The Child and Adult Care Food Program

1
The Child and Adult Care Food Program
Administrative Reviews Successful Corrective
Action

• playing a vital and integral role in improving
  the overall quality of care and daily nutritional
  health of participants

2
Administrative Review Basics

• Formal full reviews
• At least once every 3 years
• Announced or unannounced
• Duration 1-5 daysor longer
• Record review and observation
• In addition
• Technical assistance visits
• Follow-up reviews
• Record reviews

3
Are You Ready?

• Eligibility and Approval
• License(s) or alternate approval documents
• Fire inspection reports HACCP checklists
• Certified Food Safety Manager
• Adult day care approval
• Subsidy program statements (for-profit centers
  only)
• IRS Letter of Determination (non-profit
  organizations)
• CACFP Permanent Agreement Policy Statement
• CACFP Excel file

4
Are You Ready?

• Participant Records
• Complete classified Enrollment Form / IES for
  every participant (n/a for at-risk)
• Individual Plan of Care (adult day care only)
• Complete accurate MEL for each month
• (n/a for at-risk)
• Head Start certification / enrollment (if Head
  Start)
• Daily attendance records
• Sign-in/sign-out sheets (day care homes and
  centers only)

5
Are You Ready?

• Meal records
• (Point-of-service) meal count records
• Dated daily menus
• Infant / Child / Adult
• Child Nutrition (CN) labels / Product Formulation
  Statements (if needed)
• Medical Substitution Forms
• Soymilk Request Forms
• Infant Food Formula Notification (if enrolling
  infants)

6
Are You Ready?

• Additional Records
• Prior year records
• Three years after last paid claim of fiscal year
• Staff training documentation
• Annual Civil Rights Documentation
• And Justice for All poster (visibly posted)
• Building for the Future flyer (visibly posted)

7
Are You Ready?

• Financial Records
• Itemized invoices and receipts
• Payroll records (if using funds for labor)
• Time attendance records (if using funds for
  labor)
• Copies of submitted claims
• Ledger, balance sheet, financial tracking, etc.

8
Are You Ready?

• Food Service Management Company Records
• Invitation for Bids / Request for Proposals
• Submitted bids / proposals
• Contract and contract renewals
• Delivery slips

9
Are You Ready?

• Sponsoring Organization Records
• Facility / Provider Agreements
• Facility Staff / Provider Training Documentation
• Budget and Budget Approval
• Monitoring forms
• 3 per facility per year
• No more than 6 months in between visits
• At least 2 unannounced
• At least 1 unannounced visit includes meal
  observation

10
After an Administrative Review

• Exit conference discuss preliminary findings
• Administrative Review Findings Letter
• Finding / Corrective Action / Due Date
• Observation / Recommendation
• Fiscal action
• Note fiscal action may be appealed but not
  findings
• Return signed letter specify repayment plan
• Corrective Action Plan
• Written plan
• Supporting documentation

11
Successful Corrective Action

• Timely
• Pay attention to deadline - usually 30 days
• Completely and permanently corrects finding
• Demonstrate viability, capability and
  accountability

12
Successful Corrective Action

• Successful Corrective Action Plan (CAP)
• States the finding/problem
• Details procedures to address problem
• Includes who, what, when, and where
• Specifies personnel who will implement procedure
• Describes how procedures will be implemented
• Provides a timeline for implementation
• States where CAP documentation will be saved

13
State the Problem

• What was the finding?
• Use the wording and/or number from the
  administrative review findings letter
• Not a time for excuses
• Example
• Finding 1A Meal counts were not being taken at
  the point of service. The number of meals
  prepared was being recorded as the meal count.

14
Detail the Procedures

• What will you do to comply with CACFP
  requirements?
• Be specific and detailed
• Include when the procedures will be used
• Specify who will be using the procedures

15
Detail the Procedures

• Example
• Corrective Action Plan 1A The lead teacher in
  each classroom will use the CACFP
  Point-of-Service Form to record meal counts at
  the point of service. The form will be prepared
  each Monday morning with the dates for the week
  and the names of the children in the classroom.
  Names will be added if new children enroll or
  move into the class. After the children are
  seated and receive a complete meal, including
  milk at breakfast and lunch, the lead teacher
  will mark an X in the column for the meal
  (breakfast, lunch, or snack) by the name of each
  child who is eating. Children who are present but
  not eating a complete meal provided by the center
  will be marked with an O. If a child is absent,
  the box will be left blank.

16
Specify the Personnel

• Who is in charge?
• State who will implement, monitor and enforce the
  new procedure
• Example
• The director, Ms. Smith, has trained the lead
  teachers on using the new form. She will collect
  the Point-of-Service forms from each classroom on
  Friday afternoons after PM snack. She will check
  the forms to make sure they are filled out
  correctly. She will double check the totals from
  each room for each week, then add them up for
  each month. This will be reported on the claim.
  Ms. Smith will also observe the meal count
  procedures in each room at least once per month.

17
Describe Implementation

• How will staff or parents know about the new
  procedure?
• Training
• Handbook
• Website
• Personal assistance
• Example
• The director, Ms. Smith, has trained the lead
  teachers on using the new form. The procedures
  will be filed in the CACFP Procedures binder.

18
Provide a Timeline

• When is the procedure being implemented?
• Be specific provide dates
• Be reasonable
• Example
• The training was held on Friday, June 1st during
  a staff development day. Teachers were given the
  Point of Service Form to begin using on Monday,
  June 4th.

19
State Where the CAP is Saved

• Where will you keep the CAP on file?
• Administrative review documents and responses
  should be saved with current FY records.
• Policies and procedures should not be lost when
  staff leave or after 3 fiscal years.
• Example
• The CAP will be filed with the administrative
  review findings letter in the CACFP FY12 binder.
  The meal count procedures and the Point of
  Service Form will be saved in the CACFP computer
  file and in the CACFP Procedures binder.

20
Implement the CAP

• Follow the stated procedures and implementation
  plan
• Submit supporting documentation to prove that the
  plan was implemented
• Ex. Income Eligibility Statements to show correct
  classifications
• Ex. Master Enrollment List to show correct
  maintenance
• Ex. Menus that comply with meal pattern
• Ex. Training documentation to prove staff were
  trained

21
Implement the CAP

• Maximum of 90 days to finalize and implement CAP
• Meet benchmarks for long-term CAPs
• Ex Retention of prior-year records
• Permanently maintain new procedures
• Be prepared for a follow-up review

22
The End