24-8294_-_Attachment_A_-_DOEA_Handbook_Chapter_5.pdf

DEPARTMENT OF ELDER AFFAIRS PROGRAMS AND SERVICES HANDBOOK

Chapter 5 Older Americans Act (OAA) Title IIIC

Chapter 5: Older Americans Act (OAA) Title IIIC

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TABLE OF CONTENTS

Section Topic Page

I. Overview 5-3

II. Legal Authority 5-4

III. Selection of Nutrition Program Service Providers 5-4

IV. Planning for Nutrition Services 5-9

V. Contracts with Profit Making Organizations 5-14

VI. Menu Review and Approval 5-16

VII. Food Preparation and Safety Standards 5-30

VIII. Nutrition Services Incentive Program (NSIP) 5-38

IX. Nutrition Assistance Program 5-39

X. Food Service Contract Provisions 5-40

XI. Contributions for Nutrition Services and Outreach 5-43

XII. Leftover Food 5-44

XIII. Nutrition Education and Counseling 5-45

XIV. Congregate Meals 5-46

XV. Home Delivered Meals 5-49

XVI. Grab and Go Meals 5-52

Attachment 1: DOEA Form 2017 5-55

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Section I: Overview

A. The AAA may award nutrition service funds received under Title IIIC1 and Title IIIC2 for the provision of nutrition services that assist older individuals in Florida to live independently, with better health through improved nutrition and reduced isolation. Nutrition services are provided through programs coordinated with nutrition-related supportive services and include the procurement, preparation, transport, and service of meals; nutrition education; nutrition screening; nutritional assessment, and nutrition counseling. In making these awards, the AAA must ensure that congregate and home-delivered meals are provided to eligible individuals based on their assessment of need.

NOTE: While the AAA must ensure congregate meals through Title IIIC1 and home-delivered meals through Title IIIC2, the AAA may choose to procure and award separate Title IIIC1 and Title IIIC2 providers.

B. The purpose of the nutrition program is to:

1. Reduce hunger and food insecurity. (Food insecurity occurs when an individual has a limited or uncertain availability of nutritionally adequate and safe food or ability to acquire acceptable foods in socially acceptable ways.).

2. Promote socialization.

3. Promote health and well-being of older individuals by assisting them in gaining access to nutrition and other disease prevention and health-promotion services. The intent is to delay the onset of adverse health conditions resulting from poor nutritional health or sedentary behavior.

4. Nutrition services to older clients at community dining centers or in their homes include the following:

• Procurement, preparation, transportation, and service of meals;

• Nutrition counseling; and

• Nutrition education.

5. Elderly nutrition programs objectives are to:

• Prevent malnutrition and promote good health behaviors through participant nutrition education, nutrition screening, and intervention;

• Serve wholesome and delicious meals that are safe and have good quality, through the promotion and maintenance of high food safety and sanitation standards;

• Promote or maintain coordination with other nutrition-related supportive

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• Target older adults who have the greatest economic or social need with attention to low-income minority and rural clients.

Section II: Legal Authority

• Older Americans Act, Title IIIC Subpart 1, Section 331 42 U.S.C. 3030e

• Older Americans Act, Title IIIC, Subpart 2, Sections 336, 337, 339 42 U.S.C.

3030f, g, g-21

• The National Nutrition Monitoring and Related Research Act of 1990 (Public Law

101–445)

• U.S. Department of Health and Human Services Public Health Service Food and Drug Administration, Food Code: https://www.fda.gov/food

• U.S. Department of Agriculture (http://www.usda.gov)

• Americans with Disabilities Act – 42 U.S.C. 12101

• Healthy People 2030 (http://www.healthypeople.gov/)

• Dietary Guidelines (https://health.gov/our-work/nutrition-physical-activity/dietary-guidelines)

• Chapter 509.039, Florida Statutes – Food Manager Certification

• Chapter 64E-11, Florida Administrative Code – Food Hygiene

• Chapter 468.509 Florida Statutes – Dietitians/Nutritionist

• Chapter 64B8 Florida Administrative Code – Dietitians/Nutritionist

• DASH Diet (http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/index.htm)

Section III: Selection of Nutrition Program Service Providers

A. General Rules:

1. An AAA may make awards for congregate and home-delivered nutrition services to a provider that furnishes either or both services. Providers must meet the requirements of this part.

https://www.fda.gov/food http://www.usda.gov/ http://www.healthypeople.gov/ http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/index.htm)

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2. Contracts are awarded through a competitive process. Such a process shall include evaluation of each bidder’s experience in providing services to older individuals.

B. Congregate and Home-Delivered Nutrition Program Providers:

Each AAA will give primary consideration where feasible, in contracting for the provision of congregate and home delivered meals to organizations which:

1. Have demonstrated an ability to provide quality congregate and home delivered meals efficiently and reasonably;

2. Have furnished assurances to the AAA that the organization will maintain efforts to solicit voluntary support and that funds made available under this title to the organization will not be used to supplant funds from non-federal sources; and

3. Make every attempt to efficiently and responsibility meet the cultural and/or ethnic culinary needs of participants of congregate and home delivered meals.

C. Service Area and Selection of Nutrition Providers:

Each nutrition service provider under an area plan shall operate within the boundaries of the area established in the award document. A nutrition service area must be of sufficient size for:

1. Economical delivery of meals;

2. Efficient provision of nutrition education, outreach, nutrition counseling; and

3. Coordination and linkage of nutrition activities with related services programs in the service area.

D. Selection of Nutrition Providers Within a Service Area: Awards shall be made to congregate nutrition service providers serving an annual average of at least 100 meals per day, five or more days a week within the designated service area, but not necessarily at each site.

1. AAA approved exceptions for providers operating in sparsely populated rural areas include:

• Less than 100 meals per day; and

• Meals at least five days a week at sites throughout the service area, but not necessarily five days a week at each site.

NOTE: Providers operating in a sparsely populated rural area must provide outreach as set forth in this handbook (See Appendix A, Service Descriptions and Standards.)

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2. A provider of nutrition services shall target older persons in greatest economic and social need; low-income older individuals; including low- income minority older individuals, older individuals with limited English proficiency, and older individuals residing in rural areas.

E. Nutrition Provider’s Responsibilities When Establishing New Congregate (C-1)

Sites:

1. Obtain AAA approval for establishment of additional C-1 sites, which can include the use of local restaurants. When there is a break in service at an existing C-1 location, the Nutrition Provider must notify and receive approval from the AAA in order for the C-1 site to resume services and billing.

2. Determine interest and capability of the potential site.

3. Determine the number of meals per day, week or month that will be available to C-1 recipients.

4. Establish written policies and procedures in accordance with the Program and

Services Handbook and applicable state and local regulations. Written policies and procedures must address at a minimum the following:

• Handling and storage of administrative documentation;

• Client registration requirements;

• Client reporting requirements;

• Client donations;

• Instructions on how to obtain meal credits;

• The C-1 meal schedule;

• Project menus;

• Project evaluation;

• Program restrictions, i.e., maximum number of meals available to a participant per month, gratuities, and taking meals out for consumption elsewhere;

• Provision of nutrition education;

• Nutrition Program’s monitoring of the site using the Nutrition Program

Compliance Review form;

• Nutrition Program review of public health department review of restaurant; and

• Monthly billing.

5. Develop a survey for determining participant satisfaction concerning:

• If the meal option is meeting the recipient’s needs;

• The quality of the meals; and

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• The service provided by C-1 site volunteers/staff.

6. Evaluate potential site for appropriateness. Evaluation must include, but is not limited to the following:

• Location in an underserved area;

• Accessibility to elders in the community;

• Diversity of service area;

• If using a restaurant, assurance that is a fixed facility and meets the standards in Florida Administrative Code 64E-11;

• Compliance with all Americans with Disabilities Act (ADA) accessibility requirements;

• If using a restaurant, review of the three most recent health inspections; and

• Capability of meeting the administrative and operational demands of the program as outlined below.

F. Restaurant Provider’s Responsibilities:

1. To become a C-1 meal site, a potential site, including restaurants, must have the appropriate capabilities to administer components of the program to include but not limited to:

• Serving elders in a dignified and culturally sensitive manner;

• Permitting unannounced access to the food preparation area to the local nutrition provider, AAA or State Agency staff;

• Providing adequate space, permitting elders the opportunity to dine in a comfortable setting;

• Meeting or exceeding the local food service licensing, health regulations, and fire regulations;

• Following the Program and Services Handbook regulations for OAA

Title III C meals;

• Providing a pre-defined meal or meal options to authorized individuals;

and

• Developing menus by collaborating with the nutrition provider staff and qualified dietitian. If using a restaurant, the menu used should be the current restaurant menu to the greatest extent possible. The pre-defined menu or menu options must comply with the Program and Services Handbook and approved by nutrition program’s RD prior to use.

2. All C-1 sites, including restaurants, must be willing to perform at a minimum the following tasks:

• Provide participants with a written menu(s);

• Follow the procedures established by the nutrition provider to validate

5-8 that participants are registered and authorized for consumption of C-1 meals served;

• Use the system established by the nutrition provider to document the total number of meals served to participants monthly;

• Use the system established by the nutrition provider to document the total number of unduplicated participants;

• Facilitate or permit facilitation of a nutrition education program;

• Notify the Nutrition Provider immediately of any closures (temporary or permanent) or Administrative Complaints against the restaurant;

• Notify the Nutrition Provider within 24 hours of any sanitation inspections and provide a copy of the report;

• Facilitate an initial inspection of the site by nutrition provider staff. This inspection will include the completion of the Nutrition Provider’s Compliance Review Form. Thereafter, the provider must permit Nutrition Program, AAA, and the Department staff to make onsite inspections at any date or time, with or without prior notification.

3. If using a restaurant as a C-1 site, the Nutrition provider and restaurant provider’s contract files must include, but are not limited, to the following items:

• A written, executed agreement outlining the service provided;

• Copy of the restaurant’s current food service license;

• The three most recent local health inspection reports;

• A copy of the current local fire department inspection report. All items that were cited by the fire department must be corrected prior to the start of the program;

• The approved menus;

• A copy of the Professional Food Manager’s certificate(s);

• An insurance certificate stating current policy coverage and, if available, evidence of umbrella or excess liability policy;

• Designation of sections of the proposal that are claimed to be proprietary along with rationale justifying exception of these sections from Freedom of Information Act release; and

• Unit cost.

G. AAA Responsibilities:

1. The AAA must provide written notification to the Department’s Registered Dietitian at least 30 calendar days prior to a nutrition provider opening a new C-1 site, including restaurant-based meal service.

2. The AAA must provide the Department an accurate listing of all the Congregate Meal Sites and Food Service Vendors at least annually and within

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48 hours of any changes.

Section IV: Planning for Nutrition Services

A. Objectives: Nutrition service providers must establish measurable objectives related to the needs of eligible individuals in the approved service area and objectives must address the following requirements:

• Targeted individuals to be served;

• Services to be provided, including the number and frequency of meals to be served in congregate and in home-delivered settings; and

• Plans for monitoring progress toward achieving objectives.

B. Priority for Services: Nutrition services under the OAA should be reserved for those individuals age 60 years and older who have been identified as being in greatest economic or social need, and especially low-income older individuals, including low-income minority older individuals, older individuals with limited English proficiency, and older individuals residing in rural area. Additional factors which should be considered in establishing priority include those older persons who:

• Cannot afford to eat adequately;

• Lack the skills or knowledge to select and prepare nourishing and well-balanced meals;

• Have limited mobility which may impair their capacity to shop and cook for themselves; or

• Have a disabling illness or physical condition requiring nutritional support or have been screened at a high nutritional risk.

C. Nutrition Provider Staff, Consultants, and Volunteer Required Training/Credentials: Nutrition service providers shall cooperate with the AAA to ensure that training will be provided for both paid and volunteer staff.

1. Job specific training shall be available for each staff member. Each nutrition service provider shall set aside sufficient budgetary funds for training, including in-service training. This may include the payment of a tuition fee, travel, and per diem to local, statewide, or out-of-state training programs designed to expand staff capacity to effectively carry out nutrition services.

2. Food Protection Manager Training: Nutrition Programs that operate a kitchen and have three or more employees at one time engaged in the storage, preparation, display, or service of food must identify an individual as the manager and that manager must be a Certified Food Protection Manager, unless the manager is a qualified dietitian.

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The manager must be present during the food service operation. Programs that do not prepare their own food must have a Certified Food Protection Manager responsible for the storage, display, and serving of food for meal sites, but the Certified Food Protection Manager does not have to be present always. (Refer FAC 64E-11). New managers must be certified as a Food Protection Manager within 90 days of employment. The AAA may grant an extension up to 180 days.

3. Employee Food Safety Training Requirements: All food service staff and volunteers must receive annual training by a Registered Dietician (RD), or competent Certified Food Protection Manager under the direction of the RD, on the prevention of foodborne illness. Staff and volunteers must be trained prior to assuming food service assignments.

4. On-going training plans should be based upon information obtained through the evaluation of training sessions and needs identified at that time, as well as staff requests.

D. Nutrition Consultant:

1. Each nutrition service provider shall obtain the advice of a qualified dietitian in planning and providing nutrition services. The number of consultation hours should be based on the size and complexity of the nutrition service provider and may be established by the AAA.

2. The qualified dietitian shall be either a provider employee or an independent consultant, hired by the project (paid or in-kind). The dietitian paid by the project’s food service vendor is not acceptable in this position.

Qualified Dietitian Definition: For the Florida elderly nutrition program, a “qualified dietitian” is a licensed or licensed registered dietitian. The following define criteria for a registered dietitian and a licensed dietitian.

Registered Dietitians (RD) are credentialed through the Commission on Dietetic Registration (CDR). RD’s must provide a copy of their current CDR card upon hire. RD’s must remain credentialed through CDR throughout the duration of their employment.

Licensed Dietitian/Nutritionist (LD or LD/N) are credentialed through the Florida Department of Health (DOH). LD or LD/N’s must provide a copy of their current State of Florida Dietitian/Nutritionist license upon hire. LD or LD/N’s must remain licensed throughout the duration of their employment.

NOTE: A change in qualified dietitian requires a funding application packet to be submitted to the AAA, containing the following information:

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For a Licensed and Registered Dietitian:

• A resume for the provider’s qualified dietitian;

• A copy of the individual’s current registration with the Commission on

Dietetic Registration of the Academy of Nutrition and Dietetics; and

• A copy of the individual’s current Florida license with the Department of

Health (Refer to F.A.C. Chapter 64B8.)

For a Licensed Dietitian:

• A resume for the provider’s qualified dietitian; and

• A copy of the individual’s current Florida license with the Department of

Health (Refer to F.A.C. Chapter 64B8.)

3. Responsibilities and functions of the qualified dietitian shall include, but not be limited to, the following:

a. Participation in developing menus with input from the advisory council;

b. Ensuring all menus as written meet nutritional criteria as required by

DOEA (refer to Menu Planning, Development, Review, and Approval Requirements section);

c. Approval of all menus (as indicated by an authorizing signature and date on each weekly or monthly approved and posted menu) four (4) weeks prior to implementation;

d. Monitoring, at least annually, every meal site using the current Nutrition

Program Compliance Review form;

e. Monitoring, at least annually, every food service vendor’s sanitation inspection reports;

f. Reviewing corrective action plans of food service vendors for all significant or high priority findings on sanitation inspection reports;

g. Participation in development and review of food service contract annually for adherence to current nutritional requirements and delivery components of the food service vendor contract (See Food Service Contract Requirements);

h. Participation in developing and approval (as indicated by an authorizing signature and date) of the annual and monthly nutrition education plan and coordinate the provision of nutrition education so it is effective and appropriate;

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i. Providing staff and volunteer training in areas of nutrition, food service management, and food safety;

j. Participation in the development of client satisfaction preference assessment tools, and review assessment of results; and

k. Providing nutrition counseling for clients, if nutrition service provider authorizes it for clients that have high-risk nutritional scores (any score higher than 5.5 on the assessment tool). This service must be provided by a Florida Licensed Dietitian (FAC Chapter 64B8- 43). Any dietitian providing nutrition counseling should be covered by malpractice insurance.

E. Technical Assistance: Each nutrition service provider should:

• Inform the AAA of technical assistance needs for quality improvement and corrective action measures.

• Provide technical assistance to its contract agencies, other related clients, and its advisory council.

F. Records and Reports: Nutrition providers are required to:

1. Develop and maintain a record on each client which documents the following:

• Eligibility for services;

• Information related to emergency care; and

• The need for, and referral to, other appropriate services.

2. Obtain information related to congregate clients within three days of determination of status as a client rather than a guest.

3. Obtain information related to homebound clients prior to receipt of a home-delivered meal. In the event of an emergency, a home-delivered meal may be provided prior to assessment.

4. Establish recording procedures, in accordance with AAA policy, which ensure the accuracy of the number of eligible client meals served each day.

5. Submit all required reports promptly.

6. Provide access to all records and reports on demand for audit, assessment, or evaluation by authorized representatives of the AAA, state, or federal agencies.

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G. Monitoring, Assessment and Evaluation: Each provider will be subject to the monitoring policies and procedures of the Department.

H. Advisory Council: All nutrition providers must establish and maintain either a project advisory council made up of representatives from each congregate nutrition site, or a site council at each congregate nutrition site. The nutrition advisory council shall advise the nutrition program director on all matters relating to the delivery of nutrition services within the program area. All recommendations of the council shall be taken into consideration. Clients may establish site councils in addition to advisory councils with concurrence of the provider director.

1. These councils must be comprised of at least 51% clients of the nutrition program and must meet a minimum of two times per year (as evidenced by dated sign in sheet).

2. Advisory councils must meet the following additional requirements:

a. The council shall not function in a policy-making or decision-making capacity. An advisory council should not be confused with the provider or contractor board of directors, which is a legal entity with policy-making authority. No member of the board of directors or employee of the provider or contractor may serve on the advisory council except as an ex-officio member. No immediate family member of a part-time or full-time employee of the grantee or contractor may serve on the advisory council.

No DOEA staff member may serve on the advisory council.

b. Advisory Council Roles and Responsibilities:

i. Serve in an advocacy role to ensure that the program serves the elderly;

ii. Provide means for participating clients to express their views on the services provided;

iii. Assist with client satisfaction surveys;

iv. Make recommendations to the nutrition program director regarding food preferences of clients, days and hours of dining center, operations and locations and dining center furnishings regarding disabled clients.

v. Advise and make recommendations to the nutrition director regarding supportive social services to be conducted at dining centers; and

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vi. As an organized group, provide support and assistance to the ongoing development of the nutrition program.

I. Public Information and Dissemination: Each nutrition service provider, in cooperation with the AAA, is responsible for the development and dissemination of information regarding services throughout its service area. Providers will be expected to utilize all appropriate media sources to keep the public informed about the nutrition program for the elderly. (All providers should coordinate with the AAA in conducting special informational events, such as Older Americans Month, public hearings, conferences, etc.)

1. Area Agencies on Aging must ensure that relevant informational material received, such as policy clearances, technical assistance, pertinent grant or other funding opportunities, meetings, and information issuances is documented in a timely fashion.

2. Public information activities must conform to policies concerning confidentiality and public notice.

J. Coordination of Services: A nutrition service provider must utilize existing social service resources in provision of necessary services. Such efforts shall include joint planning, sharing of information, and negotiation of joint funding agreements in operation of programs for the elderly.

K. Food Service: Meals served by nutrition providers can either be prepared directly by the provider (i.e., self-preparation kitchen that serves one meal site or central kitchen which serves multiple meal sites) or through a written contractual agreement with a vendor (i.e., nearby schools, restaurants, or hospitals) or a food service management company. Meal production must comply with local, state (FAC 64E-

11) and, if applicable, federal regulations (United States Department of Agriculture and Food and Drug Administration).

Section V: Contracts With Profit-Making Organizations

A. Contracts/Subcontracts: Nutrition service providers may enter contracts or subcontracts with profit-making organizations for nutrition services only with prior written approval of the AAA. Contracts for the provision of food may be executed only with those vendors who supply meals from premises that have a valid permit, license, or certificate issued by the appropriate regulatory authority. The service provider shall comply with all federal, state, and local laws, ordinances, and codes for establishments that are preparing, handling, and serving food to clients.

The vendor must submit its three most recent sanitation inspection reports to the Nutrition Provider. If a vendor has one temporary closure and/or twelve (12) high

5-15 priority violations in the preceding twelve-month period, the inspection reports shall be sent to the AAA for further review. The AAA will then decide whether the vendor has taken appropriate action to ensure food safety compliance in order to prevent repeat violations. The vendor must agree to notify the Nutrition Provider immediately of any closure or Administrative Complaint related to food safety.

The vendor must agree to notify the Nutrition Provider within twenty-four (24) hours of any sanitation inspection and provide a copy of the report to the Nutrition Provider. It is not recommended that the AAA contracts, or subcontracts, with any vendor who has more than one temporary closure and/or more than twelve (12) high priority violations in the twelve-month period prior to entering into a contract or during a twelve-month contract period.

B. Subcontracts: If the Title III service provider subcontracts for meals, it is the responsibility of the AAA to ensure that the provider monitors the subcontractor.

The AAA must also monitor the subcontractor’s performance either directly or via communication with the Nutrition Provider. The Title III service provider must monitor the subcontractor on-site at least once per year during the contract period, with follow-up visits for corrective action or quality improvements made as needed.

1. Cooperative Monitoring: Whenever multiple service providers utilize the services of a single food service vendor’s production kitchen; the service providers may elect to monitor the subcontractor on a cooperative basis.

One nutrition service provider may monitor on behalf of other providers.

Cooperative monitoring must be arranged in advance and approved by the appropriate AAA(s). For the AAA to approve cooperative monitoring, the following conditions shall be met:

• The individual conducting the food service vendor monitoring shall have demonstrated knowledge of sanitation, food handling, food preparation, and food storage principles, and preferably be a Certified Food Protection Manager or a qualified dietitian;

• The subcontractor’s monitoring was completed in accordance with

Chapter 1, of this handbook;

• Monitoring may include review of all aspects of kitchen management including, but not limited to:

o All local and state level health department inspections;

o Meal/menu-related invoices;

o Food staff certifications;

o Staff in-service documentation;

o Standardized recipes; and o Standardized recipes to monitor for nutrient compliance.

2. Written Monitoring Report: All written reports documenting the monitoring

5-16 visit and any other reports required by the project will be reviewed by the AAA for validation of the documented services. The AAA must notify the Department’s RD in writing within 48 hours of any changes in food service vendors.

3. Corrective Action Plans: All subcontracted food service vendors must provide a written corrective action plan to the Nutrition provider for any high priority or significant findings on sanitation inspections. These corrective action plans must be approved by the provider’s RD.

Additionally, the AAA monitor should ensure the accuracy of all reports and require corrective action plans, if appropriate, to ensure that deficiencies are remedied.

Section VI: Menu Review and Approval

A. Menu Planning: The menus shall be planned and provided to the qualified dietitian for review no less than six calendar weeks in advance of implementation.

B. Menu Approval: All menus must be approved at least four calendar weeks prior to implementation. All menus must be approved in writing by a qualified dietitian. The approving qualified dietitian’s signature and date must be documented on each page of the approved and posted menu. The approving signature verifies that all menus comply with DOEA menu standards and applicable supporting nutrient analysis documentation is maintained. The AAA qualified dietitian or the nutrition program Qualified Dietitian may approve the menus. A qualified dietitian employed by the food vendor may not approve the menus, because this is a conflict of interest.

C. Menu Cycle: Nutrition Programs may choose to offer two types of menu cycles:

1. Preselect Menu: daily menu offers only one entrée. The preselect menu cycle shall be no less than four weeks in rotation of different food combinations to assure a variety of colors, flavors, and textures. Preselect cycle menus shall run for a maximum of six months before changing, and food items should not be repeated on consecutive days or consecutive days of the week.

2. Selective Daily Menu: offers two to three entrée choices. Meal sites offering a selective menu (i.e., buffet style meal service or kiosk) may decrease the menu rotation and the same menu item may be repeated on consecutive days or consecutive days of the week. However, the program must monitor acceptance and ensure menu fatigue is avoided. Selective menus shall run for a maximum of six months before changing.

D. Menu Revisions: The AAA or nutrition program qualified dietitian may require menu

5-17 revisions based upon a review or the results of client satisfaction surveys.

Requested menu revisions will be given to the service provider at least two weeks prior to scheduled menu implementation.

E. Menu Corrections: Copies of corrected menus must be resubmitted to the AAA or nutrition program qualified dietitian within one week of receipt of comments or as otherwise directed.

F. Menu Posting: Approved preselect menus shall be dated and posted in a conspicuous location at each congregate nutrition site in a font size large enough for easy review by the participants. Nutrition programs that prepare their meals must also post a copy of their menus in the food preparation area. Select Menu (i.e., buffet-style or kiosk) approved menu shall be dated and posted on/near the buffet-style serving line and should be printed in font size large enough for easy review.

G. Menu Retention: Dated and approved menu with supporting menu related documents must be kept on file, as served for a period of two years for audit purposes.

H. Menu Adherence: Approved menus shall be followed as written.

I. Menu Substitutions: A comprehensive menu substitution policy and procedure must be developed and approved by the nutrition program’s qualified dietitian. The menu substitution policy must be available for the site manager’s use. Each meal site shall maintain an on-site record of all substitutions that occur during the calendar year. Menu substitutions shall be minimal, but are allowed under the following conditions:

• Menu substitutions must be from the same food group and provide equivalent nutritional value. For example, a fruit high in Vitamin C must be substituted with another fruit high in Vitamin C.

• Prior to use, the nutrition program’s qualified dietitian must approve the menu substitution policy and procedures and the menu substitution list. It is encouraged that the menu substitution list be inclusive and thorough.

• Documentation of all menu substitutions must be kept on file for at least two years for monitoring purposes. The documentation must include the date of substitution, the original menu item, the substitution made, the reason for the substitution and the signature of the employee authorizing the substitution. Finally, the volume and frequency of substitutions must be justified by the reasons provided. For example, a seasonal fruit may be substituted for a canned fruit.

J. Menu Development:

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1. Menus should be developed with consideration for the:

• Special needs of the elderly;

• Religious, ethnic, cultural, and regional dietary practices or preferences of clients, if reasonable and feasible;

• Variety of food and preparation methods including color, combinations, texture, size, shape, taste, and appearance;

• Seasonal availability of foods;

• Availability of equipment for food preparation or meal delivery service;

and

• Budget.

2. Menu Development Methods: Menus may be developed using two different methods, computer assisted nutrient analysis or component meal pattern.

Either method of menu development must comply with the most recent edition of the Dietary Guidelines for Americans, published by the Secretary of Health and Human Services and the Secretary of Agriculture (https://health.gov/our-work/nutrition-physical-activity/dietary-guidelines).

a. The computer assisted nutrient analysis method. This method of menu development must comply with the following:

• Providing a minimum of 33 1/3 percent of the Dietary Reference

Intake/Adequate Intake (DRI/AI) for 51+ year-old adults as established by the Food and Nutrition Board of the Institute of Medicine of the National Academy of Sciences, if one meal is provided per day;

• Providing a minimum of 66 2/3 percent of the DRI/AI, for 51+ year-old adults if two meals are provided per day;

• Providing 100 percent of the DRI/AI, for 51+ year-old adults, if three meals are provided per day; and

• Any special dietary needs of program clients to the maximum extent practicable.

• Computer-Assisted Menu Development Requirements:

• Targeted Nutrients: Table One represents the most current

Dietary Reference Intakes and daily compliance range for target nutrients. The following nutrients are required to be analyzed for each component of each menu item: calories, protein, fat, fiber, calcium, zinc, sodium, potassium, vitamin B6, vitamin B12, vitamin C, and vitamin A (vegetable-derived/carotenoid sources). Calories, protein, fat, fiber, calcium, vitamin B6, and vitamin C must be provided in adequate amounts daily. Vitamin A, vitamin B12, zinc, 5-19 magnesium, sodium, and potassium may be averaged over one week. Sodium may be averaged over one week; however, no one-meal amount may exceed 1000 milligrams. It is recommended that fortified foods should be used to meet vitamin B12 needs. Holidays and birthday celebration meals (two or fewer meal types per calendar month) may be excluded from the nutrient analysis.

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Macronutrients, Minerals, & Vitamins Age-Sex Group Calorie Level Assessed Source of Goal a Female 51+ Male 51+

Macronutrient 1600 2000

Protein (% kcal) AMDR 10-35 10-35

Protein (g) RDA 46 56

Carbohydrate (% kcal) AMDR 45-65 45-65

Carbohydrate (g) RDA 130 130

Fiber (g) 14G/1000 kcal 22 28

Added Sugars (% kcal) DGA <10 <10

Total lipid (% kcal) AMDR 20-35 20-35

Saturated Fatty Acid (% kcal) DGA <10 <10

18:2 Linoleic acid (g) AI 11 14 18:3 Linoleic acid (g) AI 1.1 1.6 Minerals

Calcium mg) RDA 1200 1000 b

Iron (mg) RDA 8 8

Magnesium (mg) RDA 320 420

Phosphorus (mg) RDA 700 700

Potassium (mg) AI 2600 3400

Sodium (mg) SDRR 2300 2300

Zinc (mg) RDA 8 11 Vitamins

Vitamin A (mcg RAE d) RDA 700 900

Vitamin E (mg AT d) RDA 15 15

Vitamin D (IU d) RDA 600c 600c

Vitamin C (mg) RDA 75 90

Thiamin (mg) RDA 1.1 1.2

Riboflavin (mg) RDA 1.1 1.3

Niacin (mg) RDA 14 16

Vitamin B-6 (mg) RDA 1.5 1.7

Vitamin B-12 (mcg) RDA 2.4 2.4

Choline (mg) AI 425 550

Vitamin K (mcg) AI 90 120

Folate (mcg DFE d) RDA 400 400 a AI = Adequate Intake, CDRR = Chronic Disease Risk Reduction Level, DGA = Dietary Guidelines for Americans, 2020-2025, RDA = recommended Dietary Allowance.

b Calcium RDA for males ages 71+ years is 1,200 mg.

c Vitamin D RDA for males and females ages 71+ years is 800 IU.

d AT = alpha-tocopherol, DFE = Dietary Folate Equivalent, IU = International Units, RAE = Retinol Activity Equivalents. Sources: Institute of Medicine. Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. Washington, DC: The National Academies Press;

2006. Institute of Medicine. Dietary reference Intakes for Calcium and Vitamin D. Washington, DC: The National Academies Press; 2011.

National Academies of Sciences, Engineering, and Medicine. Dietary Reference Intakes for Sodium and Potassium. Washington, DC:

The National Academies Press; 2019.

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b. The component meal pattern menu development method. This method of menu development must comply with the following:

• Provide the minimum meal servings of the 1800-calorie component meal pattern to reflect the current Dietary Guidelines for Americans and USDA Food Intake Pattern calorie levels for a 51+ year-old adult;

• Provide a minimum of two times the minimum meal servings of the 1800-calorie component meal pattern, if two meals are provided per day;

• Provide a minimum of three times the minimum meal servings of the 1800-calorie component meal pattern, if three meals are provided per day;

• Any special dietary needs of program clients to the maximum extent practicable; and

• Applicable provisions of state or local laws regarding the safe and sanitary handling of food, equipment and supplies used in the storage, preparation, service, and delivery of meals to an older individual. Ref.

Chapter 64-E-11- Food Hygiene, F.A.C. (http://fac.dos.state.fl.us).

• The 1800-calorie component meal pattern has been developed to reflect the current Dietary Guidelines for Americans and USDA Food Intake Pattern calorie levels for a 51+ year-old adult (requirements for those programs that are not using computerized nutrient analysis).

Holidays and birthday celebration meals (two or fewer meal types per calendar month) may be excluded from the component meal pattern requirement. The component meal pattern may be deficient in vitamin E, vitamin B12, and Zinc, therefore additional nutrition education for participants on the selection of foods that are good sources of these nutrients shall be provided.

• Items that provide the following target nutrients should be identified on the menu. Vitamin C – must provide at least 25 mg per meal.

Vitamin A – must provide an average of 233 ug per day over the course of a week. For example, if one day the meal is 260 ug and the following day the meal is 200 ug, this averages to 233 ug per day. It is recommended that at least three times per week the Vitamin A is 233 ug.

• Menu Focus: Whole grains and high fiber foods should be included as much as possible. It is recommended that fortified foods should be used

5-22 to meet vitamin B12 needs. The use of nutrient dense foods, as well as fortified and enriched products, should be a priority.

DIETARY GUIDELINE MEAL PATTERN REQUIREMENT FOR ONE MEAL PER DAY

Food Group

Servings/Meal

Daily Dietary Guideline Recommendations

Grains 2 servings: 1/2 cup (cooked) pasta or rice, 1 cup cereal, 1 slice of bread (1 ounce each)

6-ounce equivalent servings daily.

Include 3-ounce equivalent of whole grain high fiber foods

Vegetable 1.7 servings: 3/4 cup cooked or 1- 1/2 cups raw equivalent measure (may serve an additional fruit instead of a vegetable)

2 ½ cups (5 servings daily). Serve a variety of vegetables, including those that are dark green, red and orange.

Fruit 1 serving: ½ cup (4 ounces) or equivalent measure

1.5 cups (4 servings daily) Focus on whole fruits and include those that are deeply colored fruits such as oranges.

Dairy 1 serving: 1 cup (8 ounces) or equivalent measure

3, 1-cup equivalent servings daily.

Select low-fat products

Protein Foods 1.7 serving: 2-ounce edible portion or equivalent measure

5 ounce-equivalent servings daily

Fat 1 serving: 1 teaspoon or equivalent measure is optional

Select foods lower in fat and saturated fat. Limit total fat to 30%, saturated 10% (20%)

Dessert Optional Select foods high in whole grains, low in fat and sugar

Optional Beverages:

water, coffee, tea, decaffeinated beverages, fruit juices.

8 ounces, minimum, per seasonal preferences

*Limit saturated fat, sodium, and added sugar

The Dietary Guideline Meal Pattern is based on the DRI for energy. It provides approximately 600 calories per meal. The number of servings for each food group is based on the USDA’s ChooseMyPlate.gov for food groups and. These profiles represent the quantities of nutrients and other components that one can expect to obtain on average from one serving of food in each group. Serving sizes are based on the

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MyPlate (https://www.myplate.gov). Although this meal pattern is based on food servings recommended in the Dietary Guidelines and Choose My Plate, it does not ensure that meals meet 1/3 of the DRI/AI and Dietary Guidelines.

• Food Group Components and Serving Sizes: Serving size shall meet or exceed the guidelines listed at https://www.myplate.gov. Some foods are classified in more than one food group. However, a serving of a food can only be counted in one food group within the same meal. For example, dried beans may be counted as either a meat alternative serving or as a vegetable serving, but not both in the same meal. Likewise, cottage cheese may be counted as either meat alternative serving or milk alternative serving, but not both.

Grains: A serving of bread is generally 1 slice (1ounce); ½ cup pasta or grain product, or 1 ounce of ready-to- eat cereal. A variety of enriched and/or whole grain bread products, particularly those high in fiber are recommended. Current guidelines are found at this website: https://www.myplate.gov/eat-healthy/grains

• Additional Notes on Grains:

o Increase servings of whole grain, wheat, bran, rye bread, and cereal products, to provide adequate complex carbohydrates and fiber.

o Limit high-fat bread and bread-alternative selections such as biscuits, quick bread, muffins, cornbread, dressings, croissants, fried hard tortillas and other high fat crackers to limit total fat as well as saturated fat.

o Bread alternatives do not include starchy vegetables such as potatoes, sweet potatoes, corn, yams, or plantains. These foods are included in the vegetable food group.

Vegetables: A serving of vegetables is generally 1 cup of raw or cooked vegetables or vegetable juice, or 2 cups of raw leafy salad greens. Vegetables may include dried beans, peas, lentils, lima beans, potatoes, plantains, sweet potato, and corn. Current guidelines are found at this website:

https://www.myplate.gov/eat-healthy/vegetables

• Additional Notes on Vegetables:

Fresh or frozen vegetables are preferred.

Vegetables as a primary ingredient in soups, stews, casseroles, or other combinations dishes should total ½ cup per serving.

Fruits: A serving of fruit is generally 1 cup of fruit, ½ cup of dried https://www.myplate.gov/ https://www.myplate.gov/ https://www.myplate.gov/eat-healthy/grains https://www.myplate.gov/eat-healthy/vegetables

5-24 fruit, or 1 cup of 100% fruit juice. Current guidelines are found at this website: https://www.myplate.gov/eat-healthy/fruits

• Additional Notes on Fruit:

o Frozen or canned fruit must be packed in juice or water.

o Title III funds may only pay for full strength fruit juices.

The only exception to this requirement is cranberry juice.

Dairy: One cup low-fat, fat-free, buttermilk, low-fat chocolate milk, soy milk, or lactose- free milk fortified with Vitamins A and D should be used. Milk should be served from its original container, usually 8 ounces in size. Any deviations from this policy should be submitted in writing to the AAA’s qualified dietitian for approval. Current guidelines are found at this website: https://www.myplate.gov/eat-healthy/dairy

• Additional Notes on Dairy:

o Low-fat or fat-free milk is recommended for the general population.

o Powdered dry milk or evaporated milk may be served at congregate meal sites, but not for the main meal except for cultural or religious reasons. Each powdered milk or evaporated milk serving size must be equivalent to one cup of milk. Powdered milk may be used with frozen home-delivered meals and emergency meals.

o Dairy alternatives, listed in the chart below, may be provided in place of milk (for the equivalent of one cup of milk).

o All milk containers must have a clearly labeled expiration date.

o Policies and procedures shall be developed, and implemented, to address instances when milk is received, e.g., without an expiration date, past the expiration date, past the sell-by date, past the best-by date, or past the use by date.

Protein Foods: Two to three ounces edible portion of meat, poultry, fish, or meat alternative (or a combination of) should be provided for the lunch or supper meal. Meat serving weight is the edible portion, not including skin, bone, or coating. A one-ounce equivalent of a meat alternate includes ¼ cup of cooked beans, 1 egg, 1 tablespoon of peanut butter, or ½ ounce of nuts or seeds. Current Guidelines below: https://www.myplate.gov/eat-healthy/protein-foods

• Additional Notes on Protein:

o A one ounce serving or equivalent portion of meat, https://www.myplate.gov/eat-healthy/fruits https://www.myplate.gov/eat-healthy/dairy https://www.myplate.gov/eat-healthy/protein-foods https://www.myplate.gov/eat-healthy/protein-foods

5-25 poultry, or fish may be served in combination with other high protein foods.

o Except to meet cultural and religious preferences and for emergency meals, avoid serving dried beans, peas or lentils, peanut butter or peanuts, and tofu for consecutive meals or on consecutive days.

o Cooked dried beans, peas, or legumes intended as the meat alternative for any meal may not also count toward the fruit/vegetable requirement for the same meal.

o Nuts and seeds may be used to meet no more than one-half of the meat alternative meal requirements and must be appropriately combined with other meats/meat alternates to fulfill the requirement.

o Cured meat products, such as ham, smoked or polish sausage, corned beef, dried beef, luncheon meats, and hot dogs are very high in sodium and the use of these type products must be limited to no more than once a week. Bacon is not considered a meat alternative, since it provides primarily fat, sodium, and few other nutrients.

o Vegetable protein products or textured vegetable protein (VPP or TVP) are low-cost alternatives and are effective in increasing the protein intake of program clients. The recommended ratio of protein product to meat is 20:80.

o Imitation cheese (which the Food and Drug Administration defines as one not meeting nutritional equivalency requirements for the natural, non-imitation product) cannot be served as meat alternatives.

Additional Menu Development Considerations:

Canned Soups: Most canned soups do not contain enough meat to make a substantial contribution to the meat requirement. For example: bean soup or pea soup: A 1-cup serving of soup contains ½ cup beans or peas. This is equivalent to one ounce of Meat/Meat Alternative. It would take 3 cups to provide the required 3 ounces of Meat/Meat Alternative.

Hot Dogs/Frankfurters: Red meat (beef, pork, etc.) and poultry (turkey, chicken) hot dogs that do not contain meat by products, cereals, binders, or extenders:

o 1 ounce of product provides 1 ounce of cooked lean meat. Look for products labeled “All Meat,” “All Beef,”

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“All Pork,” etc. If a single hotdog equals 2 ounces, it will take one and a half hot dogs to equal a 3-ounce portion.

o Hot dogs containing meat by-products, cereals, binders, or extenders are not acceptable on an ounce-for-ounce basis. Product labeling will indicate the presence of any such ingredients.

o If using hotdogs containing extenders or binders, only the cooked or lean meat portion of the product can be used toward the Meat/Meat Alternatives requirement.

Obtain product information from the manufacturer if necessary.

o Accompaniments, Condiments, and Product Substitutes:

o Include traditional meal accompaniments as appropriate, e.g., condiments, spreads, and garnishes.

Examples include: mustard and/or mayonnaise with a meat sandwich, tartar sauce with fish, salad dressing with tossed salad, and margarine with bread or rolls.

Whenever feasible, provide reduced fat alternatives.

o Salt substitutes shall not be provided. Sugar substitutes, pepper, herbal seasonings, lemon, vinegar, non-dairy coffee creamer, salt, and sugar may be provided, but shall not be counted as fulfilling any part of the nutritive requirements.

o Sugar, condiments, seasonings or dressings intended for self-service use shall be provided only in individual packages or from dispensers that protect their contents.

Fat:

o Minimize use of saturated fat in food preparation. Fats should be primarily monounsaturated and polyunsaturated vegetable oils, such as olive, peanut, corn, safflower, canola, cottonseed, and soybean oils.

o The use of butter or fortified margarine as a spread for bread is optional because of the emphasis on reducing fat content of the meals.

Desserts:

o Dessert may be provided as an option to satisfy the caloric requirements or for additional nutrients.

However…