Ohio Administrative Code Sections 173, in Part, and 174, in Part

APPENDIX B

(Ohio Administrative Code Sections 173, in part, and 174, in part)

AAA7 2011-2012 OAA Bid Packet, Appendix B 1 Chapter 173-3 Provider Agreements 173-3-01 Introduction and definitions.

(A) Introduction: Chapter 173-3 of the Administrative Code establishes criteria that each AAA shall follow when entering into a provider agreement for the provision of a service by a non-certified provider under section 173.392 of the Revised Code. (See Chapter 173-39 of the Administrative Code for criteria regarding providers certified under section 173.391 of the Revised Code.)

(B) Definitions for this chapter:

(1) “Activities of daily living” (“ADLs”) means eating, dressing, bathing, toileting, transferring in and out of bed/chair, and walking.

(2) “Area agency on aging” (“AAA”) means a public or non-profit entity that ODA designates, under Section 305 of the Older Americans Act, to serve as an AAA. Each AAA receives state and federal funds from ODA to administer aging-related programs within a particular PSA.

(3) “Assessment” means a gathering of information about a person’s current situation and ability to function. It is comprehensive and identifies the person’s strengths, problems, and care needs in the following major functional areas: physical health, utilization of medical care, ADLs, IADLs, mental and social functioning, financial resources, physical environment, and utilization of services and supports.

(4) “Assistance with self-administration of medication” has the same meaning as in section 3722.011 of the Revised Code.

(5) “Care-coordination program” means a program that an AAA may develop to coordinate and monitor the delivery of services. Examples of services that an AAA may coordinate through a care-coordination program are screening, assessment, and reassessment; care planning; and ongoing contact between the case manager and the consumer.

(6) “Consumer’s signature” means the signature, mark, or electronic signature of a consumer, or the consumer’s family caregiver, who may verify that a service was performed. Examples of means to record an electronic signature are the “SAMS Scan,” “MJM Swipe Card,” call-in verification, etc.

(7) “Family caregiver” has the same meaning as in Section 302 of the Older Americans Act.

(8) “Focal point” means a highly visible facility designated by an AAA as a focal point, under Section 306 of the Older Americans Act, where anyone in the community may obtain information and access to services for older persons and that encourages the maximum collocation and coordination of services.

(9) “Incident” means an event that is inconsistent with the routine care or routine delivery of services to a consumer. An incident may involve a consumer, family caregiver (to the extent that it impacts a consumer), provider, provider’s staff or facility, another facility, AAA’s staff, ODA’s staff, or other administrative authorities. Examples of an incident are abuse, neglect, abandonment, an accident, or an unusual situation that results in an injury to a person or damage to the person’s property or equipment.

AAA7 2011-2012 OAA Bid Packet, Appendix B 2 (10) “Instrumental activities of daily living” (“IADLs”) means preparing meals, shopping for personal items, medication management, managing money, using the telephone, doing heavy housework, doing light housework, and the ability to use available transportation without assistance.

(11) “Licensed practical nurse” (“LPN”) has the same meaning as in section 4723.01 of the Revised Code.

(12) “ODA” means “the Ohio department of aging.”

(13) “Older Americans Act” means the “Older Americans Act of 1965,” 79 Stat. 219, 42 U.S.C. 3001, as amended in 2006.

(14) “Older Americans Act funds” means funds appropriated to ODA through Title III of the Older Americans Act and any source used to match those funds. For the purposes of this chapter, “Older Americans Act funds” does not mean funds for an ombudsman program.

(15) “Older person” means, for the purposes of services reimbursed with Older Americans Act funds, any person sixty years of age or older, unless a different age is required by a state or federal law.

(16) “Plan of treatment” means a physician’s orders.

(17) “Provider” means a person who enters into a provider agreement with an AAA to provide a service, product, or program to consumers under this chapter or Chapter 173-4 of the Administrative Code. These are the three categories of providers:

(a) “Agency provider” means a legally-organized entity that employs staff.

(b) “Self-employed provider” means a legally-organized entity that is owned and controlled by one person and that does not employ a staff.

(c) “Consumer-directed individual provider” means the consumer’s relative, friend, neighbor, or other person who is hired by the consumer to provide a service to the consumer under this chapter or Chapter 173-4 of the Administrative Code.

(18) “Provider agreement” means a written agreement entered into between a provider and an AAA to procure a specific service, product, or program.

(19) “Registered nurse” (“RN”) has the same meaning as in section 4723.01 of the Revised Code.

(20) “Service plan” means a written outline of services that are provided to a consumer, regardless of the funding source for the services.

Effective: 02/19/2009

R.C. 119.032 review dates: 09/30/2013

Promulgated Under: 119.03

AAA7 2011-2012 OAA Bid Packet, Appendix B 3 Statutory Authority: 173.02; 173.04; 173.392; Section 305 (a)(1)(C) of the Older Americans Act of 1965, 79 Stat. 210, 42 U.S.C. 3001, as amended in 2006; 45 C.F.R. 1321.11

Rule Amplifies: 173.04; 173.392; Older Americans Act of 1965, 79 Stat. 210, 42 U.S.C. 3001, as amended in 2006

173-3-06.1 Adult day service.

(A) Definitions:

(1) “Adult day service” (“ADS”) means a non-residential, community-based service provided through an individualized care plan to encourage optimal capacity for self-care or maximizes functional abilities by meeting the needs of a consumer who has functional or cognitive impairments.

(2) “Direct-care staff” means an employee of an ADS facility who has direct, face-to-face contact with a consumer.

(3) “Skilled nursing” has the same meaning as in section 3721.01 of the Revised Code.

(B) Minimum requirements for an ADS:

(1) In general:

(a) Levels of ADS: A provider shall only provide an ADS at a level that the AAA authorizes and that is agreeable to the provider. The required components of the three levels of ADS are presented below and in “Table 1” to this rule:

(i) Basic ADS shall include structured activity programming, health assessments, and the supervision of one or more ADL.

(ii) Enhanced ADS shall include the components of basic ADL, plus hands-on assistance with one or more ADL (bathing excluded), supervision of medication administration, assistance with medication administration, comprehensive therapeutic activities, intermittent monitoring of health status, and hands-on assistance with personal hygiene activities (bathing excluded).

(iii) Intensive ADS shall include the components of enhanced ADS, plus hands-on assistance with two or more ADLs, regular monitoring of health status, hands-on assistance with personal hygiene activities (bathing included, as needed), social work services, skilled nursing services (e.g., dressing changes), and rehabilitative services, including physical therapy, speech therapy, and occupational therapy.

Table 1: Levels and components of ADS:

See Table at http://www.registerofohio.state.oh.us/pdfs/173/0/3/173-3- 06$1_PH_FF_N_RU_20090205_1013.pdf

(b) Transportation: The provider shall transport each consumer to and from the ADS facility by performing a transportation service that complies with rule 173-3-06.6 of the Administrative Code, unless the provider enters into a contract with another provider who complies with rule 173-3-06.6 of the Administrative Code, or unless the family caregiver

AAA7 2011-2012 OAA Bid Packet, Appendix B 4 provides or designates another person or non-provider to transport the consumer to the ADS facility.

(c) Initial assessment: The provider shall conduct an initial assessment of each consumer. The provider shall do so no later than the end of each consumer’s second day of attendance, unless the consumer is enrolled in care coordination and was assessed by the AAA no more than thirty days before the first day of ADS at the provider’s facility. The initial assessment shall contain the consumer’s:

(i) Functional and cognitive profile, which includes identification of the consumer’s ADLs and IADLs that require attention or assistance by the provider; and,

(ii) Social profile (e.g., the consumer’s social activity patterns, major life events, community services, family caregiver data, formal and informal support systems, and behavior patterns).

(d) Health assessment: A physician, RN, or LPN under the direction of an RN shall perform a health assessment of each consumer no later than thirty days after the consumer’s initial attendance at the ADS facility or before the consumer receives the first ten units of service at the ADS facility, whichever comes first. In the health assessment, the physician, RN, or LPN under the direction of an RN shall, at a minimum, include the consumer’s psychosocial profile and identification of the consumer’s risk factors, diet, and medications. If the health assessment is performed by a physician, the provider shall document the physician’s name and phone number.

(e) Individualized care plan: A physician, RN, or LPN under the direction of an RN shall draft an individualized care plan for each consumer no later than thirty days after the initial attendance at the ADS facility or before the consumer receives the first ten units of service at the ADS facility, whichever comes first. The care plan shall describe the consumer’s:

(i) Interests, preferences, and social rehabilitative needs;

(ii) Health needs;

(iii) Specific goals and how ADS should help meet those goals;

(iv) Level of involvement in the drafting of the care plan, and, if the consumer has a family caregiver, the family caregiver’s level of involvement in the drafting of the care plan; and,

(v) Ability to sign his/her signature versus alternate means for a consumer signature.

(f) Physician authorizations: Before administering any medications to the consumer or before providing nursing services, therapeutic meals, nutrition consultations, or therapeutic services to the consumer in the ADS facility, the provider shall obtain an authorization from a physician. The provider shall obtain a new physician authorization at least every ninety days.

(g) Interdisciplinary care conference: For each consumer, the provider shall conduct an interdisciplinary care conference between ADS staff members at least every six months. The provider may invite the consumer to the conference. If the consumer has a family

AAA7 2011-2012 OAA Bid Packet, Appendix B 5 caregiver, the provider shall invite the family caregiver to the conference. If the AAA is providing care coordination services to the consumer, the provider may also invite a representative from the AAA to participate in the conference. The provider shall document the decisions of the conference.

(h) Activities: The provider shall post daily and monthly planned activities in prominent locations throughout the facility.

(i) Lunch and snacks:

(i) The provider shall provide lunch and snacks to each consumer who is present during mealtime or snacktime.

(ii) The provision of lunch and snacks shall comply with the meal service requirements of rule 173-4-05 of the Administrative Code.

(j) Records: For each service performed, the provider shall document the consumer’s name; service date, arrival time, and departure time; consumer’s mode of transportation to and from the ADS facility; service description, including the level of ADS authorized, the level of ADS performed, and if the two are different, the reason why they are different; service units; name of direct-care staff in contact with the consumer; the provider’s signature; and the consumer’s signature.

(2) Physical facility: The provider shall only perform an ADS in a facility that:

(a) Has a separate, identifiable space for ADS staff and ADS activities available during all hours in which an ADS activities are performed in that facility, if the facility in which ADS is performed also houses programs for services other than ADS;

(b) Complies with the accessibility guidelines of the “Americans with Disabilities Act,” 45 C.F.R., Part 36;

(c) Has at least sixty square feet per consumer, excluding hallways, offices, rest rooms, and storage areas;

(d) Has a locked area in which the provider stores consumers’ medications that the provider administers at a temperature that meets the storage requirements of the medications;

(e) Has an area that is inaccessible to consumers in which the provider shall keep any toxic substances present in the facility;

(f) Has at least one toilet for every ten ADS consumers present and at least one wheelchair-accessible toilet; and,

(g) Has bathing facilities suitable to the needs of individual consumers, if the provider provides intensive ADS.

(3) Emergency safety plan: The provider shall:

(a) Have an emergency safety plan and shall review it annually.

AAA7 2011-2012 OAA Bid Packet, Appendix B 6 (b) Post evacuation procedures in prominent locations throughout the facility.

(4) Evacuation drills: The provider shall conduct an evacuation drill from the facility at least quarterly while consumers are present and shall document the completion of each drill.

(5) Fire extinguishers and smoke alarms:

(a) The provider shall have fire extinguishers and smoke alarms in the ADS facility and shall provide routine maintenance to them.

(b) At least annually, the provider shall conduct an inspection of the fire extinguishers and smoke alarms and shall document the completion of each inspection.

(6) Staffing levels:

(a) The provider shall have two staff members present whenever more than one consumer is present, including one who is a paid direct-care staff member and one who is certified in CPR; and,

(b) The provider shall have one RN or LPN under the direction of an RN present when a consumer is present to provide services within the nurse’s scope of practice.

(c) Activities staff:

(i) The provider shall employ at least one staff person who meets the qualifications of paragraph (B)(7)(b) of this rule to direct consumer activities.

(ii) If the provider employs a second activity staff person to lead or assist consumer activities, the second person shall meet the qualifications of paragraph (B)(7)(c) of this rule.

(7) Staff qualifications: The provider shall only permit a person to be an ADS staff member if:

(a) Every RN, LPN under the direction of an RN, social worker, physical therapist, physical therapy assistant, speech therapist, dietician, occupational therapist, or occupational therapy assistant planning to practice as a direct-care staff member possesses a current, and valid license to practice in their profession;

(b) The activity staff person who directs consumer activities has one of the following:

(i) Meets the qualifications required to direct consumer activities in a nursing home under paragraph (G) of rule 3701-17-07 of the Administrative Code;

(ii) Possesses a baccalaureate or associate degree in recreational therapy or a related degree;

(iii) Has at least two years of experience as an activity director or activity coordinator in a related position.

(c) The activity staff person who leads or assists consumer activities:

(i) Possesses a high school diploma or GED; or,

AAA7 2011-2012 OAA Bid Packet, Appendix B 7 (ii) Has at least one year of experience providing personal care activities or recreational services under the direction of a licensed or certified health care professional.

(d) Each direct-care staff member not otherwise mentioned in paragraphs (B)(7)(a) to (B)(7)(c) of this rule possesses a high school diploma or GED; a certification of completion of a vocational program in a health and human services field; or a minimum of two years of employment experience in providing or assisting with personal care services or social activities; and,

(e) Each transportation staff member meets the qualifications under rule 173-3-06.6 of the Administrative Code.

(8) Initial training: Before each new direct-care staff member provides an ADS, the provider shall provide the following training and document the staff member’s completion of:

(a) Orientation training on the expectation of employees, the employee code of conduct, an overview of personnel policies, incident reporting procedures, agency organization and lines of communication; and emergency procedures;

(b) Task-based instruction. In the documentation of a staff member’s completion of this training, the provider shall include the instructor’s title, qualifications, and signature; the date and time of instruction; the content of the instruction; and the name and signature of the direct-care staff member completing the instruction; and,

(c) Training in universal precautions for infection control procedures.

(9) Continuing education: Each direct-care staff person shall complete at least eight hours of in- service or continuing education on appropriate topics each calendar year, unless the staff person holds a professional certification that requires at least the same number of hours in order to maintain the certification. The provider shall document the staff member’s completion of the continuing education by documenting the instructor’s title, qualifications, and signature; the date and time of instruction; the content of the instruction; and the direct-care staff member’s name and signature.

(10) Performance reviews: The provider shall complete a performance review of each staff member in relation to the job description for the staff member. The provider shall document the job description and the performance review.

(C) Units of service:

(1) Units of ADS are calculated as follows:

(a) Less than four hours of ADS per day is a half-unit of ADS.

(b) Four to eight hours of ADS per day is one unit of ADS.

(c) Every fifteen minutes of ADS provided beyond eight hours in one day is a fifteen- minute unit.

(2) A provider shall not bill the AAA for more than twelve hours of ADS per day per consumer.

AAA7 2011-2012 OAA Bid Packet, Appendix B 8 (3) A unit of ADS does not include a transportation service, as defined by rule 173-3-06.6 of the Administrative Code, even if the transportation service is provided to transport the consumer to or from the ADS facility.

R.C. 119.032 review dates: 08/31/2013

Statutory Authority: 173.02; 173.04; 173.392; Section 305 (a)(1)(C) of the Older Americans Act of 1965, 79 Stat. 210, 42 U.S.C. 3001, as amended in 2006; 45 C.F.R. 1321.11

Rule Amplifies: 173.04; 173.392; Section 321 of the Older Americans Act of 1965, 79 Stat. 210, 42 U.S.C. 3001, as amended in 2006

AAA7 2011-2012 OAA Bid Packet, Appendix B 9 173-3-06.4 Homemaker service.

(A) Definitions:

(1) “Homemaker service” means a service that provides routine tasks to help a consumer to achieve and maintain a clean, safe, and healthy environment. Examples of components of a homemaker service are:

(a) Routine meal-related tasks: Planning a meal, preparing a meal, and planning a grocery purchase;

(b) Routine household tasks: Dusting furniture, sweeping, vacuuming, mopping floors, removing trash, and washing the inside of windows that are reachable from the floor, kitchen care (washing dishes, appliances, and counters), bedroom and bathroom care (changing bed linens and emptying and cleaning bedside commodes), and laundry care (folding, ironing, and putting the laundry away); and,

(c) Routine transportation tasks: Performing an errand outside of the presence of the consumer (e.g., picking up a prescription), grocery shopping assistance, or transportation assistance, but not a transportation service under rule 173-3-06.6 of the Administrative Code.

(2) “Aide” means the person who performs the activities of a homemaker service.

(B) Minimum requirements for a homemaker service by an agency provider:

(1) In general:

(a) In home: The provider shall only perform a homemaker service in the consumer’s home, with the exception of routine transportation tasks.

(b) Availability: The provider shall maintain the capacity to provide a homemaker service at least five days per week and possess a back-up plan for providing the service when the provider has no aide available.

(c) Records: For each service performed, the provider shall document the consumer’s name; service date, arrival time, and departure time; service description; service units; name of each aide in contact with the consumer; provider’s signature; and consumer’s signature.

(2) Aide qualifications: The provider may only allow an aide to provide the service if the provider has documentation that the aide successfully completed at least twenty hours of training on the following topics that included successful passage of written testing and skill testing by return demonstration:

(a) Communications skills, including the ability to read, write, and make brief and accurate oral/written reports;

(b) Universal precautions for infection control, including hand washing and the disposal of bodily waste;

AAA7 2011-2012 OAA Bid Packet, Appendix B 10 (c) A homemaker service;

(d) Recognition of emergencies, knowledge of emergency procedures, and basic home safety; and,

(e) Documentation skills.

(3) Employee manual: The provider shall maintain, comply with, and make available upon request a written manual of its policies and procedures that, at a minimum, shall addresses:

(a) The procedure for reporting and documenting an incident;

(b) The need to obtain the consumer’s written permission before releasing information concerning the consumer to anyone;

(c) The required content, handling, storage, and retention of consumer records; and,

(d) Personnel matters, including job descriptions, qualifications to provide the service, performance appraisals, documentation of orientation training, and an employee code of ethics.

(4) Aide training:

(a) Orientation training: Before allowing an employee to have direct, face-to-face contact with a consumer, the provider shall provide orientation training to the aides or other employee that, at a minimum, addresses the expectations of employees, the employee code of ethics, an overview of the provider’s personnel policies, incident reporting procedures, the agency’s organization and lines of communication, and emergency procedures.

(b) Continuing education: The provider shall maintain evidence that each aide successfully completes eight hours of continuing education every twelve months, excluding agency orientation and program-specific orientation.

(5) Aide supervision:

(a) The provider shall employ at least one aide supervisor who:

(i) Is an RN;

(ii) Is an LPN who works under the supervision of a RN;

(iii) Has successfully completed a baccalaureate or associate degree in a health and human services field; or,

(iv) Has completed at least two years of work as an aide.

(b) Before allowing an aide to begin providing a homemaker service to an individual consumer, the aide supervisor shall visit the consumer’s home to define the expected activities of the aide and prepare a written care plan for consumer. The visit may occur at the aide’s initial visit to the consumer.

AAA7 2011-2012 OAA Bid Packet, Appendix B 11 (c) After the aide provides subsequent homemaker services to the individual consumer, the aide supervisor shall evaluate compliance with the care plan, the consumer’s satisfaction, and the aide’s performance by conducting a visit to the consumer at least once every ninety-three days and documenting this evaluation. The supervisor may do this without the presence of the aide being evaluated. In the documentation, the supervisor shall include the date of the visit, supervisor’s name, the consumer’s name, the consumer’s signature, and supervisor’s signature.

(C) Minimum requirements for a homemaker service by a self-employed provider:

(1) Availability: The provider shall maintain the capacity to provide a homemaker service at least five days per week and possess a back-up plan for providing the service when he/she is unavailable.

(2) Records: The provider shall document each episode of a homemaker service, including the date of service, the time of arrival, the time of departure, a description of the tasks performed, his/her signature, and the consumer’s signature.

(D) Minimum requirements for a homemaker service by a consumer-directed individual provider:

(1) Availability: The provider shall maintain the capacity to provide a homemaker service at least five days per week and possess a back-up plan for providing the service when he/she is unavailable.

(2) Records: The provider shall document each episode of a homemaker service, including the date of service, the time of arrival, the time of departure, a description of the tasks performed, his/her signature, and the consumer’s signature.

(E) Unit of service: A unit of homemaker service is one hour of homemaker service.

R.C. 119.032 review dates: 08/31/2013

AAA7 2011-2012 OAA Bid Packet, Appendix B 12 173-3-06.5 Personal care service.

(A) Definitions:

(1) “Personal care service” means a service comprised of tasks that help a consumer achieve optimal functioning with ADLs and IADLs. Examples of components of a personal care service are:

(a) Tasks that are components a homemaker service under rule 173-3-06.4 of the Administrative Code, if the tasks of the homemaker service are specified in the consumer’s care plan and are incidental to the care furnished, or are essential to the health and welfare of the consumer, rather than the consumer’s family;

(b) Tasks that assist the consumer with managing the household, handling personal affairs, and providing assistance with self-administration of medications;

(c) Tasks that assisting the consumer with ADLs and IADLs; and,

(d) Respite services.

(2) “Personal care aide” (“PCA”) means the person who performs the activities of a personal care service.

(B) Minimum requirements for a personal care service:

(1) In general:

(a) In home: The provider shall only perform a personal care service in the consumer’s home, with the exception of routine transportation tasks that are components of a homemaker service.

(b) Availability: The provider shall maintain the capacity to provide personal care services at least five days a week and possess a back-up plan for providing the service when the provider has no PCA available.

(c) Records: For each service performed, the provider shall document the consumer’s name; service date, arrival time, and departure time; service description; service units; name of each PCA in contact with the consumer; provider’s signature; and consumer’s signature.

(2) PCA qualifications:

(a) ODA recommends that a provider not allow an employee to begin providing the service unless the employee is listed on the Ohio department of health’s nurse aide registry or has successfully completed the “Council on Aging Learning Advantages” program. However, the provider may allow any employee to provide the service if the provider has documentation that the employee successfully completed one or more of the following:

AAA7 2011-2012 OAA Bid Packet, Appendix B 13 (i) One year of employment as a supervised home health aide or nurse aide that included the successful passage of written testing and skill testing by return demonstration;

(ii) A vocational program in a healthcare field that included the successful passage of written testing and skill testing by return demonstration; or,

(iii) Sixty hours of training on the following topics that included successful passage of written testing and skill testing by return demonstration:

(a) Communications skills, including the ability to read, write, and make brief and accurate oral/written reports;

(b) Universal precautions for infection control, including hand washing and the disposal of bodily waste;

(c) A homemaker service under rule 173-3-06.4 of the Administrative Code;

(d) Recognition of emergencies, knowledge of emergency procedures, and basic home safety;

(e) Reading and recording temperature, pulse, and respiration;

(f) Basic elements of body functioning and changes in body function that should be reported to a supervisor;

(g) Physical, emotional, and developmental needs of consumers, including the need for privacy and respect for consumers and their property;

(h) Techniques in personal hygiene and grooming that include bed, tub, shower, and partial bath techniques; shampoo in sink, tub, or bed; nail and skin care; oral hygiene; toileting and elimination; safe transfer and ambulation; normal range of motion and positioning; and adequate nutrition and fluid intake; and,

(i) Observation, reporting, and documentation of consumer status and services provided.

(b) Before allowing a person to provide a personal care service as a PCA, the provider shall conduct written testing and skill testing by return demonstration of the person on the topics under paragraph (B)(2)(a)(v) of this rule. The provider shall document the completion of training and testing, including the site and date of the training, the number of hours of training performed, a list of instructional materials and subject areas covered, the qualifications of the trainer and the tester, the trainer’s and tester’s signatures, and all testing results.

(3) Employee manual: The provider shall maintain, comply with, and make available upon request a written manual of company policies and procedures that, at a minimum, shall addresses:

(a) The procedure for reporting and documenting an incident;

AAA7 2011-2012 OAA Bid Packet, Appendix B 14 (b) The need to obtain the consumer’s written permission before releasing information concerning the consumer to anyone;

(c) The content, handling, storage, and retention of consumer records; and,

(d) Personnel matters, including job descriptions, qualifications to provide the service, performance appraisals, documentation of orientation training, and an employee code of ethics.

(4) PCA training:

(a) Orientation training: Before allowing an employee to have direct, face-to-face contact with a consumer, the provider shall provide the PCA or other employee with orientation training that, at a minimum, addresses the expectations of employees, the employee code of ethics, and overview of the provider’s personnel policies, incident reporting procedures, the provider’s organization and lines of communication, and emergency procedures.

(b) Additional training: The provider shall conduct additional training and skill testing by return demonstration of PCAs who are expected to provide tasks that are not included in the training topics listed in paragraph (B)(2)(a)(v) of this rule.

(c) Continuing education: The provider shall maintain evidence that each PCA successfully completes eight hours of in-service continuing education every twelve months, excluding agency orientation and program-specific orientation.

(5) PCA supervision:

(a) The provider shall ensure that a PCA supervisor is available to respond to emergencies when the PCAs are scheduled to work.

(b) The provider shall only allow a RN (or a LPN under the direction of a RN) to be the PCA supervisor, trainer, or tester.

(c) Before allowing a PCA to begin providing a personal care service to an individual consumer, the PCA supervisor shall visit the consumer’s home to define the expected activities of the PCA and prepare a written care plan for consumer. The visit may occur at the aide’s initial visit to the consumer.

(d) After the PCA provides subsequent personal care services to the individual consumer, the PCA supervisor shall evaluate compliance with the care plan, the consumer’s satisfaction, and the PCA’s performance by conducting a visit to the consumer at least once every sixty-two days and documenting this evaluation. The supervisor may do this without the presence of the PCA being evaluated. In the documentation, the supervisor shall include the date of the visit, supervisor’s name, the consumer’s name, the consumer’s signature, and supervisor’s signature.

(6) Monitoring: The provider shall have a monitoring system to verify that services are provided according to the care plan. In this system, the provider shall include a plan for:

(a) Maintaining records of the information obtained through the monitoring system; and,

AAA7 2011-2012 OAA Bid Packet, Appendix B 15 (b) Conducting random checks of the accuracy of the monitoring system. For the purpose of conducting these checks, a random check is considered to be a check of no more than five per cent of the home care visits each PCA makes to different consumers.

(C) Unit of service: A unit of personal care service is one hour of personal care service.

R.C. 119.032 review dates: 08/31/2013

AAA7 2011-2012 OAA Bid Packet, Appendix B 16 173-3-06.6 Transportation service.

(A) “Transportation service” means a service that transports a consumer from one place to another through the use of a provider’s vehicle and driver. Examples of places to which the service may transport a consumer are a medical office, congregate nutrition program site, grocery store, senior center, or government office.

(B) Minimum requirements for a transportation service:

(1) In general:

(a) Type of provider: Only a driver employed by an agency provider or a driver who is a self-employed provider may provide the service. A consumer-directed individual provider shall not provide the service.

(b) Availability: An agency provider shall possess a back-up plan for times when a driver or vehicle is unavailable. A self-employed provider shall possess a back-up plan for times when he/she or his/her vehicle is unavailable. The back-up plan may describe the process for providing the service when the driver or vehicle is unavailable or it may describe the process for notifying the consumer that a driver or vehicle is unavailable.

(c) Into and out of vehicle: As part of each service provided, the driver shall help the consumer to safely enter and exit the vehicle. The agency provider shall maintain a policy for drivers that lists any additional responsibilities assigned to the driver by the provider agreement (e.g., helping a consumer from the door of their home to the vehicle or helping a consumer from inside their home to the vehicle). The agency provider shall inform every consumer of this policy before providing the service to the consumer (e.g., “Our driver will only pick you up if you meet him/her at the curb” or “Our driver will only pick you up if you meet him/her at the door of your home”). The self-employed provider shall maintain a policy that lists any additional responsibilities assigned to him/her by the provider agreement. The self-employed provider shall inform every consumer of this policy before providing the service to the consumer (e.g., “I will only pick you up if you meet me at the curb” or “I will only pick you up if you meet me at the door of your home”).

(d) Records: For each service provided, the driver shall document the consumer’s name; service date; pick-up point and time of the pick up; destination point and time of the drop off; service units; driver’s name; and driver’s signature.

(2) Vehicle inspections:

(a) The provider shall create a written plan for preventative maintenance and inspection of each vehicle and wheelchair lift used for this service which shall include the recommended preventative-maintenance schedule of the vehicle or wheelchair lift and the:

(i) “Annual Vehicle Inspection” on form ODA0004 (http://www.aging.ohio.gov/information/rules/forms.aspx). The provider shall only use a vehicle for the service if a mechanic who is certified by the national institute for automotive service excellence (i.e., “ASE-certified”) or another

AAA7 2011-2012 OAA Bid Packet, Appendix B 17 mechanic approved by the PAA inspected it no more than twelve months beforehand and the answers to all questions on the form were “yes”; and,

(ii) “Pre-Trip Vehicle Inspection” on form ODA0008 (http://www.aging.ohio.gov/information/rules/forms.aspx). The provider shall only use a vehicle if, before providing the first service of the day, the driver inspected it and the answers to all questions required by the form were “yes.”

(b) The provider shall deem that a vehicle that holds a current, valid license from the Ohio medical transportation board to operate as an ambulette is a vehicle that complies with paragraph (B)(2)(a)(i) of this rule.

(c) The provider shall maintain documentation on compliance with paragraph (B)(2)(a) of this rule.

(3) Driver qualifications:

(a) Before providing the first service, the driver shall:

(i) Hold a current, valid driver’s license for at least two years, hold any driver’s license endorsement that is necessary to operate the type of vehicle used for the service, and have fewer than six points issued under Chapter 4506. or 4507. of the Revised Code (or have points issued under statutes of the driver’s home state that are substantially equivalent to six points issued under Chapter 4506. or 4507. of the Revised Code if the driver is a resident of another state);

(ii) Obtain a signed statement from a licensed physician acting within the scope of the physician’s practice that states that the driver has no medical or physical condition, including an incurable vision impairment, that may impair safe driving, passenger assistance, emergency treatment, or the health and welfare of a consumer or the general public;

(iii) Pass drug and alcohol tests. The drug tests check for the use or abuse of amphetamines, cannabinoids (THC), cocaine, opiates, and phencyclidine (PCP). The driver receives a passing score if the drug tests do not find the drugs in his/her blood, breath, or urine. The alcohol tests check blood-alcohol content. The driver receives a passing score if the alcohol tests do not find a blood-alcohol content in the driver’s blood that is higher than Ohio’s maximum blood-alcohol content. The driver shall obtain the drug and alcohol tests from a hospital or another entity that the Ohio department of health permits to conduct the tests;

(iv) Pass a training course in first aid and CPR offered by the American red cross, the American heart association, the national safety council, medic first aid international, American safety and health institute, or an equivalent organization approved by ODA;

(v) Possess the ability to understand written and oral instructions;

(vi) Possess the ability to comply with paragraph (B)(1)(c) of this rule; and,

(vii) Possess the ability to comply with the documentation requirement and the “Pre-Trip Vehicle Inspection” requirement under paragraphs (B)(1)(d) and (B)(2) (a)(ii) of this rule.

AAA7 2011-2012 OAA Bid Packet, Appendix B 18 (b) No later than six months after a driver provides his/her first service or no later than six months after the effective date of this rule, whichever occurs later, the driver shall:

(i) Complete a defensive-driving course sponsored or endorsed by the national safety council or the Ohio department of transportation. The driver shall also complete a defensive-driving course every three years thereafter; and,

(ii) Complete an introductory course approved by ODA on passenger-assistance training that includes the following topics:

(a) Sensitivity to aging;

(b) Overview of diseases and functional factors commonly affecting older adults;

(c) Environmental considerations affecting consumers (e.g., ice on steps);

(d) Consumer assistance and transfer techniques;

(e) Management of a wheelchair, including the proper methods for securing a wheelchair;

(f) Inspection and operation of a wheelchair lift and other types of assistive equipment; and,

(g) Emergency procedures.

(c) Exceptions:

(i) Any driver for an urban or rural transit system is deemed to comply with paragraph (B)(3)(a) of this rule.

(ii) Any driver who successfully passed the defensive-driving course required under paragraph (B)(3)(b)(i) of this rule no more than three years before the effective date of this rule is deemed to comply with paragraph (B)(3)(b)(i) of this rule. (For example, a driver for an urban or rural transit system may have recently completed a defensive-driving course in order to qualify for his/her job. Therefore, he/she is not required to take another defensive-driving course before transporting a consumer under this rule. He/she is only required to complete a defensive-driving course every three years after the date he/she most recently passed a defensive-driving course.)

(iii) Any driver who successfully passed the introductory course required under paragraph (B)(3)(b)(ii) of this rule no more than three years before the effective date of this rule is deemed to comply with paragraph (B)(3)(b)(ii) of this rule. (For example, a driver for an urban or rural transit system may have recently completed the introductory course in order to qualify for his/her job. Therefore, he/she is not required to take another introductory course on transporting older persons and people with disabilities before transporting a consumer under this rule. He/she is only required to complete the refresher course every three years after the date he/she most recently passed the introductory course.)

AAA7 2011-2012 OAA Bid Packet, Appendix B 19 (d) The agency provider shall maintain documentation on the compliance of each driver (or the self-employed provider shall maintain documentation on his/her compliance) with the driver qualifications in paragraph (B)(3) of this rule.

(C) Unit of service:

(1) A one-way trip constitutes one unit of transportation service.

(2) The unit rate in a provider agreement shall reflect the provider’s fully-allocated costs, including administrative costs, training costs, and documentation costs.

R.C. 119.032 review dates: 07/10/2009 and 08/31/2013

Statutory Authority: 173.02; 173.392; Section 305 (a)(1)(C) of the Older Americans Act of 1965, 79 Stat. 210, 42 U.S.C. 3001, as amended in 2006; 45 C.F.R. 1321.11

Rule Amplifies: 173.392; Sections 321, 414, and 416 of the Older Americans Act of 1965, 79 Stat. 210, 42 U.S.C. 3001, as amended in 2006

Prior Effective Dates: 12/16/2005 (Emer.), 3/30/2006, 02/15/2009

AAA7 2011-2012 OAA Bid Packet, Appendix B 20 173-3-09 Appeals.

(A) Introduction: Each AAA and ODA, subject to the conditions specified in the procedures below, shall honor all written request for appeal hearings that are submitted by providers against whom an AAA has taken an adverse action. (An appeal hearing under this rule is not an adjudication hearing under Chapter 119. of the Revised Code.)

(B) Appeal to the AAA:

(1) Written process: Each AAA shall maintain in writing a process that allows a provider to appeal an adverse action related to a provider agreement funded with Older Americans Act funds.

(2) Final AAA decision: An AAA that conducts an appeal hearing shall forward a copy of the provider’s written request for the appeal hearing and a copy of the AAA’s final decision on the matter to ODA no later than five business days after the date the AAA renders its final decision.

(C) Appeal to ODA:

(1) AAA first: ODA shall only honor a request for an appeal hearing before ODA if the provider has fully complied with the written process for appealing an adverse action by the AAA that committed the adverse action and that AAA has rendered its final decision on the appeal.

(2) Request a hearing: To request a hearing before ODA, the provider shall submit a written request to ODA’s director via certified mail no later than fifteen business days after the date the AAA renders its final decision. In the request, the provider shall describe the adverse action he/she is appealing and why he/she believes the AAA’s decision on the matter is inappropriate.

(3) Processing a request: After ODA receives the request for an appeal hearing, ODA shall, in a timely manner, schedule a hearing and select a hearing officer to preside over the hearing. ODA shall schedule the hearing no later than thirty days after the date that ODA receives the provider’s request for a hearing. ODA shall notify the provider and the AAA whose final decision the provider is appealing of the date, time, and location of ODA’s appeal hearing.

(4) Hearing process:

(a) The hearing officer shall afford an adequate opportunity for both the provider and the AAA to present their positions and provide evidence, but may limit or terminate the discussion/testimony if:

(i) The provider or the AAA is unruly or combative;

(ii) The provider’s or AAA’s discussion/testimony is unnecessarily redundant;

(iii) The provider or the AAA negotiate a written agreement that resolves the issue(s) that prompted the hearing; or,

(iv)The provider, in a written statement, withdraws its request for the hearing.

(b) The hearing officer shall make an audio recording of the hearing or ODA shall pay a court reporter to record the hearing.

AAA7 2011-2012 OAA Bid Packet, Appendix B 21 (5) Final ODA decision: The hearing officer shall review the testimony or evidence collected at the hearing and shall make a written recommendation to ODA regarding whether the AAA’s action was appropriate. ODA shall render its final decision on the appeal no later than thirty business days after the date of the hearing and shall send a copy of the decision, and the rationale for the decision, to the provider and the AAA.

(D) As used in this rule, “adverse action” means an AAA’s action concerning a particular provider to not award a provider agreement to that provider; to prematurely terminate a provider agreement with that provider; or to not renew a multi-year provider agreement with that provider for the second, third, or fourth year of the provider agreement.

R.C. 119.032 review dates: 09/30/2013

Rule Amplifies: 173.392; Section 212 of the Older Americans Act of 1965, 79 Stat. 210, 42 U.S.C. 3001, as amended in 2006

AAA7 2011-2012 OAA Bid Packet, Appendix B 22 Chapter 173-4 Nutrition Programs and Nutrition-Related Services

173-4-01 Introduction and definitions.

(A) Introduction: Chapter 173-4 of the Administrative Code establishes criteria that each AAA shall follow when entering into a provider agreement for the provision of a nutrition program or a nutrition- related service by a non-certified provider under section 173.392 of the Revised Code. (See Chapter 173-39 of the Administrative Code for criteria regarding providers certified under section 173.391 of the Revised Code.)

(B) Definitions for this chapter:

(1) “Area agency on aging” (“AAA”) means a public or non-profit entity that ODA designates, under Section 305 of the Older Americans Act, to serve as an AAA. Each AAA receives state and federal funds from ODA to administer aging-related programs within a particular PSA.

(2) “Consumer’s signature” means the signature, mark, or electronic signature of a consumer, or the consumer’s family caregiver, who may verify that a service was performed. Examples of means to record an electronic signature are the “SAMS Scan,” “MJM Swipe Card,” call-in verification, etc.

(3) “Expiration date” means the date that ensures that the consumer has notice of when a product is no longer safe to eat and needs to be discarded.

(4) “Family caregiver” has the same meaning as in Section 302 of the Older Americans Act.

(5) “Licensed dietitian” (“LD”) means a person who holds a current, valid license to practice as a licensed dietitian issued under Chapter 4759. of the Revised Code. A LD assesses nutritional needs and food patterns, makes recommendations for appropriate food and nutrient intake, provides nutritional education and counseling, and develops nutritional care standards for individuals and groups.

(6) “Means testing” means the consideration a consumer’s financial resources (i.e., “means”) in order to determine eligibility for a service or to determine cost sharing or voluntary contribution amounts.

(7) “ODA” means “the Ohio department of aging.”

(8) “Older Americans Act” means the “Older Americans Act of 1965,” 79 Stat. 219, 42 U.S.C. 3001, as amended in 2006.

(9) “Older Americans Act funds” means funds appropriated to ODA through Title III of the Older Americans Act.

(10) “Outbreak of food-borne illness” means the occurrence of two or more cases of a similar illness resulting from the ingestion of a common food or a single case of illness if the consumer is ill with botulism or chemical poisoning.

AAA7 2011-2012 OAA Bid Packet, Appendix B 23 (11) “Planning and service area” (“PSA”) means a geographical region of Ohio that ODA designates as a PSA under Section 305 of the Older Americans Act. ODA lists the PSAs it has designated in rule 173-1-03 of the Administrative Code.

(12) “Provider” means an organization that has entered into a provider agreement with an AAA to provide any one or more of the following within the PSA: a congregate nutrition program, a home-delivered nutrition program, a restaurant and grocery meal service, or a nutrition-related service.

(13) “Serving size” means a standardized amount of a food, such as a cup or an ounce, that is used in providing dietary guidance or in making comparisons among similar foods.

R.C. 119.032 review dates: 07/31/2013

Rule Amplifies: 173.392; Sections 214, 331, 336, and 339 of the Older Americans Act of 1965, 79 Stat. 210, 42 U.S.C. 3001, as amended in 2006

AAA7 2011-2012 OAA Bid Packet, Appendix B 24 173-4-02 Eligibility criteria.

(A) A person may participate in a congregate nutrition program if:

(1) The person is at least sixty years of age;

(2) The person is the spouse of an eligible person, regardless of age or abilities;

(3) The person provides volunteer services during meal-preparation hours or meal-service hours and only receives a meal (and not any other nutrition-related services of the congregate nutrition program);

(4) The person is a guest who is otherwise ineligible to participate in a congregate nutrition program and who pays the provider for the provider’s actual contracted unit cost of the meal; or,

(5) The person is a staff member who is otherwise ineligible to participate in a congregate nutrition program and who pays the provider’s suggested donation or pays a rate mutually agreed upon by the provider and the AAA.

(B) A person may participate in a home-delivered nutrition program if:

(1) The person is at least sixty years of age and meets one of the following criteria:

(a) The person is unable to prepare his/her own meals;

(b) The person is unable to participate in a congregate nutrition program because of physical or emotional difficulties; and,

(c) The person lacks another meal support service in the home or the community.

(2) The person is the spouse of an eligible person, regardless of age or abilities, who lives in the home of the eligible person;

(3) The person provides services during meal-preparation hours or meal-delivery hours and only receives a meal (and not any other nutrition-related services of the home-delivered nutrition program); or,

(4) The person is a guest who is otherwise ineligible to participate in a home-delivered nutrition program and who pays the provider for the provider’s actual contracted unit cost of the meal; or,

(5) The person is a staff member who is otherwise ineligible to participate in a home-delivered nutrition program and who pays the provider’s suggested donation or pays a rate mutually agreed upon by the provider and the AAA.

(C) The AAA shall establish procedures that allow providers of a congregate or home-delivered nutrition program the option to offer a meal to the following persons with disabilities:

AAA7 2011-2012 OAA Bid Packet, Appendix B 25 (1) A person who is less than sixty years of age and is a person with a disability who resides in a facility that is primarily occupied by residents who are at least sixty years of age at which a congregate nutrition program or home-delivered nutrition program is provided; or,

(2) A person with a disability who resides in a home with another person who is eligible to participate in a home-delivered nutrition program.

R.C. 119.032 review dates: 07/31/2013

Rule Amplifies: 173.392; Sections 336 and 339 of the Older Americans Act of 1965, 79 Stat. 210, 42 U.S.C. 3001, as amended in 2006

AAA7 2011-2012 OAA Bid Packet, Appendix B 26 173-4-03 Enrollment process.

(A) Congregate nutrition program: Before enrolling a person into a congregate nutrition program, the provider of the program, the AAA, or another entity designated by the AAA, shall ensure that the person who desires to enroll in the program meets the eligibility criteria for a congregate nutrition program in rule 173-4-02 of the Administrative Code.

(B) Home-delivered nutrition program:

(1) Before enrolling a person into a home-delivered nutrition program, the provider of the program shall ensure that the person who desires to enroll in the program meets the eligibility criteria for a home-delivered nutrition program under rule 173-4-02 of the Administrative Code.

(2) The AAA may establish criteria for initial and annual eligibility assessments that a provider may conduct by telephone with a consumer or a consumer’s family caregiver. Face-to-face assessments are preferred.

(3) For any person who is discharged from a hospital or nursing home, the AAA may deem that the discharge summary from the hospital or nursing home complies with paragraphs (B)(1)(a) and (B)(1)(b) of rule 173-4-02 of the Administrative Code for seven calendar days following the discharge so that the person may receive home-delivered meals immediately following the discharge. A provider may only deliver meals after the thirtieth calendar day following the discharge if an assessment is performed that that verifies that the person who desires to receive home-delivered meals meets the eligibility criteria for a home-delivered nutrition program under rule 173-4-02 of the Administrative Code.

(C) If a waiting list for enrollment into a congregate nutrition program or a home-delivered nutrition program exists, the provider shall develop a prioritization system that distributes meals equitably by prioritizing persons who are determined to have high nutritional risk. At a minimum, the provider shall base the nutritional risk status of a person upon the following:

(1) The nutritional risk status of the consumer as determined by a nutrition health screening service conducted under rule 173-4-08 of the Administrative Code;

(2) The nutritional risk status of a married couple is determined by the spouse with the higher nutritional risk; or,

(3) The income of the person, since the person with the lowest income should receive the service before those with higher incomes, although income level is not a criterion for eligibility for this service.

R.C. 119.032 review dates: 07/31/2013

AAA7 2011-2012 OAA Bid Packet, Appendix B 27 Statutory Authority: 173.02; 173.392; Section 305 (a)(1)(C) of the Older Americans Act of 1965, 79 Stat. 210, 42 U.S.C. 3001, as amended in 2006; 45 C.F.R. 1321.11

Rule Amplifies: 173.392; Sections 336 and 339 of the Older Americans Act of 1965, 79 Stat. 210, 42 U.S.C. 3001, as amended in 2006

AAA7 2011-2012 OAA Bid Packet, Appendix B 28 173-4-04 Congregate nutrition program.

(A) “Congregate nutrition program” means a program that consists of administrative functions; meal production; the provision of nutritious, safe, and appealing meals for eligible consumers in a group setting; and the provision of the nutrition-related services described in rules 173-4-05 to 173-4-09 of the Administrative Code. The purpose of a congregate nutrition program is to promote health, to reduce risk of malnutrition, to improve nutritional status, to reduce social isolation, and to link older adults to community services.

(B) Minimum requirements for a congregate nutrition program:

(1) Eligibility and enrollment:

(a) Before the provider provides a meal to a person, the provider shall verify the person’s eligibility under rule 173-4-02 of the Administrative Code.

(b) For a guest or paid staff member who desires to receive a meal from the provider but is ineligible to participate in a congregate nutrition program, the provider shall require the guest or paid staff member to pay for the meal. The provider shall use all collected fees to expand the service for which the fees were given and to supplement (not supplant) funds given to the provider to provide the service.

(2) Frequency of meals: The provider may provide meals five to seven days per week. If this frequency is not feasible, the provider may provide meals on a less-frequent basis, if the less- frequent basis is approved by the AAA.

(3) Voluntary contributions:

(a) The provider shall provide each consumer with the opportunity to voluntarily contribute to a meal’s cost and the provider shall accept the voluntary contributions. When soliciting for voluntary contributions, the provider shall:

(i) Clearly inform each consumer that he/she has no obligation to contribute and that the contribution is purely voluntary. It is the consumer who determines how much he/she is able to contribute toward the meal’s cost. The provider may not deny a consumer a meal because the consumer does not contribute;

(ii) Protect each consumer’s privacy and confidentiality with respect to the consumer’s contribution or lack of contribution; and,

(iii) Establish appropriate procedures to safeguard and account for all contributions.

(b) The provider shall use all collected contributions to expand the congregate nutrition program for which the contributions were given and to supplement (not supplant) funds given to the provider to operate the program.

(c) The provider may not choose to base suggested contribution levels on a means test. Instead, the provider may choose to base suggested contribution levels on one or more of the following options:

(i) A suggested contribution;

AAA7 2011-2012 OAA Bid Packet, Appendix B 29 (ii) A set range of suggested contribution levels based on income ranges from the United States census bureau; and,

(iii) The meal’s actual cost. For a person whose self-declared income is at or above one hundred eighty-five per cent of the poverty line, the provider shall encourage a voluntary contribution based on the meal’s actual cost.

(4) Records: The provider shall develop and utilize a system for documenting meals served. Acceptable methods for documenting meals served include the following:

(a) On a daily, weekly, or monthly basis, obtain the signatures of consumers who received meals on an attendance sheet; or,

(b) Maintain a daily, weekly, or monthly attendance sheet for meals that is signed by the provider or a designee of the provider.

(5) Nutrition consultation and nutrition education: The provider agreement shall determine whether it is the responsibility of the provider or the AAA to provide to each consumer enrolled in the congregate nutrition program a nutrition consultation service under rule 173-4-06 of the Administrative Code, a nutrition education service under rule 173-4-07 of the Administrative Code, or both services.

(6) Food safety and sanitation:

(a) The provider shall maintain documentation that demonstrates that all meals prepared by the provider or a subcontractor comply with sections 918.01 to 918.31 of the Revised Code and Chapter 3717-1 of the Administrative Code, which is also known as “The State of Ohio Uniform Food Safety Code.”

(b) The provider shall maintain appropriate licenses and demonstrate compliance with local health department inspections and Ohio department of agriculture inspections.

(c) No later than five calendar days after receipt of a critical citation issued by the local health department or the Ohio department of agriculture, the provider shall report to the AAA the critical citation and also a corrective action plan.

(d) Regardless of whether the food items are purchased or donated, the provider shall only use food items from a source approved by the AAA.

(e) The provider shall not reuse a food item that has been served to a consumer that is a time/temperature controlled for safety food.

(f) The provider may not serve food obtained from food banks or other food sources that surpasses its use by date or expiration date.

(g) The provider shall develop written materials on the procedure for allowing a consumer to remove items from the congregate nutrition program after the consumer finishes eating.

(7) Food temperatures:

(a) Thermometers:

AAA7 2011-2012 OAA Bid Packet, Appendix B 30 (i) To protect the integrity of packaged food (e.g., milk carton or thermal meal container), a provider may use an infrared thermometer that measures the food’s surface temperature.

(ii) If the provider measures the packaged food’s temperature with an infrared thermometer and finds that the food does not meet standards, the provider shall use a probe thermometer to measure the food’s internal temperature. Before inserting a probe thermometer into the food, the provider shall clean and sanitize the probe thermometer and practice proper hand-washing techniques.

(b) Monitoring:

(i) A provider who produces food on site shall measure the food temperatures when the food is ready to serve. If the temperatures do not meet standards, the provider shall reheat or refrigerate the food until the proper temperatures are reached.

(ii) A provider who receives bulk food from food preparers shall measure the food temperatures upon receiving the food from the food preparers. If the temperatures do not meet standards, the provider shall not accept the food.

(8) Food-borne illness:

(a) The provider shall promptly notify the local health department when any person complains of a food-borne illness.

(b) No more than two calendar days after the occurrence or receipt of a complaint regarding an outbreak of food-borne illness, the provider shall report the complaint to the AAA.

(9) Emergencies: The provider shall develop and implement written contingency procedures for emergency closings due to short-term weather-related emergencies, loss of power, kitchen malfunctions, natural disasters, etc. In the procedures, the provider shall include:

(a) Providing timely notification of emergency situations to consumers; and,

(b) The distribution of:

(i) Information to consumers on how to stock an emergency food shelf; or,

(ii) Shelf-stable meals to consumers for emergency situations.

(10) Staff training:

(a) For each staff member, whether the staff member works as a paid employee or a volunteer, the provider shall provide an orientation and adequate training to perform assigned responsibilities.

(b) Using a protocol established by the AAA, the provider shall maintain documentation of training provided to each staff member, whether the staff member works as a paid employee or a volunteer.

AAA7 2011-2012 OAA Bid Packet, Appendix B 31 (11) Quality assurance:

(a) The provider shall monitor all aspects of the congregate nutrition program and take action to improve services. This includes the monitoring of food packaging, food temperatures during storage, food preparation, holding food before and during the meal service, retention of food quality characteristics (e.g., flavor and texture), delivery of the food to the congregate nutrition site, and all applicable federal, state, and local regulations.

(b) The provider shall develop and implement an annual plan to evaluate and improve the effectiveness of the program’s operations and services to ensure continuous improvement. In the plan, the provider shall include:

(i) A review of the existing program;

(ii) Satisfaction survey results from consumers, staff, and program volunteers;

(iii) Program modifications made that responded to changing needs or interests of consumers, staff, or volunteers;

(iv) Proposed program and administrative improvements; and,

(v) Results of program monitoring.

(c) The provider shall elicit comments from consumers on the dining environment, type of food, portion size, food temperatures, nutrition program schedule, and staff professionalism.

R.C. 119.032 review dates: 07/31/2013

Statutory Authority: 173.02; 173.392; Section 305 (a)(1)(C) of the Older Americans act of 1965, 79 Stat. 210, 42 U.S.C. 3001, as amended in 2006; 42 C.F.R. 1321.11

Rule Amplifies: 173.392; Section 213.20 of Am. Sub. H. B. No. 119 (127th G.A.); Section 305 (a)(1)(C) of the Older Americans Act of 1965, 79 Stat. 210, 42 U.S.C. 3001, as amended in 2006

AAA7 2011-2012 OAA Bid Packet, Appendix B 32 173-4-04.1 Home-delivered nutrition program.

(A) “Home-delivered nutrition program” means a program that consists of administrative functions; meal production; the delivery of nutritious and safe meals to eligible consumers in a home setting; and the provision of the nutrition-related services described in rules 173-4-05 to 173-4-08 of the Administrative Code. The purpose of a home-delivered nutrition program is to sustain or improve a consumer’s health through safe and nutritious meals served in a home setting.

(B) Minimum requirements for a home-delivered nutrition program:

(1) Eligibility and enrollment: Before the provider provides a meal to a person, the provider shall verify the person’s eligibility under rule 173-4-02 of the Administrative Code.

(2) Frequency of meals: Each provider may provide five to seven days per week. In areas where this frequency is not feasible, the provider may provide meals on a less-frequent basis, if the frequency is approved by the AAA.

(3) Delivery:

(a) The provider shall only leave a meal with the consumer or the family caregiver.

(b) The provider shall develop and implement procedures for assuring the delivery of safe meals.

(c) The provider shall use supplies and carriers for packaging and transporting meals that are appropriate for the length of the route.

(d) The provider may make arrangements with a consumer to deliver an additional meal so that the consumer may store the additional meal for consumption at an upcoming time if it is anticipated that he/she will not be home during an upcoming normal delivery time and, as a result, would otherwise have no meal.

(4) Voluntary contributions:

(a) The provider shall provide each consumer with the opportunity to voluntarily contribute to a meal’s cost and shall accept the voluntary contributions. When soliciting for voluntary contributions, the provider shall:

(i) Clearly inform each consumer that he/she has no obligation to contribute and that the contribution is purely voluntary. It is the consumer who determines how much he/she is able to contribute toward the cost. The provider shall not deny a consumer a meal because the consumer does not contribute;

(ii) Protect each consumer’s privacy and confidentiality with respect to the consumer’s contribution or lack of contribution; and,

(iii) Establish appropriate procedures to safeguard and account for all contributions.

(b) The provider shall use all collected contributions to expand the home-delivered nutrition program for which the contributions were given and to supplement (not supplant) funds given to the provider to operate the program.

AAA7 2011-2012 OAA Bid Packet, Appendix B 33 (c) The provider shall not choose to base suggested contribution levels on a means test. Instead, the provider may choose to base suggested contribution levels on one or more of the following options:

(i) A suggested contribution;

(ii) A set range of suggested contribution levels based on income ranges from the United States census bureau; and,

(iii) The meal’s actual cost. For a person whose self-declared income is at or above one hundred eight-five per cent of the poverty line, the provider shall encourage a voluntary contribution based on the meal’s actual cost.

(5) Records: The provider shall develop and utilize a system for documenting meals delivered. Acceptable methods include the following:

(a) On a daily, weekly, or monthly basis, obtain the signatures of consumers who received meals on a route sheet;

(b) Maintain a daily, weekly, or monthly route sheet that identifies the name of each consumer, the number of meals served to that consumer, the delivery person’s signature, and any other necessary documentation; or,

(c) Another documentation system approved by the AAA.

(6) Nutrition consultation and nutrition education: The provider agreement shall determine whether it is the responsibility of the provider or the AAA to provide to each consumer enrolled in the home-delivered nutrition program a nutrition consultation service under rule 173-4-06 of the Administrative Code, a nutrition education service under rule 173-4-07 of the Administrative Code, or both services.

(7) Food safety and sanitation:

(a) The provider shall maintain documentation that demonstrates that all meals prepared by the provider or a subcontractor comply with sections 918.01 to 918.31 of the Revised Code and Chapter 3717-1 of the Administrative Code, which is also known as “The State of Ohio Uniform Food Safety Code.”

(b) The provider shall maintain appropriate licenses and demonstrate compliance with local health department inspections and Ohio department of agriculture inspections.

(c) No later than five calendar days after receipt of a critical citation issued by the local health department or the Ohio department of agriculture, the provider shall report to the AAA the critical citation and also a corrective action plan.

(d) Regardless of whether the food items are purchased or donated, the provider shall only use food items from a source approved by the AAA.

(e) The provider shall not reuse a food item that has been served to a consumer that is a time/temperature controlled for safety food.

AAA7 2011-2012 OAA Bid Packet, Appendix B 34 (f) The provider shall not serve food obtained from food banks or other food sources if the food has surpassed its use by date or expiration date.

(8) Food temperatures:

(a) Thermometers:

(i) To protect the integrity of packaged food (e.g., milk carton or thermal meal container), a provider may use an infrared thermometer to measure the surface temperature.

(ii) If the provider measures a temperature of packaged food with an infrared thermometer that does not meet standards, the provider shall use a probe thermometer to obtain the food’s internal temperature. Before inserting a probe thermometer into the food, the provider shall clean and sanitize the probe thermometer and practice proper hand-washing techniques.

(iii) If the food is in a closed environment (e.g., an insulated tray system or a thermostatically-controlled food-delivery vehicles), the provider may measure the closed environment’s ambient air temperature.

(b) Monitoring:

(i) The provider shall monitor a thermostatically-controlled food-delivery vehicle’s food temperatures on a quarterly basis. If the temperatures are outside standards, the provider shall monitor the vehicle’s temperatures on three consecutive delivery days. Once the temperatures meet standards, the provider may revert to monitoring the vehicle’s food temperatures on a quarterly basis.

(ii) The provider shall monitor food temperature of the last meal in a non- thermostatically-controlled vehicle on a new route until the route’s food temperatures meet standards. Once the temperatures meet standards, the provider shall monitor the route’s temperatures according to the frequency under paragraph (B)(8)(b)(iii) of this rule.

(iii) The provider shall monitor food temperature of the last meal in a non- thermostatically-controlled vehicle on each established route on a monthly basis. If the temperatures on a particular route are outside standards, the provider shall monitor the route’s temperatures on three consecutive delivery days. Once the temperatures meet standards, the provider may revert to monitoring the route’s food temperatures on a monthly basis.

(c) Disposition of meals after measuring temperature:

(i) The provider shall not deliver a meal if the food temperatures do not meet standards. If the provider is unable to serve a meal to a consumer because the food temperatures do not meet standards, the provider shall serve a shelf-stable meal or an alternative meal as a replacement meal, if doing so is approved by the AAA.

(ii) The provider may deliver a meal to a consumer if the vehicle’s driver measures the food temperature with a probe thermometer placed into the food container at the point of food packaging, rather than probing the food.

AAA7 2011-2012 OAA Bid Packet, Appendix B 35 (iii) The provider may deliver a meal to a consumer if the provider measures the food temperature by measuring the ambient air temperature, rather than probing the food, if the thermometer is placed in the food carrier system at the point of food packaging.

(9) Food-borne illness:

(a) The provider shall promptly notify the local health department when any person complains of a food-borne illness.

(b) No more than two calendar days after the occurrence or receipt of a complaint regarding an outbreak of food-borne illness, the provider shall report the complaint to the AAA with which it has entered into a contract or grant to provide the home-delivered nutrition program.

(10) Emergencies: The provider shall develop and implement written contingency procedures for emergency closings due to short-term weather-related emergencies, loss of power, kitchen malfunctions, natural disasters, etc. In the procedures, the provider shall include:

(a) Providing timely notification of emergency situations to consumers; and,

(b) Either the distribution of:

(i) Information to consumers on how to stock an emergency food shelf; or,

(ii) Shelf-stable meals to consumers for an emergency food shelf.

(11) Staff training:

(a) For each staff member, whether the staff member works as a paid employee or a volunteer, the provider shall provide an orientation and adequate training to perform assigned responsibilities.

(b) Using a protocol established by the AAA, the provider shall maintain documentation of training provided to each staff member, whether the staff member works as a paid employee or a volunteer.

(12) Quality assurance:

(a) The provider shall monitor all aspects of the program and take action to improve services. This includes the monitoring of food packaging, food temperatures during storage, food preparation, holding food before and during the meal service, retention of food quality characteristics (e.g., flavor and texture), delivery of the food, and all applicable federal, state, and local regulations.

(b) The provider shall develop and implement an annual plan to evaluate and improve the effectiveness of the program’s operations and services to ensure continuous improvement. In the plan, the provider shall include:

(i) A review of the existing program;

(ii) Satisfaction survey results from consumers, staff, and program volunteers;

AAA7 2011-2012 OAA Bid Packet, Appendix B 36 (iii) Program modifications made that responded to changing needs or interests of consumers, staff, or volunteers; and,

(iv) Proposed program and administrative improvements.

(c) The provider shall elicit comments from consumers on the type of food, portion size, food appearance, food packaging, food temperatures, nutrition program schedule, and staff professionalism.

R.C. 119.032 review dates: 07/31/2013

Rule Amplifies: 173.392; Section 213.20 of Am. Sub. H. B. No. 119 (127th G.A.); Sections 336 and 339 of the Older Americans Act of 1965, 79 Stat. 210, 42 U.S.C. 3001, as amended in 2006

AAA7 2011-2012 OAA Bid Packet, Appendix B 37 173-4-05 Meal service.

(A) “Meal service” means a service through which a congregate nutrition program, a home-delivered nutrition program, or a restaurant and grocery meal service provides a safe and nutritious meal to consumers to help sustain health through a congregate nutrition program, home-delivered nutrition program, or restaurant and grocery meal service.

(B) Minimum requirements for a meal service:

(1) Dietary guidelines and dietary reference intakes:

(a) The provider shall only provide a meal that complies with the most recent “Dietary Guidelines for Americans” which are published by the secretaries of the United States department of health and human services and the United States department of agriculture and found on http://www.health.gov/dietaryguidelines.

(b) The provider shall provide a meal that meets one-third of the dietary reference intakes (DRIs), which are a comprehensive set of nutrient reference values based on healthy persons for assessing and planning individual and group diets. The food and nutrition board, institute of medicine, and the national academy of sciences establishes DRIs and lists them on http://fnic.nal.usda.gov/.

(2) Menu planning:

(a) In general:

(i) The provider shall assure that all menus meet the meal requirements of this rule.

(ii) The provider shall only offer a menu that is approved by a LD.

(iii) The provider shall only offer menu substitutions that are approved by a LD.

(iv) The provider shall list the serving size for each food item on each production menu.

(b) Methods for determining nutritional adequacy: The provider shall offer a menu to consumers that is nutritionally adequate as determined by nutrient analysis, menu patterns, or a combination of both. “Nutrient analysis” means a process by which food, beverage, and supplement intake are evaluated for nutrient content over a specific period of time that is based upon standard references for nutrients in the component foods. “Menu pattern” means a menu-planning tool used to identify the types and amounts of foods that are recommended to meet specific nutritional requirements. Of these options, the preferred method is to determine nutritional adequacy by means of nutrient analysis.

(i) Nutrient-analysis method: The provider shall only determine the nutritional adequacy of a meal by means of nutrient analysis if:

(a) The provider’s nutrient-analysis software has been approved by the LD of the AAA with which the provider has entered into a provider agreement to provide a meal service;

AAA7 2011-2012 OAA Bid Packet, Appendix B 38 (b) The leader nutrients and target values fall within the compliance range for the adjusted DRI nutrient-value requirements established by “Table 1” of this rule. The target values for each leader nutrient are based upon one meal per day (one-third of the DRI) for the average older population served by the nutrition program. The provider using the nutrient analysis option shall meet the compliance range for leader nutrients in the daily menu or as averaged based on the week’s menu for ten out of the fourteen leader nutrients; and,

Table 1

LEADER NUTRIENTS TARGET VALUES COMPLIANCE RANGES

Calories 685 calories 600-800 calories

Protein 19 gm No less than 17 gm

Fat 23 gm No more than 25 gm

Vitamin A 300 µg No less than 234 µg

Vitamin B6 0.57 mg No less than 0.5 mg

Vitamin B12 0.8 µg No less than 0.7 µg

Vitamin C 30 mg No less than 25 mg

Vitamin D 3.33 µg No less than 2.5 µg

Calcium 400 mg No less than 360 mg

Magnesium 140 mg No less than 107 mg

Zinc 3.7 mg No less than 2.66 mg

Sodium 767 mg No more than 1350 mg

Potassium 1050 mg No less than 700 mg

Fiber 9 gm No less than 6 gm

(c) When serving two meals to a consumer in one day, the target values and compliance ranges are doubled (two-thirds of the DRI). When serving three meals to a consumer in one day, the target values and compliance ranges are tripled (one hundred per cent of the DRI).

(ii) Menu-pattern method: The provider shall only determine the nutritional adequacy of a meal by means of a menu pattern if the provider complies with the following requirements:

(a) All meals: The only menu pattern a provider shall use is the menu pattern in “Table 2” of this rule.

AAA7 2011-2012 OAA Bid Packet, Appendix B 39 Table 2

FOOD TYPES BREAKFAST or BRUNCH LUNCH or DINNER

Meat or meat alternate 1-2 servings 2-3 servings

Vegetables or fruits 2 servings 3 servings

Bread or bread alternate 2 servings 2 servings

Milk or milk alternate 1 serving 1 serving

Desserts/baked goods 1 serving (optional) 1 serving (optional)

Accompaniments (e.g., condiments, sauces, spreads) 1-2 servings 1-2 servings

Beverages (e.g., water and other beverages)Optional Optional

(b) Double classification: Although the provider has the option to classify some individual food items as belonging to one food type or another in “Table 2” of this rule, the provider may only classify a single serving of any individual food item in any single meal as part of one type. For example, although the provider may classify a serving of dried beans as either a meat alternate or vegetable, the provider may not classify dried beans as both a serving of a meat alternate a vegetable in the same meal. Also, although the provider may classify cheese as either a serving of a meat alternate or a serving of a milk alternate, the provider may not classify cheese as both a serving of a meat alternate and a milk alternate in the same meal.

(c) Meat or meat alternates:

(i) The provider shall not serve high-fat and high-sodium processed meats (e.g., hot dogs, bologna, or sausage) more than twice per month.

(ii) The provider shall serve a variety of meat and meat alternates to help meet the DRI requirements for protein, iron, vitamin B6, vitamin B12, and zinc.

(iii) The provider may serve meatless meals that contain eggs; dried beans, peas, or lentil soups or entrees; tofu-based products; or vegetarian lasagna provide variety, contain costs, and assist with special dietary needs, so long as they meet the DRI requirements for protein.

(iv) When planning a meal under the menu-pattern method, the provider may use the guidelines on http://aging.ohio.gov/information/nutrition/nutritionguidelinesandresource s.to determine one serving of meat or meat alternate.

(d) Vegetables and fruits:

(i) Throughout each week, the provider shall serve a variety of fruits and vegetables, in particular, from all five sub-groups: the dark-green sub-group, the

AAA7 2011-2012 OAA Bid Packet, Appendix B 40 orange sub-group, the legumes sub-group, the starch sub-group, and the other sub-group.

(ii) The provider shall consider all vegetables (and full-strength vegetable juices) and all fruits (and full-strength fruit juices) to be vegetables and fruits. The provider shall consider cranberry juice a fruit even if it is not full-strength cranberry juice.

(iii) The provider shall prefer usage of fortified juices, low-sodium vegetable juice, or tomato juice over other juices.

(iv) The provider shall consider one-half cup of cooked, dried beans, peas, or lentils; one-half cup of full-strength (i.e., one hundred per cent) vegetable juice; or, one cup of raw, leafy vegetables as one serving of vegetables.

(v) The provider shall consider a serving of soup, stew, casserole, or other combination dish a serving of a vegetable only if the soup, stew, casserole, or other combination dish contains at least one-half cup of vegetables.

(vi) The provider shall not consider rice, spaghetti, macaroni, or noodles a vegetable.

(vii) The provider shall consider a medium-sized apple, a banana, an orange, or a pear; one-half cup of full-strength fruit juice; or, one fourth of a cup of dried fruit to be one serving of fruit.

(viii) The provider shall consider a menu item to be a serving of fruit if one serving of the item contains at least one-half cup of fruit (e.g., fruit cobbler).

(ix) The provider shall only consider fresh fruit, frozen fruit, or canned fruit (packed in its own juice, with light syrup, or without sugar) to be fruit.

(e) Bread or bread alternates:

(i) The provider shall prefer to serve a variety of enriched and/or whole-grain bread products, particularly those high in fiber.

(ii) The provider shall not consider starchy vegetables (e.g., potatoes, sweet potatoes, corn, yams, and plantains) a serving of bread or a bread alternate.

(iii) The provider shall not consider breading on meat (or a meat alternate) or on vegetables a serving of bread or a bread alternate.

(iv) When planning a meal under the menu-pattern method, the provider may use the guidelines on http://aging.ohio.gov/information/nutrition/nutritionguidelinesandresources to determine one serving of bread or bread alternate.

(f) Milk or milk alternates:

(i) The provider shall prefer to use low-fat milk, calcium-fortified milk, or milk alternatives.

AAA7 2011-2012 OAA Bid Packet, Appendix B 41 (ii) The provider shall not consider juice both a serving of fruit and a serving of milk in the same meal.

(iii) The provider shall not consider cheeses or tofu both a meat and a milk alternative in the same meal.

(iv) When planning a meal under the menu-pattern method, the provider may use the guidelines on http://aging.ohio.gov/information/nutrition/nutritionguidelinesandresources to determine one serving of milk or milk alternate.

(g) Desserts and baked goods (if provided in meal):

(i) The provider shall prefer to serve healthier desserts that include fruit, whole grains, low-fat products, and/or products with limited sugar content.

(ii) The provider shall consider one-half cup of fruit and one-half cup of simple dessert (e.g., pudding, gelatin desserts, ice cream, frozen yogurt, ice milk, and sherbet) to be a serving of dessert or a baked good.

(iii) The provider shall prefer to serve fresh, frozen, or canned fruits that are packed in juice or light syrup as a dessert item in addition to the serving of fruit that may be provided as another part of the meal.

(iv) The provider shall not serve cakes, pies, cobblers, and cookies more than twice per week.

(h) Accompaniments:

(i) The provider shall consider one teaspoon of fortified margarine, butter, mayonnaise, or vegetable oil; or one tablespoon of salad dressing to be a serving of an accompaniment.

(ii) The provider shall not serve more than two servings of fats and oils in a meal. Fat used as an ingredient in a menu item is not counted.

(i) Beverages: Although servings of a beverage are optional, the provider shall prefer to serve water and other beverages with meals for proper hydration.

(3) Ingredient information: The provider shall offer information on the ingredient content of meals served through a system that is approved by the AAA.

(4) Consumer choice: The provider shall offer a consumer who receives a meal service the opportunity to make choices about the meals served by using one or more of the following methods:

(a) At a minimum, allow each consumer to choose from two of the following:

(i) Meat and meat alternates;

(ii) Vegetables and fruits;

AAA7 2011-2012 OAA Bid Packet, Appendix B 42 (iii) Bread or bread alternates;

(iv) Milk or milk-alternates;

(v) Desserts and baked goods (if offered); or,

(vi) Entrees consisting of servings of meat and meat alternates combined with servings of other foods.

(b) Allow consumers to select an alternative meal type (e.g., boxed lunch, frozen meal, or vacuum-packed meal) that has the same nutrient content of a regular meal or follows the meal pattern for a regular meal; or,

(c) Offer consumers of home-delivered meals options regarding the frequency of meal deliveries.

(5) Alternative meals: Before a provider may offer alternative meals, the provider shall determine the need, feasibility, and cost effectiveness of offering alternative meals by using the knowledge and expertise of a LD, by listing serving sizes of food items in alternative meals in menus, and by obtaining the approval for the alternative meal plan and any menu substitutions and substitution lists from the LD. The provider shall only provide alternative meals that meet the following:

(a) Therapeutic meals:

(i) The provider may only provide a therapeutic meal as ordered by a physician, or another healthcare professional with prescriptive authority, as part of a treatment of a disease or a clinical condition to eliminate, decrease, or increase certain foods or nutrients in the diet.

(ii) The provider may only provide a therapeutic meal if the physician’s order is on file with the provider or the AAA.

(iii) The physician or case manager of the AAA shall review the written order for a therapeutic meal and update it according to the physician’s order.

(iv) The provider shall assure that the therapeutic diet contains nutrients consistent with the diet order by either utilizing nutrient analysis or by obtaining a list of food items from the physician or an LD.

(b) Dysphagia therapeutic meals:

(i) The provider may provide a dysphagia therapeutic meal for someone with a diagnosed neurological condition that makes oral or pharyngeal swallowing difficult or dangerous. The provider shall make the dysphagia meal with a consistency that is specific to the consumer’s needs.

(ii) The physician or other healthcare professional with prescriptive authority shall order either a level one (pureed) or level two (chopped or ground) dysphagia therapeutic diet. The order shall include thickening agents, if required.

(c) Diabetic meals using carbohydrate choices:

AAA7 2011-2012 OAA Bid Packet, Appendix B 43 (i) The provider shall take the following principles into consideration when planning a diabetic meal using carbohydrate choices: The amount of carbohydrates consumed and the timing of meals, rather than the source of the carbohydrates, are the keys to controlling blood-sugar levels. One carbohydrate choice is equivalent to fifteen grams of carbohydrates. Carbohydrates are found in bread/starch, milk, fruit, starchy vegetables, and desserts.

(ii) If the provider uses a menu pattern to plan a diabetic meal using carbohydrate choices, the provider:

(a) Shall limit a consumer to four to five carbohydrate choices per meal;

(b) Shall allow a consumer no carbohydrate choices for meat or meat alternates. Dried beans, peas, and lentils are considered starchy vegetables;

(c) Shall allow one carbohydrate choice per serving of starchy vegetables and use the same items and serving sizes listed in paragraph (B)(2)(b)(ii) (d) of this rule. Starchy vegetables include baked beans; corn; corn-on- the-cob; cooked, dried beans (e.g., garbanzo beans, pinto beans, kidney beans, white beans, split peas, black-eyed peas, navy beans, and soy beans); lima beans; lentils; mixed vegetables with corn; peas, plantain; potato; sweet potato; winter squash (e.g., acorn, butternut, pumpkin); and yams;

(d) Shall allow one carbohydrate choice per serving of fruit. One carbohydrate choice equals one piece of a small or medium-sized fresh fruit; one-half cup of unsweetened, frozen fruit; one-half cup of unsweetened, canned fruit; one-half cup of unsweetened fruit juice; one- fourth cup of dried fruit; or one-half cup of cranberry juice cocktail;

(e) Shall allow one carbohydrate choice per serving of milk, yogurt, or soy beverage; but do not allow any carbohydrate choice for cheese or tofu. One carbohydrate choice is equivalent to one cup of buttermilk, low-fat milk, or skim milk fortified with vitamins A and D; one cup of lactose- reduced or lactose-free milk; six ounces of yogurt; or one cup of soy beverage that is enriched with calcium and vitamins A and D;

(f) Shall allow one carbohydrate choice per serving of desserts or baked goods. One carbohydrate choice equals one ounce or a two-inch square of an unfrosted brownie or cake, two small plain cookies, one-half cup of ice cream or frozen yogurt; one-half cup of sugar-free pudding; or, a slice of pie that is one-sixteenth of an eight-inch-diameter pumpkin or custard pie; and,

(g) May use the guidelines on http://aging.ohio.gov/information/nutrition/nutritionguidelinesandresource s to plan a meal using carbohydrate choices.

(d) Modified meals:

AAA7 2011-2012 OAA Bid Packet, Appendix B 44 (i) The provider may only provide a modified meal if the nutritional adequacy of the meal is determined by nutrient analysis or the menu pattern.

(ii) A modified meal may be provided to a consumer without a order from a health care professional.

(iii) If the provider offers modified meals, the provider shall offer:

(a) Lower-sodium substitutions for foods containing 480 mg of sodium (or more) per serving;

(b) Dental soft substitutions that are chopped, ground, or pureed and that are similar in nutritive value, but have a softer consistency to help with chewing;

(c) Milk-alternate substitutions, if milk is offered on the menu; or,

(d) Low-fat, low-cholesterol substitutions, if the regular menu item is high in fat and cholesterol according to the standards established in the national cholesterol education program diet or the heart- healthy diet program. “Heart-healthy diet” means a diet that involves a decrease in the consumption of foods high in cholesterol and fat compared to an average diet.

(i) Foods that are high in fat include fatty meats (e.g., ribs, regular hamburger, bacon, sausage, cold cuts, salami, bologna, corned beef, hot dogs, fried meats, fried fish, chicken skin, turkey skin); sauces and gravies; fried vegetables; whole milk dairy products (e.g., whole milk, two per cent milk, whole-milk yogurt, ice cream, cream, half and half, cream cheese, sour cream, whole-milk cheeses); high-fat bakery items (e.g., biscuits, croissants, pastries, doughnuts, pies, cookies, muffins) and solid fats (e.g., butter, stick margarine, shortening, lard).

(ii) Foods that are high in cholesterol include organ meats (e.g., liver).

(iii) The provider shall not offer a consumer receiving a modified meal food that includes egg yolks more than twice per week.

(e) Vegetarian meals:

(i) The provider may provide any of the following categories of vegetarian diets:

(a) “Vegan diet” (i.e., “total vegetarian diet”) means a diet of only foods derived from plants (e.g., fruits, vegetables, legumes (dried beans and peas), grains, seeds, and nuts).

(b) “Lacto-vegetarian diet” means a diet of only foods derived from plants and also cheese and other dairy products.

AAA7 2011-2012 OAA Bid Packet, Appendix B 45 (c) “Ovo-lacto-vegetarian diet” means a diet of only plant foods, cheese and other dairy products, and eggs.

(d) “Semi-vegetarian diet” means a diet that does not include red meat, but includes chicken, fish, plant foods, dairy products, and eggs.

(ii) The provider may only provide a vegetarian meal if the meal has the same nutrient content of a regular meal or follows the meal pattern for a regular meal as closely as possible.

(f) Salad bar or soup and salad bar meals:

(i) The provider may provide a salad bar or soup and salad bar meal service that allows consumers to serve themselves a partial or complete meal from an array of cold foods or a combination of hot and cold foods contained in a piece of equipment designed to maintain foods at proper temperatures.

(ii) A salad bar served as a meal accompaniment shall offer at least three raw vegetables, one of which is deep green or orange; two fruits; two salad dressings, one of which is low fat; one mixed salad that contains fruits or vegetables like coleslaw, waldorf salad, etc. This counts as two servings of fruits or vegetables.

(iii) A salad bar served as a meal replacement shall offer four raw vegetables, one of which is deep green or orange; two fruits; two meats or meat substitutes; a calcium source equivalent to eight ounces of milk per serving; two salad dressings; and two servings from the bread group; and one dessert. This counts as a full meal if all menu requirements are met.

(iv) A soup and salad bar served as a meal replacement shall meet the criteria under paragraph (B)(5)(f)(iii) of this rule and contain one soup that is a lower- sodium and lower-fat soup.

(v) The provider shall obtain the approval of a LD before serving a salad bar or soup and salad bar meal.

(g) Ethnic or religious meals:

(i) The provider may provide an ethnic or religious meal to meet the particular dietary needs arising from religious requirements, cultural backgrounds, or ethnic backgrounds.

(ii) The provider shall only provide an ethnic or religious meal if the meal has the same nutrient content of a regular meal or follows the meal pattern for a regular meal unless restricted by religious requirements or ethnic background.

(h) Breakfast and brunch-style meals: A provider may only offer a breakfast or brunch- style meal if the breakfast or brunch-style meal has the same nutrient content of a regular meal or follows the breakfast meal pattern.

(i) Sacked lunches and boxed lunches:

(i) The provider may only provide a sacked or boxed lunch that has the same nutrient content of a regular meal or follows the meal pattern for a regular meal.

AAA7 2011-2012 OAA Bid Packet, Appendix B 46 (ii) The provider may only provide a sacked or boxed lunch if the provider includes a use by date.

(j) Frozen, vacuum-packed, cooked-chilled, and modified atmosphere packed (MAP) meals: A “vacuum-packed” meal is a prepared, pre-cooked meal that is packaged in a container in which all the air is removed before the container is sealed to prolong the shelf life and preserve the flavor. A “modified atmosphere packed” (“MAP”) meal is a prepared, pre-cooked meal in which a combination of gases (e.g., oxygen, carbon dioxide, nitrogen) are introduced into the package at the time it is sealed to extend the shelf life of the food package:

(i) The provider may only provide a frozen, vacuum-packed, cooked-chilled, or MAP meal that has the same nutrient content of a regular meal or follows the meal pattern for a regular meal.

(ii) If the frozen, vacuum-packed, cooked-chilled, or MAP meal is intended as a second meal, the two meals served that day shall together meet two-thirds of the DRI.

(iii) The provider shall refrigerate frozen, vacuum-packed, cooked-chilled meals, and MAP meals during delivery to the consumer.

(iv) The provider shall provide written preparation instructions for the consumer.

(v) The provider shall label the meal with the use by date or expiration date on the meal package.

(vi) The provider may only provide a frozen, vacuum-packed, cooked-chilled, or MAP meal to a consumer if the consumer’s assessment stipulates that the meal is appropriate.

(k) Non-perishable, emergency, and shelf-stable meals. A “shelf-stable meal” is a meal that is non-perishable, ready-to-eat, stored at room temperature, and eaten without heating. Shelf-stable meals use commercially-produced, approved sources (e.g., canned food, dried foods, or ultra-high temperature pasteurized items such as shelf-stable milk, shelf-stable puddings, shelf-stable juices, and shelf-stable creamers):

(i) Every provider of a congregate or home-delivered nutrition program shall develop a written plan for continuing services for the congregate and home- delivered meal service during a weather-related emergency or other emergency. At a minimum, in the plan, the provider shall explain how it plans to enact one of two strategies:

(a) Distribute information to consumers on how a consumer may stock his/her emergency food shelf; or,

(b) Distribute shelf-stable meals to consumers for storage on a consumer’s emergency food shelf.

(ii) The provider may only provide a non-perishable, emergency, or shelf-stable meal that has the same nutrient content of a regular meal or follows the meal pattern.

AAA7 2011-2012 OAA Bid Packet, Appendix B 47 (iii) The provider may only provide a non-perishable, emergency, or shelf-stable meal if the provider includes a use by date or an expiration date with the meal.

(6) Medical food and food for special dietary use:

(a) Medical food:

(i) The AAA shall determine the need, feasibility, and cost-effectiveness of establishing a service for implementing medical food by using the knowledge and expertise of a LD.

(ii) Under the “Orphan Drug Amendment of 1988,” Public Law 100-290, medical food is formulated to be consumed or administered internally under the direction of a physician and is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation.

(iii) Medical food is not intended for the general public.

(iv) Examples are enteral products that treat:

(a) Kidney disease (dialyzed patients with chronic or acute renal failure);

(b) Liver disease (liver dysfunction, and encephalopathy);

(c) Hypermetabolic states (severe burns, trauma, or infection); or,

(d) Lung disease (chronic obstructive pulmonary disease, and acute respiratory distress syndrome).

(b) Food for special dietary use:

(i) The provider shall determine the need, feasibility, and cost-effectiveness of establishing a service for implementing food for special dietary use by using the knowledge and expertise of a LD.

(ii) Under the “Food, Drug, and Cosmetics Act,” 21 U.S.C. 350 (c)(3), food for special dietary use means a particular use for which a food purports or is represented to be used, including, but not limited to:

(a) Supplying a special dietary need that exists by reason of a physical, physiological, pathological, or other condition, including, but not limited to, the condition of disease, convalescence, allergic hypersensitivity to food, being underweight, being overweight, or the need to control the intake of sodium or simple sugars; or,

(b) Supplying a dietary need by a food for special dietary use as the sole item of the consumer’s diet.

(iii) Food for special dietary use is intended for the general public and may be used as a supplement to a normal diet or as a meal replacement.

AAA7 2011-2012 OAA Bid Packet, Appendix B 48 (iv) Examples of food for special dietary are:

(a) Thickened liquids used for dysphasia;

(b) Gluten-free products for those with celiac sprue;

(c) Meal-replacement liquids;

(d) High-calorie liquid supplements;

(e) High-calorie, high-protein liquid supplements for those with fluid restrictions;

(f) High-calorie puddings; or,

(g) A meal replacement with additional calcium for those at risk of fractures or recovering from fractures.

(c) Providers offering medical food or food for special dietary use shall:

(i) Only offer a consumer medical food or food for special dietary use if a physician, or healthcare professional with prescriptive authority, has prescribed the food for the consumer no more than ninety calendar days ago;

(ii) Keep any prescription for the food on file with the provider or the AAA;

(iii) Ask the physician, or healthcare professional with prescriptive authority, who has written a prescription for the food to review and update the prescription every ninety calendar days; and,

(iv) Rely upon LDs for oversight for consumers who receive medical food or food for special dietary use, who may use the food in the following ways:

(a) It may replace a meal for a consumer if it is ordered by a physician or healthcare professional with prescriptive authority and meets one-third of the DRI, except in cases where the consumer’s nutrition care plan dictates otherwise; or,

(b) It may be needed as an addition to a complete meal, or to replace one item in the menu pattern. The combined meal plus the medical food or food for special dietary use shall meet one-third of the DRI, except in cases where the consumer’s nutrition care plan dictates otherwise.

(7) Dietary supplements: The AAA shall not allow dietary supplements nor reimburse a provider for them unless they qualify as medical food or food for special dietary use under paragraph (B) (6) of this rule. Under the “Dietary Supplement Health and Education Act of 1994,” 21 U.S.C. 321, dietary supplements are intended for ingestion in pill, capsule, tablet, or liquid form.

(C) Units of service:

(1) Congregate nutrition program: A unit of service is one meal prepared and served under this rule and rule 173-4-04 of the Administrative Code.

AAA7 2011-2012 OAA Bid Packet, Appendix B 49 (2) Home-delivered nutrition program: A unit of service is one meal prepared and delivered under this rule and rule 173-4-04.1 of the Administrative Code.

(3) Restaurant and grocery meal service: A unit of service is one meal acquired under this rule and rule 173-4-04.2 of the Administrative Code.

R.C. 119.032 review dates: 07/31/2013

Rule Amplifies: 173.392, Sections 336 and 339 of the Older Americans Act of 1965, 79 Stat. 210, 42 U.S.C. 3001, as amended in 2006

AAA7 2011-2012 OAA Bid Packet, Appendix B 50