Senior Nutrition Program Standards

WASHINGTON STATE 
DEPARTMENT OF SOCIAL AND HEALTH SERVICES 
Aging and Long-Term Support ADMINISTRATION

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Availability and Frequency of Services

CNS providers must serve hot or other appropriate meals at least once a day, five or more days per week. CNS meals may be hot or cold. HDNS providers must provide five or more home-delivered meals per week. Home-delivered meals may be hot, cold, frozen, dried, or shelf-stable with a satisfactory storage life. If a provider operates both CNS and HDNS, the five days per week frequency requirements must be met for congregate and home-delivered meals independently, e.g., if the provider delivers 7 meals to home-delivered participants, congregate meals must still be served on 5 or more days per week.

Exceptions to the frequency of service may be made for CNS:

  1. in a rural area or where such frequency is not feasible, and a lesser frequency is approved by the AAA;
  2. in the case of a provider serving an ethnic community, where such frequency is not feasible, and there are other congregate nutrition sites in the area open on the days the ethnic provider is closed.

When funding permits, service providers should consider, where feasible and appropriate, serving two or more meals per day, seven days a week, and providing meals on holidays.

Written program objectives related to the number and frequency of meals to be served by the provider and the service level of nutrition education and, if provided, nutrition outreach, must be developed by or for the service provider. These objectives must be specific, verifiable, and achievable.

There should be written procedures to be followed by the service provider in the event of weather-related or other emergencies, disasters, or situations which may interrupt congregate meal service, home deliveries, or the transportation of participants to the nutrition site.

In no way may a nutrition program operated by specific groups, such as churches, social organizations, senior centers or senior housing developments restrict participation in the program to their own membership or other­wise show discriminating preference for such membership.

Definition and Purpose

The Senior Nutrition Program consists of both Congregate and Home-Delivered Nutrition Services to help increase the nutrient intake of older individuals who might not eat adequately, and, through better nutrition, assist them to remain healthy and independent in their communities. Hot or other appropriate meals are served five or more days per week, where feasible. Each meal served contains at least one-third of the current Recommended Dietary Allowances as established by the Food and Nutrition Board of the Institute of Medicine of the National Academy of Sciences. A variety of nutrition services may also be provided, such as nutrition assessment, education, therapy, and counseling.

Congregate Nutrition Services (CNS) are offered in a variety of settings, such as senior and community centers, churches, schools, and adult day care facilities. In these settings, participants are given the opportunity to form new friendships and to interact in a social environment. In addition to nutrition services, supportive services, such as transportation, shopping assistance, physical activity programs, health screening, health promotion, and other services may be available.

Home-Delivered Nutrition Services (HDNS) provide nutritious meals delivered to individual residences and other nutrition services to older persons who are normally unable to leave their homes without assistance and are vulnerable according to the criteria in Section III. Services are intended to maintain or improve the nutritional status of these individuals, support their independence, prevent premature institutionalization, and allow earlier discharge from hospitals, nursing homes, or other residential care facilities.

The CNS and HDNS are authorized by the Older Americans Act, Public Law 106-510, codified at 42 U.S.C. 3030e through 3030g. The Nutrition Services Incentive Program (NSIP) is codified at 42 U.S.C. 3030a.

Funding

The Senior Nutrition Program may be funded by Older Americans Act Titles IIIB, C and E, and the Nutrition Services Incentive Program (NSIP); the Senior Citizens Services Act; local public and private funds; and income generated by the program, including voluntary contributions from participants.

Senior Nutrition Program Funding Sources
Funding Source Allowable Uses Prohibited Uses/Conditions
OAA Title IIIB, IIIC Subparts 1 and 2 Any program costs for eligible participants Costs must be allowable under applicable OMB Circulars and the AAA contract. These funds can not be used for meals served to individuals 1) for whom the cost of the meal is paid by another source, or is included in the rate for another service the individual is receiving, or 2) who are required to meet income eligibility criteria to receive the service through which the meal is served, e.g., COPES home-delivered meals; COPES adult day care meals; Medicaid Adult day health meals; adult day care or health meals for which Child and Adult Care Food Program (7CFR Part 226) funds have been claimed; SCSA- or Respite-funded adult day care or health meals.
OAA Title IIIE Costs for meals or other nutrition services for caregivers under 60 Use of IIIE must be in the AAA FCSP Plan and contract with the provider.
NSIP U.S. produced food Any program costs other than U.S. produced foods are not allowable. Funds can not be used toward the cost of meals served to individuals who are not eligible for OAA-funded CNS or HDNS.
SCSA Any program costs for eligible participants Costs must be allowable under applicable OMB Circulars and the AAA contract.
Local public or private funds Determined by the fund source Determined by the fund source.
Program income (participant contributions or other income generated by the program) To expand the service for which the contribution was made. Participant contributions may not be spent on costs for services other than those for which the contributions were made. Program income must be spent prior to OAA funds. Accumulation of one month’s worth of income is allowable.
 

Location of Congregate Nutrition Services

Congregate nutrition sites must be located where there are major concentrations or high proportions of the target group of older persons. They must be located close to, and preferably within walking distance of, areas where members of the target group reside. Examples of appropriate congregate nutrition site locations are community centers in low-income areas, subsidized housing complexes, senior centers, schools, adult day services, and religious facilities. Congregate nutrition sites located in communities where there are significant numbers of minorities should make special efforts to serve these minorities.

In order to provide CNS at an adult day care or adult day health service, the service provider must be contracted to provide CNS in accordance with these SNP Standards. Meals served at the adult day care or health service that can be paid for through the CNS must meet the following criteria:

  1. the individual served the meal is eligible for CNS according to Section IIIA, and
    1. attending the adult day care or health service for the purpose of receiving congregate nutrition services rather than adult day care or health services, or
    2. the cost of the adult day services for the individual is covered by a source other than COPES, Medicaid, SCSA or Respite or any other means-tested program, and OAA funds are allocated specifically for meals for these individuals; and
  2. the individual is given the opportunity to donate toward the cost of the meal.

Program Services

Information and Referral to Basic Food Program

The nutrition program service provider must provide information for partici­pants to take advantage of benefits available to them under the Basic Food Program. The Basic Food Program helps low-income individuals and families obtain a more nutritious diet by supplementing their income with Basic Food benefits to purchase food. Basic Food Assistance can be applied for at local Community Services Offices or online using the Online Application for Services

Providers must coordinate their activities with local agencies that conduct outreach for the Basic Food Program to facilitate participation of eligible older persons in the program.

Nutrition Education

Good nutrition prolongs independence by maintaining physical strength, mobility, endurance, hearing, vision, and cognitive abilities. Eighty-seven percent of older Americans have one or more chronic diseases that can be improved by nutrition therapy, including cancer, chronic lung disease, heart disease, dementia, diabetes mellitus, high blood cholesterol, high blood pressure, osteoporosis, obesity and overweight, and failure to thrive (Draft Nutrition Screening Initiative Policy Statement: Nutrition: Proven Effective in Managing Chronic Disease in Older Americans.)
Nutrition education can be defined as any set of learning experiences designed to facilitate the voluntary adoption of eating and other nutrition-related behaviors conducive to health and well-being. It is an integral part of providing nutrition services to older persons. 
Nutrition services providers must conduct nutrition education activities, consistent with the goals and content described below, at a minimum of two times per calendar year at each site. Providers are encouraged to use existing nutrition education resources from the Basic Food Nutrition Education Program, Washington State University Cooperative Extension, Senior Farmers Market Nutrition Program, or Department of Health’s 5-a-Day Program. 
Nutrition education should include information on physical activity in addition to nutrition. In recognition of the importance of physical activity on health and the prevention of disease, the Dietary Guidelines for Americans recommend being physically active each day. Regular physical activity sustains the ability of older adults to live independently, and benefits individuals with arthritis and those with depression and anxiety. It may reduce the risk of cognitive decline in older adults, and is effective in helping to manage many chronic diseases.

  1. Nutrition Education Goals
    1. To create positive attitudes toward good nutrition and physical activity and provide motivation for improved nutrition and lifestyle practices conducive to promoting and maintaining the best attainable level of wellness for an individual.
    2. To provide adequate knowledge and skills necessary for critical thinking regarding diet and health so the individual can make healthy food choices from an increasingly complex food supply.
    3. To assist the individual to identify resources for continuing access to sound food and nutrition information.
  2. Nutrition Education Content 
    The Dietary Guidelines, which include maintenance of a healthy weight, daily physical activity, food safety, and moderation of alcohol intake should serve as the framework for all nutrition education activities. The Dietary Guidelines can be found here.
    A nutrition education program makes available information and guidance pertaining to:
    1. Food, including the kinds and amounts of food that are required to meet one's daily nutritional needs.
    2. Nutrition, including the combination of processes by which the body receives substances necessary for maintenance of its functions and for growth and renewal of its components, i.e., ingestion, digestion, absorption, metabolism, and elimination.
    3. Behavioral practices, including the factors which influence one's eating and food preparation habits.
    4. Consumer issues, including the management of food purchasing­ power to obtain maximum food value for the money spent.
    5. Information on physical activity.
    6. Information on the roles of nutrition and physical activity in maintaining health and independence, and preventing or managing chronic diseases such as diabetes, heart disease, high blood pressure, osteoporosis, and arthritis.
  3. Nutrition Education Activities 
    Nutrition education consists of activities which provide visual and verbal information and instruction to participants or participants and caregivers in a group or individual setting. The presentations or activities may be led by an RD or ICE, or someone else overseen by an RD or individual with comparable expertise (ICE; see definition under Section VIIB Staffing). The minimum length of one nutrition education presentation is five minutes. 
    Examples of nutrition education activities include: presentations, cooking classes, food preparation demonstrations, field trips, plays, panel discussions, planning and/or evaluating menus, food tasting sessions, question and answer sessions, gardening, physical fitness programs, videos, etc. For home-delivered participants, activities can include the distribution of educational materials.

    When nutrition education is being provided by the nutrition program service provider, all costs associated with the delivery of nutrition education services must be budgeted and charged appropriately to that service.

Nutrition Outreach

Nutrition outreach is an activity designed to seek out and identify, on an ongoing basis, the hard-to-reach, isolated, and vulnerable target group of eligible individuals throughout the program area. Nutrition outreach should be provided as necessary to reach the target population. It may be provided by the AAA, nutrition services provider, or by another contracted provider on behalf of one or more nutrition services providers. 

When nutrition outreach is being provided by the nutrition program service provider, all costs associated with the delivery of nutrition outreach services must be budgeted and charged appropriately to that service.

Nutrition Risk Screening

Nutrition screening is a first step in identifying individuals at nutritional risk or with malnutrition. The OAA requires nutrition programs to provide nutrition risk screening. At a minimum, nutrition program service providers must administer the 10 questions from the Nutrition Screening Initiative Checklist (NSI Checklist, Appendix I, http://www.aafp.org ) to participants and determine their nutrition risk scores. HDNS providers may administer the NSI checklist alone or incorporate the questions into the participant assessments. The number of participants determined to be at high risk must be included in the data submitted to the AAA for the State Performance Report to the Administration on Aging. 

For participants whose screening indicates nutritional risk, service providers should suggest they bring the checklist to their doctor, dietitian or other qualified health or social service professional and ask for help to improve their nutritional health.

Nutrition Therapy

Nutrition therapy includes assessment of nutritional status, evaluation of nutritional needs, and interventions or counseling to achieve optimal outcomes. Nutrition counseling, as a component of nutrition therapy, is the provision of individualized advice and guidance to individuals, who are at nutritional risk because of their health or nutritional history, dietary intake, medications use or chronic illnesses, about options and methods for improving their nutritional status, working with the individual's physician as appropriate. 
If provided by the nutrition program, nutrition therapy or counseling must be provided by an RD or ICE (see Section VIIB. Staffing). The service includes:

  1. Assessing present food habits, eating practices and related factors.
  2. Developing a written plan for appropriate nutrition intervention.
  3. Assisting the individual to implement the written plan.
  4. Planning follow-up care and evaluating achievement of objectives.

Nutritious Meals

Nutritious meals are served to the eligible population in congregate settings, enabling participants to socialize and participate in other activities that may be provided, and delivered to the homes of eligible participants who have difficulty leaving their homes unassisted. Meals must contain at least one-third of the current Recommended Dietary Allowances (see Section VIIE Menus and Menu Planning for detailed nutrient requirements).

Referral to Information and Assistance Program

Subject to participant consent, all participants who appear to have need for other services should be referred to the Information and Assistance Program.

Target Population and Eligibility

Congregate Nutrition Services

  1. Congregate Nutrition Services
    Any individual aged 60 and over is eligible for CNS, however, services should be targeted to individuals aged 60 and over who are unable to prepare meals for themselves because of:
    1. A disabling condition, such as limited physical mobility, cognitive or psychological impairment, sight impairment, or
    2. Lack of knowledge or skills to select and prepare nourishing and well balanced meals, or
    3. Lack of means to obtain or prepare nourishing meals, or
    4. Lack of incentive to prepare and eat a meal alone.

    Other individuals who are eligible for a meal are:

    1. The primary participant’s spouse, regardless of age;
    2. Individuals with disabilities who are not older individuals but who reside in housing facilities occupied primarily by older individuals at which congregate nutrition services are provided;
    3. Individuals with disabilities, regardless of age, who reside at home with and accompany older eligible individuals to the congregate site;
    4. Individuals, regardless of age, providing volunteer services during the meal hours;
    5. An eligible participant’s unpaid caregiver aged 18-59 whose meal is paid for through Title IIIE Family Caregiver Support Program or other funds.

    To the degree feasible, the provider shall ensure that preference is given to those individuals aged 60 and over who meet the vulnerability criteria in Section IIIB3, with further preference given to low-income and minority individuals and to those with the greatest economic and social need. 
    In accordance with the AAA or service provider policy and the funding available, the following individuals may be served a congregate meal once the needs of the eligible population have been met:

    1. Staff of the nutrition program;
    2. Anyone who pays the full cost of the meal.

    Waiting list policies shall be developed by the AAA and CNS provider in consultation with eligible participants.

Home-Delivered Nutrition Services

  1. Home-Delivered Nutrition Services 
    To be eligible for HDNS, individuals must be aged 60 and older and:
    1. Homebound; the definition of homebound is normally unable to leave home unassisted, and for whom leaving home takes considerable and taxing effort. A person may leave home for medical treatment or short, infrequent absences for non-medical reasons, such as a trip to the barber or to attend religious services. 
      AND
    2. Unable to prepare meals for themselves because of:
      1. A disabling condition, such as limited physical mobility, cognitive or psychological impairment, sight impairment, or 
        Lack of knowledge or skills to select and prepare nourishing and well balanced meals, or
      2. Lack of means to obtain or prepare nourishing meals, or
      3. Lack of incentive to prepare and eat a meal alone.

      AND

    3. Meet the vulnerability criteria. A person is considered vulnerable if s/he:
      1. Is unable to perform one or more of the activities of daily living (ADL’s) or instrumental activities of daily living (IADL’s) listed below without assistance due to physical, cognitive, emotional, psychological or social impairment.
        Activities of daily living are eating, dressing, bathing, toileting, transferring in and out of bed/chair, walking.
        Instrumental activities of daily living are preparing meals, shopping, medication management, managing money, using the telephone, doing housework, transportation; or 
        Has behavioral or mental health problems that could result in premature institutionalization; or is unable to perform the activities of daily living listed in #1, or is unable to provide for his/her own health and safety, primarily due to cognitive, behavioral, psychological/emotional conditions which inhibit decision-making and threaten the ability to remain independent. 
        AND
      2. Lacks an informal support system: Has no family, friends, neighbors or others who are both willing and able to perform the service(s) needed, or the informal support system needs to be temporarily or permanently supplemented.

    Other individuals who are eligible for a home-delivered meal, if resources are available, are:

    1. The spouse, regardless of age, of a participant receiving home-delivered meals funded through OAA or the Medicaid Waiver home-delivered meal service (COPES);
    2. Individuals with disabilities who are not older individuals but who reside in the same home with other individuals eligible for the service;
    3. Individuals, regardless of age, providing volunteer services in the home-delivered meals program.
    4. An eligible participant’s unpaid caregiver aged 18-59 whose meal is paid for through Title IIIE Family Caregiver Support Program or other funds.

    To the degree feasible, the provider shall ensure that preference is given to low-income and minority individuals and to those with the greatest economic and social need. 
    Waiting list policies shall be developed by the AAA and HDNS provider in consultation with eligible participants. 
    In accordance with the AAA or service provider policy, the following individuals may be served a home-delivered meal once the needs of the eligible population have been met:

    1. Staff of the nutrition program;
    2. Anyone who pays the full cost of the meal.

Participant Assessments for Home-Delivered Nutrition Services

Each HDNS service provider must assess individuals requesting home-delivered meals for eligibility according to the criteria in Section IIIB. The HDNS provider may conduct the assessment or have a formal written agreement with another program to conduct the assessment. 
There shall be an initial in-home assessment and subsequent periodic in-home reassessments of the older person. Initial assessments should be completed within two weeks of the participant's first meal. Subsequent reassessments should be completed annually, or sooner if an assessment indicates the participant will need home-delivered meals on a temporary rather than permanent basis, e.g., the participant is recovering from surgery or illness, and is expected to recover their ability to provide for themselves nutritionally. 
The written agreement between the home-delivered nutrition program service provider and the program responsible for doing the assessments (if they are not the same) should include the following information:

  1. Responsibilities and obligations of each program;
  2. Specific programmatic procedures to be followed by each program;
  3. Assessment form to be used;
  4. Orientation and/or training regarding the HDNS and the assessment process.

A HDNS provider which will do its own assessment must also establish specific written procedures on how the assessments will be conducted. 
The assessment of each individual must include a determination of eligibility according to the criteria for HDNS (Section IIIB), however it should focus not only on the individual's deficits but also on his or her strengths and informal supports so that those with the greatest need receive the service when resources are limited. The assessment of strengths and informal supports should furnish answers to alternate means of providing services or assistance. 
It is recommended that the nutrition risk screening be incorporated into the assessment, as well as questions to obtain the data required by the AAA and ALTSA for reporting purposes. 
With the consent of the older person, or his or her representative, conditions or circumstances which place the older person or the household in imminent danger must be brought to the attention of appropriate officials for follow-up.