THE CHILD AND ADULT CARE FOOD PROGRAM

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

Administrative Reviews &

Successful Corrective Action

Administrative Review Basics Formal “full” reviews

At least once every 3 years Announced or unannounced Duration: 1-5 days…or longer Record review and observation

In addition: Technical assistance visits Follow-up reviews Record reviews

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

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)

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)

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)

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.

Are You Ready?

Food Service Management Company Records Invitation for Bids / Request for

Proposals Submitted bids / proposals Contract and contract renewals Delivery slips

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

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

Successful Corrective Action Timely

Pay attention to deadline - usually 30 days

Completely and permanently corrects finding

Demonstrate viability, capability and accountability

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

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.”

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

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.”

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.”

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.”

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.”

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.”

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

Implement the CAP

Maximum of 90 days to finalize and implement CAP

Meet benchmarks for long-term CAP’s Ex: Retention of prior-year records

Permanently maintain new procedures Be prepared for a follow-up review

The End