation The most recent consumer contributions policy was adopted in September 2005 and HDM is considered a Type II service under the policy, with 7 requirements for compliance. Durham DSS typically talks with the client about contributing and maintains the documentation of that contact. Contributions are typically mailed directly to MOW. Contributions are receipted in the MOW office and the amount collected is reported to DSS for entering into the ARMS system. 4
An annual update to the Provider Assurance Form, documenting that the home-delivered meals recipient has been informed about the opportunity to contribute towards the service, is required by the Consumer Contributions Policy. The client is provided information about the unit cost of the meal. All of the client records at DSS had the required Provider Assurance Form and it was appropriately updated. Currently, only one client regularly makes a contribution of $10 each month. However, it was noted that for the month of September 2013, DSS reported a total of $25, which was incorrect ($25 was the total billed to DSS for clients not home in the month of September, rather than the consumer contributions total). This was an error in keying from the MOW report into ARMS and was corrected during the review period. OAA Title III-C Nutrition Program # 93.045 Compliance Supplement Compliance Supplement Criteria Requirement a. Activities Allowed or Unallowed: Yes* b. Allowable Cost/Cost Principles: Yes ( ) Compliance Supplement Criteria Yes No N/A c. Cash Management N/A d. Davis-Bacon Act: N/A e. Eligibility: Yes f. Equipment and Real Property Management: N/A g. Matching, Level of Effort, Earmarking: Yes h. Period of Availability of Federal Funds: Yes i. Procurement, and Suspension and Debarment: Yes j. Program Income: Yes k. Real Property Acquisitions and Relocation Assistance: l. Reporting: Yes m. Sub-recipient Monitoring: Yes n. Special Tests and Provisions: Yes o. Conflict of Interest: N/A N/A 5
*A compliance issue with unit reimbursement was corrected during the review period. Nutrition Services Incentive Program (NSIP) #93.053 Compliance Supplement Compliance Supplement Criteria Requirement a. Activities Allowed or Unallowed: Yes* b. Allowable Cost/Cost Principles: Yes ( ) Compliance Supplement Criteria Yes No N/A c. Cash Management: N/A d. Davis-Bacon Act N/A e. Eligibility: Yes f. Equipment and Real Property Management: N/A g. Matching, Level of Effort, Earmarking: N/A h. Period of Availability of Federal Funds: Yes i. Procurement, and Suspension and Debarment: Yes j. Program Income: N/A k. Real Property Acquisition and Relocation Assistance: l. Reporting: Yes m. Sub-recipient Monitoring: Yes n. Special Tests and Provisions: N/A o. Conflict of Interest: N/A *A compliance issue with unit reimbursement was corrected during the review period. N/A Compliance The following compliance issues with home-delivered meals were noted during the monitoring: 6
Two emergency shelf-stable meals for each HCCBG-funded client had been ordered and reimbursed during the month of September 2013, but were not yet distributed to clients. This was the result of an apparent misunderstanding between DSS and the Meals on Wheels staff, but these meals are not reimbursable until clients have actually received them (pg. 47, Nutrition Service Standards, Incomplete meals, unserved meals, and leftover food served as second helpings cannot be reported for reimbursement.) This compliance issue was corrected immediately following the monitoring, with the emergency meals distributed to HCCBG-funded clients on November 18 and November 29, 2013. The DSS staff and the MOW staff have been informed that in the future, all meals must be actually delivered to clients before reimbursement is submitted in ARMS. Route temperatures for hot foods was noted to be below the required 135 degrees, and in some cases cold foods were higher than the required 45 degrees or less ( http://ehs.ncpublichealth.com/docs/rules/2600-rulebookfinal-7-23-12..pdf ) Although Meals on Wheels is not inspected by the Health Department for food service because the meals are pre-plated, the Nutrition Service Standards indicate that route temperatures are to be in compliance with these temperature requirements throughout the distribution process. Nine out of twenty-two routes (41%) reviewed in September were problematic with route temperatures, though the meals were in compliance at the time of delivery to the Meals on Wheels site. This is a potential health and safety issue and will need further investigation to determine why temperatures are not remaining in compliance throughout the distribution process. DSS, Meals on Wheels and Food Runners are attempting to address the problem and are requested to continue working on this issue, and to forward monthly route records to the AAA for review, along with a description of progress. This compliance issue will be closed when the problem is resolved and meal temperatures are in compliance throughout the distribution process. Additionally, it was noted that the Food Runners kitchen staff was not consistently signing the delivery ticket at the end of the daily food production, as specified by the Nutrition Service Standards. This was brought to the attention of the FR s kitchen manager during the monitoring visit, and he will instruct new staff on this requirement. This will not require action or a response from the DSS and MOW staff but in order to avoid future compliance issues, staff should observe for any future problems with the signing of delivery tickets and address it with the caterer, if noted. 7
Comments, Assistance, Recommendations Meals on Wheels continues to grow their program and services, and their partnership with Durham DSS is a vital part of keeping Durham s older adults in their home for as long as possible. After many years of staff turnover, it appears that Ms. Adland s leadership is providing the organization with stability and strategic planning for the future. She is actively working to improve the service delivery, fundraising and perception of the Meals on Wheels program in the Durham community. The records maintained by the Durham DSS staff were noted to be complete and wellorganized. The social work staff has done very well with maintaining the documentation requirements for individual service recipients and are to be commended on this. TJAAA staff members continue to be available to provide assistance to either, as needed and requested. 8