Loading...
HomeMy WebLinkAboutFY15 SRC GIBBS-EFTING MGT SERV EVALUATION. 11 I M, 1444G� � Dear Avril: New Hanover County Senior Resource Center 2222 South College Road Wilmington, NC 28403 Telephone 910�798-6400 Fox 910�798-6411 April 9, 2015 Enclosed you will find the New Hanover County Senior Resource Center Nutrition Program Subcontractor Performance Evaluation that was completed on April 9, 2015. I have included the letter from Ginny Brinson referencing the annual requirement for such evaluation per the Hoinc and Community Care Block Grant policies and procedures. This report has been reviewed by Ben and is now ready for your signature. The director's signature is required on the HCCBG Subcontractor Performance Evaluation forins (2), one for the home delivered meals and one for the congregate meals. The f6mis have been flagged for your convenience. I will forward to Ginny after receiving the packet back from you. Thank you. Ellen Connor, Nutrition Program Manager New Hanover County Senior Resource Center 2222 S. College Road Wilmington, NC 28403 +h t 3 1 L. Arc4_,-gcicy0n Cape.Vear. Ctnrnc-il of Gover7nnwnts TO: Region tI HCCBG Providers and Subcontractors Jim Fish & Yvette Gosline, BSRI. Amanda Harrelson, Columbus County Department of Aging Ben Brow, New Hanover Senior Resource Venter Wes Davis, render Adult Services, Inc. Jackie Williams, Pender DS FROM: Ginny Brinson, Aging Specialist DATE: February 2, 2015 RE: Subcontractor Monitoring SFY 2O1 This is a reminder that you each is responsible annually for conducting subcontractor monitoring as well as completing Exhibit 14A: `List of Subcontractors'. Annually, as part of the contracting process with counties, local providers must r) complete and submit to the AAA Exhibit 14A listing all subcontractors in place to provide community -based services to older adults and 2) submit a copy of each subcontract to the AAA. Exhibit 14A shall be submitted to the AAA by Monday, March 2, 2015. Exhibit r4A can be found on the Division of Aging and Adult Services website, (See the second hyperlink below.) Please refer to Section 308, Monitoring of Community Service Providers, of the Area Agency on. Aging (AAA) Policies and Procedures Manual: (308.2, A. Monitoring Plan) for details: hti : ww",.nedhhs. ov a in monitor sec o8 AAA201 . df. Also due annually, between January r and June r, Community Service Providers must complete "Subcontractor Performance Evaluations" and submit to the AAA.. Subcontractor Performance Evaluation tools can be found at http:/Iv,,Aw.ncdhhs.gov/aainiz/monitor/mtools.htm and are due at Cape Fear AAA by Friday, May 1, 2015. Those services for which you are responsible listing on Exhibit 14A and monitoring include: rl3SRI: In Home Aide, Transportation, and Nutrition Columbus County Department ofAging: Nutrition New Hanover Senior Resource Center: Adult Day Care /Health, In Horne Aide, Nutrition, and Transportation Pender°Adult Services: In Home Aide, and Transportation fender DSS: In Home Aide. Please contact me if you have questions or need assistance. CC: Jane Jones, AAA Director .vrJ�Il( w .., ,i::K, r C,4;""`'r , ^,.d1s.t✓ i i[1;navF= 0..?".G'' fr7C1'!C}:1!`! *,'.c'. 1 380 Hcfb 3 rr Drive . Wilmington NC' 28401 4 (910) 395 4553 ° (800 218 -6575 - Pax: (9)0) ?95- 2584 ww ,v,copefeorcoq, ras Ginny Brinson, Aging Specialist Area Agency on Aging Cape Fear Council of Governments 1480 Harbour Drive Wilinington., NC 28401 Dear Ginny: New Hanover County Senior Resource Center 2222 South College Road Wilmington, NC 28403 Telephone 910-798-6400 Fax 910-798-6411 April 9, 2015 In compliance with the Area Agency on Aging (AAA) Policies and Procedures Manual, Section 308, Monitoring of Community Service Providers, on April 9,12015, an evaluation was completed on Gibbs-Effing Management Services, the food service subcontractor who provides home delivered and congregate meals at the New Hanover County Senior Resource Center. This monitoring procedure establishes a yearly review to verify that Gibbs-Efting Management Services has met the terms and conditions of the subcontract as well as to ascertain the quality of services provided to older adults at our facility. As part of the subcontractor assessment it has been verified that the subcontractor is not suspended or debarred by the State of NC, is not barred from doing business at the federal level, and has submitted a notarized "State Grant Certification of No Overdue'l-ax Debts". The subcontractor, Gibbs-Efting Management Services, does not have a business license. The business' Articles of Incorporation have been attached. Furthermore, the subcontractor maintains a permit with the North Carolina DHHS Division of Public Health Environmental Health Section which has been attached. The assessment process included a review of compliance with the written contract between the New Hanover County Senior Resource Center and the subcontractor, Gibbs-Efling Management Services. Additionally, the subcontractor was evaluated using the relevant sections of the North Carolina Division of Aging and Adult Services Nutrition Services Assessment Too]. The results of the monitoring are as follows: Baseline Compliance Yes No N/A Food is prepared in a Grade A kitchen? (DAAS Std. p.21) X Hot food is not less than 135 degrees? (DAAS Std. p. 25) X Cold food is not more than 45 degrees? (DAAS Std. p. 25) X Menus meet 1/3 of the RDA & menu Standards? (DAAS Std. p. 16) X Food is packaged and transported safely? (DAAS Std, p.21-25) X Consumer Contributions opportunity is offered? X With one exception (listed below) the subcontractor met all other requirements of the contract, including all local, county, state, and federal guidelines including all Home and Community Care Block Grant guidelines. Please refer to "Description of Non - Compliance Findings -. A comprehensive outline of the subcontractor's scope of work may be found on page 2 of the HCCBG Subcontractor Perforniance Evaluation form. On the day of the evaluation, food presentation and palatability based on direct experience and interactions with seniors was positive. Areas of kitchen where food is handled and served it kept clean and in good repair. Over the course of the last six months, a concerted effort has been made to maintain the highest level of cleanliness in the kitchen. A cleaning schedule has been established and maintained. The approved menu is posted in numerous locations in the kitchen and dining area. The cost sharing contribution sign is located at the serving line. The recent health inspection report with a high "A" rating is posted in a visible location in the dining area. Recent Changes: e The addition of new signs a in the Dining area details the emergency plan in the event of a fire or explosion • Development of monthly food safety and sanitation trainin s with food service staff and volunteers Description of Non-Compliance Findings Menu change form not completed for menu substitution occurrence in March 2015. Menu change form has been given to subcontractor to submit to registered dietitian for menu analysis which must be completed by June IT 2015. In the meantime, if you have any questions, please do not hesitate to contact me. Thank you for your continued guidance. Sincerely, Ellen Connor, Nutrition Program Manager New Hanover County Senior Resource Center F- 0, q ■ k � F-- A o cis cta m C� O CL (D c (1) C) E W u >* m c Z (D < = 0 « � k � k ■ 0 r 4) a. 3 w a 0 U) 0 0 U) c E5 0 \\ / \�) 2 k �� LU cc (D E W u >* m c Z (D < = 0 « � k � k ■ 0 r 4) a. 3 w a 0M00ME3 I 2/¥ & 7 (A� / / § j $ 7� \./ § CD CL 0/ \)d 2 0 \ \cr \� \ CD 0 tea) � § A /ƒm CL §?\ » e� \x/ \\&� o n Cr & &° \j ° ¥ � \ k �� / \) /fk * © \/ // $2 � \ e 7 B, � NC DIVISION OF AGING AND ADULT SERVICES AND NC AREA AGENCIES ON AGING NUTRITION SERVICES ASSESSMENT TOOL PART I Staff Interviews and Review of Related Documentation Provider Agency: New Hanover County Senior Resource Center Assessment Date: 4/9/15 Agency Staff Interviewed: Signature of AAA Interviewer: Nutrition Service Reimbursements: 1. Check all nutrition services reimbursed through the NC Division of Aging: Meal Options: 2. Check all options for service delivery supported by the Home and Community Care Block Grant: Yes No Comments Congregate Nutrition 180 ❑ ❑ ❑ Frozen meals Congregate Nutrition — NSIP -only 181 ❑ 1 -3 days/wk Shelf- stable meals ❑ ® Congregate Liquid Nutritional Supplement 182) Rare occasion ❑ ❑ ❑ ❑ Home - delivered Nutrition 020 ® ❑ ❑ Additional meals: evening meal Home - delivered Nutrition — NSIP -only (021 ) ❑ Additional meals: weekend meals ❑ ❑ Home - delivered Liquid Nutritional Supplement (022 ) ❑ ❑ ❑ ❑ Meal Options: 2. Check all options for service delivery supported by the Home and Community Care Block Grant: 3. Check all options for service delivery supported by other funding sources and reported for NSIP -only (formerly USDA -only) reimbursement: Yes No Frequency? (e.g., 5 days /wk, emergencies, as funding allows, occasional) Hot lunches ® ❑ 5 days/wk Frozen meals ® ❑ 1 -3 days/wk Shelf- stable meals ® ❑ Rare occasion Liquid nutritional supplements ❑ ❑ Additional meals: morning meal ❑ ❑ Additional meals: evening meal ❑ ❑ Additional meals: weekend meals ❑ ❑ Therapeutic diet meals ❑ ❑ 3. Check all options for service delivery supported by other funding sources and reported for NSIP -only (formerly USDA -only) reimbursement: Part II — AAA Observations and Review of Activities at Nutrition Sites and on Home - delivered Meal Routes Page 1 Yes No Frequency? (e.g., 5 days/ k, emergencies, as funding allows, occasional) Hot lunches ❑ ❑ Frozen meals ❑ ❑ Shelf- stable meals ❑ ❑ Liquid nutritional supplements ❑ ❑ Additional meals: morning meal ❑ ❑ Additional meals: evening meal ❑ ❑ Additional meals: weekend meals ❑ ❑ Therapeutic diet meals ❑ ❑ Part II — AAA Observations and Review of Activities at Nutrition Sites and on Home - delivered Meal Routes Page 1 C = Congregate only HD = Home-delivered o!lly_ None = Both N.A. Yes No C-4. Nutrition provider has on file a completed Attachment A: Site Review El Z F-1 for each nutrition site. C-5. Congregate meal provider offers at least one hot or other appropriate ❑ Z ❑ meal per day in a congregate setting, [Standards p. 3] C-6. Documentation is on file that fire drills are conducted quarterly at each congregate nutrition site. [Standards p. 34] List exceptions: El Z ❑ C-7. A current fire department inspection report has been completed for all sites according to the local fire code inspection schedule, or agency can show efforts to have inspection completed. [Standards p. 34] List ❑ z El exceptions: Current fire permit posted on site C-8. There are paid site managers, and they are paid for no more than 4 hours per day out of the Home and Community Care Block Grant. El Z 1:1 [Standards p. 29] C-9. Site managers are responsible for activities at their sites and post a calendar of activities at the beginning of each month at each site. El Z ❑ [Standards p. 27] C-10. Documentation is on file that site managers have received training or are knowledgeable because of previous experience about site operations, record-keeping requirements, community resources and referral procedures, food safety, and food portioning. [Standards p. 29] ❑ Z El C -11. Each nutrition site has an emergency plan for medical emergencies and evacuation in case of fire or explosion. [Standards p. 341 ❑ z ❑ C-12. Each nutrition site has posted in at least one visible location a written plan that describes procedures to follow in case a participant becomes ill or injured. [Standards p. 34] ❑ z 1:1 13. Except for holidays or emergencies, meals are offered 5 days per week, 52 weeks per year, or DAAS has approved a waiver for lesser frequency. [Standards p. 33] ❑ Z El 14. Nutrition provider offers nutrition counseling as part of nutrition services. If yes, please describe how services are delivered. [Standards p. 27] ❑ ❑ ❑ Part 11— AAA Observations and Review of Activities at Nutrition Sites and on Home-delivered Meal Routes Page 2 Part II — AAA Observations and Review of Activities at Nutrition Sites and on Home - delivered Meal Routes Page 3 N.A. Yes No 15. Food is prepared on -site. If not, name the current vendor for food preparation and delivery: Gibbs - Efting Management Services uses kitchen on -site for meal ❑ ® ❑ preparation 16. An annual survey of participants soliciting menu suggestions and client satisfaction is on file. [Standards p. 12] Comments? Attached El ® ❑ 17. The nutrition provider arranges for the services of a licensed dietitian/ nutritionist. [Standards p. 29] ® ❑ ❑ 18. Describe the arrangements for the dietitian /nutritionist's involvement in the nutrition program (for example, who employs the dietitian, does the dietitian develop the menus and recipes, how often does the dietitian review menus, how does the dietitian receive menu substitutions for approval, etc.) Gibbs - Efting Management Services develops the menu and recipes which are then submitted to subcontractor's RD for nutrient analysis. Menus are updated quarterly. N.A. Yes No 19. Does the nutrition provider have approval from the Environmental Health Specialist to use time rather than temperature for the serving of any specific food item in the nutrition program? [Standards p. 21] If so, explain: ❑ ® ❑ Time as a public health control is used for all menu items, following the guidelines of the NC Food Code Manual page 33 and 34. See attachment. 20. The nutrition provider notifies the AAA if the sanitation grade falls below "A" or 90 %. [Standards p. 20] ❑ ® ❑ 21. Food is received by staff or trained volunteers. Meal arrival time is documented, signed by the person receiving the food. If food is held prior to serving in warming or refrigeration equipment, temperatures are taken and recorded at the time of food delivery. [Standards p. 21] List any ® ❑ ❑ exceptions noted by nutrition staff: 22. There is a paid nutrition program director. [Standards p. 29] ❑ ® ❑ 23. The nutrition program director successfully completed within the first 12 months of employment at least 15 hours of instruction in food service ❑ ® ❑ sanitation. [Standards p. 29] Part II — AAA Observations and Review of Activities at Nutrition Sites and on Home - delivered Meal Routes Page 3 Answer the following as true /false statements. N.A. Yes No 24. The nutrition program director participated within the first 12 months of El ® ❑ employment in DAAS training on nutrition program management. D ® ❑ [Standards p. 29] 25. The nutrition staff can demonstrate efforts to train current volunteer staff. [Standards p. 29] - People whose dietary needs cannot be met through the meals Answer the following as true /false statements. N.A. True False 26. Nutrition provider does not use funds to purchase vehicles to deliver El ® ❑ meals. [Standards p. 35] 27. Nutrition provider does not provide meals to ineligible people without reimbursement of the full cost of the meal. [Standards p. 35] Ineligibility criteria on Standards p. 6: - People whose dietary needs cannot be met through the meals offered. ❑ ® ❑ - People residing in long -term care facilities or enrolled in care - providing programs (including adult day care /day health, except that people attending day care /day health centers may receive meals on the da s they do not participate in the adult day ro ram ). 28. Nutrition provider does not serve therapeutic meals without a physician's order on file and unless the program has the capability to ❑ ® ❑ provide the service. Standards p. 35 29. Nutrition provider staff and volunteers do not administer medical El ® ❑ treatment or medications. [Standards p. 35] 30. Nutrition provider staff and volunteers do not carry out financial ❑ ® El transactions except those related to donations. [Standards p. 35] 31. Nutrition provider staff and volunteers do not provide unapproved ❑ ® ❑ meals to participants. [Standards p. 35] 32. Nutrition provider staff and volunteers do not accept gifts. ❑ ® ❑ Standards p. 35 33. Congregate nutrition sites are not closed or combined on a temporary or permanent basis (except in an emergency) without the ❑ prior written approval of the AAA administrator assuring that options for maintaining services have been considered. [Standards p. 35] Part II — AAA Observations and Review of Activities at Nutrition Sites and on Home - delivered Meal Routes Page 4 N.A. Yes No 34. Utilization levels for the HCCBG budget at the time of the AAA ❑ ❑ assessment are consistent with budget projections for the fiscal year. If not, describe appropriate adjustments. As of 2/28/15 service summary: HDM is over budget by 4 %, Congregate is precisely on target. Part II — AAA Observations and Review of Activities at Nutrition Sites and on Home - delivered Meal Routes Page 4 35. Reconciliation of Units: The purpose of this question is to reconcile the total number of units, by service, reimbursed from ARMS to the total number of units recorded on the ZGA - 903 (turnaround documents). With nutrition staff, reconcile a sample month of units by completing the following: F. Explain any difference between units reimb d ARMS (A) and adjusted units recorded (E): Congregate Home - No Nutrition delivered ❑ ❑ Meals A. = The total units reimbursed by ARMS for the month of ❑ (See the ZGA 370 or the Units of Servi s Verification Report) 38. Verify program income reported in ARMS: ❑ B. =Total units submit d for keying from the ZGA 903 to ARMS ❑ The amount of program income in ARMS for the month of is the for the month chos ab C. - Less units not accepte MS for the chosen month (see error report, if applicable. f t e provider keys directly into referenced date. If not, explain. ARMS, enter zero) D. + Add units keyed and accepted MS in the month chosen above that were disallow �n a previous month(s). E. = Total (B — C + D): Item A (total units ursed) and item E (adjusted units recorded) should equa . ww F. Explain any difference between units reimb d ARMS (A) and adjusted units recorded (E): Part II AAA Observations and Review of Activities at Nutrition Sites and on Home- delivered Meal Routes Page 5 N.A. I Yes No 36. Two individuals open, count, and record consumer contrib ns. ❑ ❑ ❑ 37. The person making deposits is different from the people cou t` and E] ❑ recording contributions. 38. Verify program income reported in ARMS: ❑ ❑ ❑ The amount of program income in ARMS for the month of is the same as the program amount in the agency's General Ledger for the same referenced date. If not, explain. Part II AAA Observations and Review of Activities at Nutrition Sites and on Home- delivered Meal Routes Page 5 39. Program Income Verification: The purpose of this question is to verify the amount of program income (cost sharing) collected at the provider's nutrition site equals the amount recorded in the provider's accounting records. With assistance from nutrition /agency staff, trace one or more sample transactions from the point of collecting program income through recording in the General Ledger: $ Amount co cted at Nutrition Site on (date) $ Amount counte recorded at location sand (if the administrve offices are a different location from nutrition site) $ Amount recorded oneposit slip for the sample date. $ Amount recorded in Gen r Ledger or accounting records of the provider. There should be a clear audit trail fr' , t point of counting program income to the point of deposit and recording in the General L d :Explain any difference in these amounts: r F q N.A Yes No HD -40. Home - delivered meal provider delivers at least one ' cold, frozen, dried, canned, or supplemental meal per day to home d older ❑ ❑ ❑ adults. Standards p. 3 HD -41. Nutrition provider has written procedures for reporting cha in the eligibility of home - delivered meal clients (i.e., termination of sery ❑ ❑ 1:1 [Standards p. 7] HD -42. Nutrition provider has procedures to document eligible home - delivered meal clients receive telephone client reassessments every other ❑ ❑ ❑ 6 months. DAAS Adm Ltr No. 05 -13 Corrective Action/Technical Assistance: Part II — AAA Observations and Review of Activities at Nutrition Sites and on Home- delivered Meal Routes Page 6 NC DIVISION OF AGING AND ADULT SERVICES AND NC AREA AGENCIES ON AGING NUTRITION SERVICES ASSESSMENT TOOL AAA Observations and Review of Activities at Nutrition Site(s) and on Home - delivered Meal Routes) (make additional copies of this section as necessary for each site or route) Name of nutrition site visited and date: New Hanover County Senior Resource Center N.A. Yes No C -1. Obtain copy of agency's Attachment A: Site Review. AAA's observations on -site agree with provider's assessment. If not, note ❑ ® ❑ exceptions: C -2. Identify the names of 3 -5 individuals who received a meal on the day of the site visit: [Include 2 or more of these names in the client record reviews, OR verify that these names are included in the agency's client database during Part III: Desk Review.] N.A. Yes No C -3. A calendar of activities for the month is posted on -site. ❑ ❑ ❑ C -4. There is a contribution system in full view. ❑ ® ❑ C -5. A written plan is posted in at least one visible location that describes procedures to follow in case a participant becomes ill or injured. ❑ C -6. Congregate food temperatures are taken immediately before serving on the day of the site visit, and serving time is recorded. ❑ ❑ ❑ C -7. Food temperatures taken on day of congregate site visit: 171 Meat/meat alternative (specify turkey tetrazzini) above Grains or other carbohydrates (specify ) 160 Vegetable or Fruit (specify spinach 178 Vegetable or Fruit (specify Pineapple Crisp) 32 Milk (if other source of calcium, specify ) Other (specify C -8. Approved menu is posted in meal serving area. ❑ Part 11— AAA Observations and Review of Activities at Nutrition Sites and on Home- delivered Meal Routes Page 7 Part II - AAA Observations and Review of Activities at Nutrition Sites and on Home- delivered Meal Routes Page 8 N.A. Yes No 9. Approved menu is posted in meal preparation area of nutrition site. ❑ ® ❑ 10. Approved menu is served on day of site visit. ❑ ® ❑ 11. If the approved menu is not served on day of visit, reviewer observes that caterer has sent appropriate notification of menu changes. ® ❑ ❑ 12. On day of visit, food prepared off -site is received by staff or a trained volunteer, who document meal arrival time and sign the delivery ticket. Food temperatures are taken and recorded if food is held in warming or ® ❑ ❑ refrigeration equipment prior to serving. 13. The areas where food is handled or served are clean and in good ❑ ® EJ repair. 14. The Health Department sanitation permit is posted in a visible location El ® ❑ at nutrition site. 15. Prior to serving congregate meals, home - delivered meals are individually plated, packaged, and transported immediately. ❑ ® ❑ 16. In general, packaging and transport equipment appears to be clean, in good repair, and capable of maintaining food temperatures and protecting food from potential contamination. Comments? ❑ ® ❑ 17. If frozen meals are provided, they are dated with the date delivered to ❑ ❑ ❑ the nutrition program. 18. Note observations about food presentation and palatability based on direct experience or interactions with clients on day of site visit. Meal well received by seniors. Correct portion size given. Nice color to meal. 19. Note observations about the perceived eligibility of clients in attendance on day of site /route visit: All fit guidelines of HCCBG grant - at least 60 years of age. Young caregiver of one grant recipient brought own lunch 20. On day of site /route visit, compare meals prepared or received, meals served, and meals unserved: 50 Meals ordered 51 Meals prepared or received 51 Meals served 0 Meals unserved N.A. Yes No 21. Contributions are counted and recorded at the site by two individuals. ❑ ❑ ❑ If Home delivered only rr% to) at a central office. If not, describe the procedures observed.`1 �° n Part II - AAA Observations and Review of Activities at Nutrition Sites and on Home- delivered Meal Routes Page 8 Home - delivered Meal Route: Name of route that AAA rides and date: Corrective Action: Technical Assistance: Part 11— AAA Observations and Review of Activities at Nutrition Sites and on Home - delivered Meal Routes Page 9 N.A. Yes No HD -22. Clients receiving meals on the route appear to need service. [If perceion raises question, reviewer should include this client in desk ❑ D El review of criept r rds.] HD -23. Volunteers I ontributions and take them back to nutrition site El El El or central office. HD -24. Home - delivered emperatures taken on route: Meat /meat alternative (sp ` . ) Grains or other carbohydrates (sp ) Vegetable or Fruit (specify ) Vegetable or Fruit (specify ) Milk (if other source of calcium, specify ) Other (specify ) Corrective Action: Technical Assistance: Part 11— AAA Observations and Review of Activities at Nutrition Sites and on Home - delivered Meal Routes Page 9 NC DIVISION OF AGING AND ADULT SERVICES AND NC AREA AGENCIES ON AGING NUTRITION SERVICES ASSESSMENT TOOL PART 111 Desk Review Desk review of Health Department permits: 1. The nutrition provider has on file copies of current Environmental Health permits for each nutrition site. List the site, date of inspection, and grade for each site: Site Date of Inspection Grade Site Date of Inspection Grade SRC 3/13/15 98.50 Desk review of clients observed receiving meals: N.A. Yes No 2. Unless two or more of the client names recorded during the site visits Meal tickets document each food item that was delivered, record the end of are included in the client record review /unit verification, verify that the are included in the agency's client database. Identify selected ® El 1-1 clients: ❑ list exceptions: Comparison of one week of approved menus N.A. Yes No and one week of meal delivery tickets at one site /route: 3. Select one week of meal delivery tickets or comparable documentation. Meal tickets document each food item that was delivered, record the end of preparation time, and are signed by the food production manager. If not, ❑ ® ❑ list exceptions: 4. Compare the selected week of meal tickets or comparable documentation to approved menus for that week. The approved menus were followed, or menu changes are documented on menu change forms. ❑ ® ❑ List exceptions: 5. In what form does the caterer provide to the agency on the date food is delivered written notification that emergency menu substitutions have been made? Examples include meal delivery ticket notation or menu change form. Menu change form would be used in the event of a substitution Part III — Desk Review Page 10 Desk review of menu files: N.A. Yes No 6. Menus are changed at least two times per year. [Standards p. 13] El ® ❑ 7. Each page of menus has been signed by a licensed dietitian /nutritionist #1 #2 to certify that the menus meet all federal and state requirements. ❑ ® ❑ Standards p. 12 3/25/15 3/27/15 3/31/15 8. A nutrient analysis is on file with each certified menu. [Standards p. 12] ❑ ® ❑ 9. Menu change forms are on file with each certified menu to document Meals ordered: 305 284 53 - date of delivery, 280 Meals received or prepared: 305 284 - specific food substitution, and ❑ ® ❑ - signature of the production manager and /or dietitian authorizing the 44 35 277 menu change. [Standards p. 12] 3 9 2 10. Menu substitutions are approved by the dietitian /nutritionist within 90 days or no later than July 31't. [Standards p. 12] If not, list exceptions: El ® F-1 Desk review of meals ordered and meals served: 11. Select 5 random dates and compare meals ordered and meals served for either congregate or home - delivered clients: #1 #2 #3 #4 #5 Date: 3/20/15 3/23/15 3/25/15 3/27/15 3/31/15 Site or route: HDM HDM Cong Cong HDM Meals ordered: 305 284 53 37 280 Meals received or prepared: 305 284 53 37 280 Meals served: 298 281 44 35 277 Meals unserved: 7 3 9 2 3 Temderature documentation review: C -12. Congregate: Review a month of temperature records for at least 50% of nutrition sites and attach a completed Attachment B: Congregate Temperature Review. HD -13. Home - delivered: Review a month of temperature records for at least 50% of nutrition routes and attach a completed Attachment B: Home - delivered Temperature Review. Client record reviews and unit verifications: C -14. Congregate: � Select a sample o *4p review and conduct unit verifications for meals received by these clients. Attach a t h ent C rksheets and related documentation for con re ate, con re ate sent, n .re ate thera eutic diet meals. HD -15. Home - delivered: Select a sample of clients for record review and conduct µunit` .. f meals received by these clients. Attach all appropriate Attachment C worksheets snit, ocumentation for HD, HD supplement, and /or HD therapeutic diet meals. Part III — Desk Review Page 11 NC DIVISION OF AGING AND ADULT SERVICES AND NC AREA AGENCIES ON AGING NUTRITION SERVICES ASSESSMENT TOOL Attachment A: Congregate Nutrition Site Review Attachment A must be on file for each nutrition site and available for review by the AAA during the assessment process. Name of Nutrition Site: NHC Senior Resource Center Name of provider staff who completed form: Ellen Connor Title: Nutrition Program Manager Date form completed: 04/09/15 Signature: i Attachment A — Congregate Nutrition Site Review Page 12 Yes No 1 The site is located to be accessible to people eligible for services and ® ❑ targeted by the Older Americans Act. 2 The site is an attractive facility where all eligible persons feel free to visit ® ❑ and where their cultural and ethnic background will not be offended. 3 The site has at least 12 -14 square feet per person excluding halls, ® E bathrooms, and kitchen areas. 4 The site has an adequate number of sturdy tables for the number of ❑ ❑ individuals on the attendance roll and chairs appropriate for older adults. 5 The site has at least one table surrounded by adequate aisle space (3 ft. 8 in.) to allow for persons with canes, walkers, crutches, or wheelchairs to ® ❑ move with ease. When necessary, this table shall be of sufficient height (2 ft. 8 in. ) to permit persons in fixed -arm wheelchairs to dine comfortably. 6 The site has at least 2 exits which are unlocked during hours of operation. ® ❑ 7 Emergency and evacuation plans are posted. ® ❑ 8 Visible, usable fire extinguishers are in place, and instructions for use are ® ❑ posted. 9 The site is heated during colder months to at least 72 degrees Fahrenheit ❑ ❑ while participants are present. 10 The approved menus are posted in both the congregate serving area and ® ❑ the meal preparation area of the site. 11 A calendar of activities and programs is posted at the beginning of each ❑ ❑ month. 12 A current permit from the Health Department is posted. ® ❑ 13 The site has a system for voluntary, confidential donations b partici ants. ® ❑ 14 Parking is available. ® ❑ 15 The site has a safe and appropriate place to mount and dismount from vans ® ❑ or other group transportation vehicles. Name of provider staff who completed form: Ellen Connor Title: Nutrition Program Manager Date form completed: 04/09/15 Signature: i Attachment A — Congregate Nutrition Site Review Page 12 0 z z 0 cn ui U z LU CD 0 w 0 z Z ui m MY) z to Lu Cl) LU C.) > Cl) w LU w in _j W z 0 z F- z z LL 0 z 0 cn L) z 1, m L. 4) CL E 0 m (D 2 (D +-j m 0 E m C: 0 O a) 0 of (D ❑ ❑ ❑ ❑ 0 0 (4- 13 0 0 W C/) c-0 c 0 0 0 E L2 E _0 0 (D cn 0 0 -C a) 40- 0 0) C: -0 0 a) E El 0 R El 1:1 0 0-0 i O o 0—,, 0 0 (D -C U) � > C -0 0 0 0 0 E 2 E E a) " -0 0) C)- a) -2 1:1 ❑ 1:1 El El El E � a) 0— � () — a) > cll U) (z a) Q) 0)-0 m -0 0 El El ❑ = , a).— 0- _j5 -0 , a) > " QL.M 0 E I E: < 0 0 E (D U) o :tf — " 0L 4- _0 E -o 0 0 z El El 1:1 1:1 1:1 El a) a) o " -0 Q. 0 0 0 0 LL a) a) r— U) U) U) U) it to U) 4t M Q. Z_ Q Z Cl) W U Z W Q Q W Q U Z 0 z Q U) W L) W N J M cl Q Z Q 0 Z 0 Q U. Z /0 VI U Z J 0 0 F- F- Z W m W Q W LA- W Z _0 Z i L L Q. E H _N a� L 0 m C .0 0 m E Q on a c O 0— E =5 0 c U) ai U) 0 O O C a) E 0 0 L Q I 3 0 ly- U) U O L c 0 — CO C :) O c a> � U o O o U � O 0 U 4- 4- c cn 0 0 0 0) � � O O U � 0 y— +� � U tII ❑ ❑ ❑ ❑ ❑ ❑ ❑ a> a) !, " - c L - () 0 ^0 0 :3 L L E O O U O O U o E .� ° _ O o ° o L LL `? a) Q) 0 =3 :3 Z) CO � } w W W of 4f W It W Q on a Instructions: Grantee should complete this certification for all state funds received. Entity should enter appropriate data in the yellow highlighted areas. The completed and signed form should be provided to the state agency funding the grant Lmbe attached 1v the contract for the grant funds. A copy of this form, along with the completed contract, should be kept by the funding agency and available for review b the Office of the State Auditor April 14,2015 To State Agency Head and Chief Fiscal Officer Certification: We certify that Gibbs-Efting Management Services does not have any overdue tax debts, as defined byN.C.G.S.1O5-243,1.sh the federal, State, or local level. VVe further understand that any person who makes a false statement in violation of N.C.G.S. 143C-6-23(c) is guilty of a criminal offense punishable as provided byN.C.G.S, 143C'10'1. Sworn Statement: Ryan Gibbs and Doug Efting, being duly sworn, say that we are the President and Secretary, respectively, of Gibbs Effing M nagement Services of Wilmington in the State of North Carolina and that the fore ingye ' cation true, accurate and complete to the best of our knowledge and was made and u bscrib ' by us e also acknowledge and understand that any misuse of State funds ri will be reported t t e appropite authorities for further action, FZNW*MM Sworn to and subscribed befo�e me on the day of the date of said certification. +(Nta�rySignaturd and Sea-1) My Commission Exp\rea:�1����c�\] m there are any questions, please contact the North Carolina Office of State Budget and Management mCGmmts@oawmoc.00v (919) 807-4795 'G.8. 105-243J defines: "Overdue tax debt. — Any part cfe tax debt that remains unpaid QO days ormore after the notice of final assessment was mailed to the taxpayer. The term does not include a tax debt, however, if the taxpayer entered into an installment agreement for the tax debt under G.S. 105-237 within 90 days after the notice of final assessment was mailed and has not failed to make any payments due under the installment agreement." MS&NCD Form 0008 Eff. July 1.20nn Revised July 18, 2006, 7107, 9/08, 7110 This form is available in electronic format (Microsoft Word document) m�Lvu��u�1�u�� Grant Forms SOSID: 1101689 State of North Carolina Date Filed: 6/10/2009 12:00:00 PM Department of the Secretary of State Elaine F. Marshall North Carolina Secretary of State ARTICLES OF INCORPORATION C200915900527 i Pursuant to §55 -2 -02 of the General Statutes of North Carolina, the undersigned does hereby submit these Articles of Incorporation for the purpose of forming a business corporation. 1. The name of the corporation is: GIBBS EFTING MANAGEMENT SERVICES INC. 2. The number of shares the corporation is authorized to issue is: 100,000 shares 3. These shares shall be: (check either a or b) a. E all of one class, designated as common stock; or b. ❑ divided into classes or series within a class as provided in the attached schedule, with the information required by N.C.G.S. Section 55 -6 -01. 4. The street address and county of the initial registered office of the corporation is: Number and Street 4815 Grouse Woods Drive City Wilmington State NC Zip Code 28411 County New Hanover 5. The mailing address, if different from the street address, of the initial registered office is: Number and Street 4815 Grouse Woods Drive City Wilmington NC Zip Code 28411 6. The name of the initial registered agent is: Ryan P Gibbs 7. Principal office information: (must select either a or b.) a. R The corporation has a principal office. The street address and county of the principal office of the corporation is: Number and Street 4815 Grouse Woods Drive City Wilmington State NC Zip Code 28411 County New Hanover County New Hanover The mailing address, if different from the street address, of the principal office of the corporation is: Number and Street 4815 Grouse Woods Drive City Wilmington State NC Zip Code 28411 b. ❑ The corporation does not have a principal office. County New Hanover CORPORATIONS DIVISION P. O. BOX 29622 RALEIGH, NC 27626 -0622 (Revised January, 2002) (Form B -DI) 8, Any other provisions, which the corporation elects to include, are attached. 9. The name and address of each incorporator is as follows: azzim 4815 Grouse Woods Drive Wilmington NC 284115 10. These articles will be effective upon filing, unless a date and/or time is specified: This the 5th day of JUNE 200 9 Signature Ryan P Gibbs, Incorporator Type or Print Name and Title NOTES: 1. Filing fee is $125. This document must be riled with the Secretary of State. CORPORATIONS DIVISION P. 0. BOX 29622 (Revised January, 2'002) RALEIGH, NC 27626-0622 (Form B-01) F 'Et E ti PROCEDURES FOR USING TIME IN LIEW OF TEMPERATURE a North Carolina Department of Health and Human Services Division of Public Health 1632 Mail Service Center a Raleigh, North Carolina 27699-1632 Beverly Elves Perdue, Govemor L. Layton Long, J Y, JMSA, RFJiS Albert A. Delia, Acting Secretag, State Fnvironmmt2l Health Director October 18, 2012 MEMORANDUM To: Environmental Health Directors, Supervisors, Coordinators, and Specialists Food Industry Representatives Frorn: Cheryl Slachta, REHS, Environmental Health Regional Specialist Food Protection Program Through., Larry Michael, REHS, MPH, Program Head Food Protection Program Subject: Time as a Public Health Control Clarification I-auria Gerald, 1%ff), NfIll I State Health Director There have been questions related to interpreting the North Carolina Food Code Manual, Section 3-501.19, Time as a Public Health Control (TPHC). This rule states that "written procedures shall be prepared in advance, maintained in the FOOD ESTABLISHMENT and made available to the REGULATORY AUTHORITY upon request.' Prior to the adoption of the NC Food Code, the Time in Lieu of Temperature (TILT) Committee approved all Franchise or Chain establishment TILT procedures. The current rule does not require prior approval. Establishments that use TPHC rather than temperature must meet the standards set forth in Section 3-501.19 of the NC Food Code Manual. The establishment shall prepare written procedures in advance and shall follow them. Violations of Section 3- 501.19 are recorded under item 22 on the inspection report. No violation exists if the establishment has written procedures that address all criteria in Section 3-501.19 and the procedures are being followed, The Division will maintain a TPHC contact person to assist establishments and local health departments with questions related to TPHC and promote consistency by maintaining a list of chain establishments` TPHC procedures. Chains are encouraged to submit their procedures to the Division in advance to facilitate awareness of acceptable procedures throughout the state. Please send questions and chain TPHC procedures to Cheryl Slachta (cheryi.slachta@dhhs.nc.gov) or send to the mailing address at the top of this memo. Approvals prior to September 1, 2012, will remain in effect until further notice or until amended to meet Section 3-501.19 The TPHC Committee is working with establishments to review pre-Food Code adoption procedures. Updates will be provided at the following link_ http://ehs ncpublichealth.Gom/dfp_till.htm. Please contact your Environmental Health Regional Specialist if you have additional questions. Narth Car&" fthfic H fth ® h.4*4' doh, ..'h C.�- ­O-y tz'C". Location, 5605 Siw ForL, Rd, -Raleigh, N. C 27609-3811 -I,- Equal op'p-p"'to F-0ye, Page 32 of 43 - 501.19 Time as a Public Health Control. 1. (A) Except as specified under (D) of this section, if time without temperature control is used as the public health control for a working supply of POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) before cooking, or for READY -TO -EAT POTENTIALLY HAZARDOUS FOOD (TIME /TEMPERATURE CONTROL FOR SAFETY FOOD) that is displayed or held for sale or service: (1) Written procedures shall be prepared in advance, maintained in the FOOD ESTABLISHMENT and made available to the REGULATORY AUTHORITY upon request that specify: Pt 1. (a) Methods of compliance with Subparagraphs (13)(1) -(3) or C)(l) -(5) of this section; Pf' and 2. (b) Methods of compliance with § 3- 501.14 for FOOD that is prepared, cooked, and refrigerated before time is used as a public health control. Pr 2. Time — maximum up to 4 hours (1) If time temperature control is used as the public health control up to a maximum of 4 hours: 1. (1) The FOOD shall have an initial temperature of 5 °C (41 "F) or less when removed from cold holding temperature control, or 57 °C (13 57) or greater when removed from hot holding temperature control; P 1 (2) The FOOD shall be marked or otherwise identified to indicate the time that is 4 hours past the paint in time when the FOOD is removed from temperature control; Pe 3. (3) The FOOD shall be cooked and served, served at any temperature if READY -TO- EAT, or discarded, within 4 hours from the point in time when the FOOD is removed from temperature control; P and 4. (4) The FOOD in unmarked containers or PACKAGES, or marked to exceed a 4 -hour limit shall be discarded. P 3. Thne — maximum up to 6 hours (C) If time without temperature control Is used as the public health control up to a maximum of 6 hours:. (1) The FOOD shall have an initial temperature of 5 "C (41 "1°) or less when removed from temperature control and the FOOD temperature may not exceed 21'C (70"T) within a maximum time period of 6 hours; 1, 2. (2) The FOOD shall be monitored to ensure the warmest portion of the FOOD does not exceed 21 °C (70'F) during. the 6 -hour period, unless an ambient air temperature is maintained that ensures the FOOD does not exceed 21 °C (707) during the 6 -hour holding period; Pf 3. (3) The FOOD shall be marked or otherwise identified to indicate: Pf 1. (a) The time when the FOOD is removed from 5"C (41RF) or less cold holding temperature control, P" and 2. (b) The time that is 6 hours past the point in time when the FOOD is removed from cold holding temperature control; Pf 4. (4) The FOOD shall be: 1. (a) Discarded if the temperature of the FOOD exceeds 2l °C (70 °F), "or 2. (b) Cooped and served, served at any temperature if READY -TO -EAT, or discarded within a maximum of 6 hours from the point in time when the FOOD is removed from 5 °C (41"F) or less cold holding temperature control; P and 5. (5) The FOOD in unmarked containers or PACKAGES, or marked with a time that exceeds the 6 -hour limit shall be discarded. r 4. (D) A FOOD ESTABLISHMENT that serves a HIGHLY SUSCEPTIBLE POPULATION may not use time as specified under T' (A), (B) or (C) of this section as the public health control for raw EGGS. Meal satisfaction surveys were distributed in Feb 2015 Home Delivered Meal results Completed Surveys = 96 How would you rate the quality of the meals Excellent 25 Good 57 Fair 13 Poor 1 Unsatisfactory u, Good How would you rate the portions of the meals Excellent 22 Good 61 Fair 10 Poor 3 Unsatisfactory u, Good How would you rate the variety of the meals Excellent 17 Good 50 Fair 24 Poor 5 Unsatisfactory u, Good 0 Excellent Pt Good %, Fair • Poor • Unsatisfactory ff Excellent u, Good t, Fair ra Poor 0 Unsatisfactory J I How does the food taste Excellent 18 Good 57 Fair 21 Poor Unsatisfoctory How would you rate the appearance of the food? Excellent 31 Good 53 Fair 12 Poor Unsatisfactory ''gill in Excellent Good K Fair W, Poor a Unsatisfactor Y ------ -- - - Meal satisfaction surveys were distributed in Feb 2015 Home Delivered Meal results HDM Surveys = 96 How would you rate the responsiveness of the staff to y, to your concerns Excellent 64 Good 29 Fair 1 Poor Unsatisfactory Undecided 2 Does the arrival time of your meal work well for you Always 73 Sometimes 23 Almost never Never Are the volunteer drivers respectful and kind Always 96 Sometimes Almost Never Never FA Always 0 Sometimes �*,, Almost never R Never a Is Always Sometimes Almost Never rv, Never M overall, how would you rate your experience with the SRC meal program Excellent 63 Good 29 Fair 4 Poor Unsatisfactory . y IN Excellent \ : \\ a Good' \\ 1 ƒ�\ \ N Fair y � a Poor \� \� � \/� \ � � \� ^� 0 Unsatisfactory Meal satisfaction surveys were dis distributed in Feb 2015 Congregate results Surveys completed 27 How would you rate the facilities of the Friendship Cafi Excellent 8 Good 16 Fair 3 Poor Unsatisfactory How would you rate the quality of the meals Excellent 3 Good 18 Fair 5 Poor Z. Unsatisfactory 1 Excellent 3 Good 16 Fair 6 Poor Z. Unsatisfactory 5 Excellent W Good Fair Poor N Unsatisfactory 0 Excellent Good Fair Rk Poor R Unsatisfactory Is Excellent Good Fair Poor 9 Unsatisfactory MMIMIM=- Excellent 3 Good 15 Fair 6 Poor 1 Unsatisfactory 2 TrOM-TITTIMM� M Good 14 Fair 7 Poor Unsatisfactory 1 m Excellent W, Good F a i r im Poor tory 0, Unsatisfactory Meal Satisfaction Surveys were di! distributed in Feb 2015 Congregate results Surveys completed: 27 How would you rate the appearance of the food Excellent 6 Good 14 Fair 6 Poor 1 Unsatisfactory How would you rate the responsiveness of the staff to your concerns Excellent 11 Good 9 Fair 6 Poor I Unsatisfactory Are the dining room volunteers respectful and kind Always 20 Sometimes 7 Almost never Never 0 Excellent Nu, Good 11" Fair #A Poor K Unsatisfactory 0 Excellent s,, Good ,, Fair R Poor W Unsatisfactory a Always v Sometimes I Almost never a Never EM Overall, how would you rate your experience with the SRC Nutrition Program Excellent 10 Good 13 Fair 3 Poor Unsatisfactory I IN Excellent h' Good Fair 6, Poor a Unsatisfactory