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.

(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.

Effective: 03/05/2009

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

Promulgated Under: 119.03

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

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,

(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:

(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.

Effective: 03/05/2009

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

Promulgated Under: 119.03

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

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.

Effective: 03/05/2009

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

Promulgated Under: 119.03

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

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;

(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:

(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.

(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.

Effective: 03/05/2009

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

Promulgated Under: 119.03

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

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.

(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,

(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:

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

(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 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.

(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.

(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.

(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; 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.

Effective: 03/23/2009

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

Promulgated Under: 119.03

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; 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

173-4-04.2 Restaurant and grocery meal service.

(A) “Restaurant and grocery meal service” means a service that consists of administrative functions; meal production; and the provision of nutritious, safe, and appealing meals for eligible consumers who are at least sixty years of age; 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 the service 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 restaurant and grocery meal service:

(1) Through an agreement with a restaurant or grocery, the provider or the AAA may provide a meal service from the restaurant or grocery to a consumer who is geographically isolated, to a consumer with religious or ethnic dietary needs, or to a consumer who needs meals at a time when the usual congregate nutrition program is not open, such as during mornings, evenings, or weekends, or to a consumer who needs a home-delivered meal, or as authorized by the AAA.

(2) Vouchers: The provider or the AAA may institute a system of issuing meal vouchers for congregate or home-delivered meals that a consumer may redeem at the restaurant or grocery so long as the provider or the AAA:

(a) Offers the vouchers to the eligible consumers while asking for a voluntary contribution;

(b) Keeps the consumer’s level of the voluntary contribution in confidence;

(c) Provides instructions to the consumer on how to voluntarily contribute as little or as much as the consumer can afford; and,

(d) Clearly informs 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.

(3) Consumer identification: The provider or the AAA shall adopt one of the following three policies when providing a meal service through a restaurant or grocery:

(a) A policy that requires a consumer to register with the provider or the AAA to receive an identification card. When the consumer visits the restaurant or grocery store, the consumer may show the identification card to the designated staff person at the restaurant or grocery store to receive a prepared meal or to select a prepared meal from a menu of meals that meet the meal requirements established in rule 173-4-05 of the Administrative Code. The restaurant or grocery shall provide the consumer with the opportunity to voluntarily contribute to the cost of the meal;

(b) A policy that requires a consumer to register with the provider or the AAA to receive meal vouchers. At the time the vouchers are received, the provider or AAA shall provide the consumer with the opportunity to voluntarily contribute to the cost of the meal. When the consumer visits the restaurant or grocery store, the consumer shall provide a voucher to the designated staff person at the restaurant or grocery store to receive a prepared meal or to select a prepared meal from a menu of meals that meet the meal requirements established in rule 173-4-05 of the Administrative Code; or,

(c) A policy that requires the restaurant or grocery that has entered into an agreement with the provider or the AAA to verify that a new consumer is at least sixty years of age before providing a meal, to have each consumer sign in, to complete the required SAMS data, and to obtain a disclosure signature from the consumer. The restaurant or grocery shall regularly submit all required documentation to the AAA that identifies the individual consumers and the number of meals served to those consumers.

(4) Menus: The restaurant or grocery shall only provide meals that:

(a) Comply with the meal requirements and unit-of-service requirements under rule 173-4-05 of the Administrative Code;

(b) Are approved by a LD;

(d) Include menus or food production menus that list serving sizes for each food item.

(5) Food safety and sanitation:

(a) The restaurant or grocery shall maintain documentation that all meals prepared by the restaurant or grocery 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 restaurant or grocery 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 of the Ohio department of agriculture, the restaurant or grocery shall report to the provider or the AAA the critical citation and also a corrective action plan.

(6) Food-borne illness:

(a) The restaurant or grocery shall promptly notify the local health department when a person complains of an outbreak of food-borne illness.

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

(7) Emergencies: The provider or the AAA shall distribute information to consumers on how to stock an emergency food shelf.

(8) Staff training: Using a protocol established by the AAA, the restaurant or grocery shall maintain documentation of training provided to each staff member.

(9) 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.

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

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

(b) Maintaining receipt of the meal vouchers.

(11) Quality assurance: The provider or the AAA shall elicit comments from consumers on dining environments, food appearance, type of food, food temperatures, and staff professionalism.

(12) Definitions:

(a) “Grocery” has the same meaning as “retail food establishment” in rule 3717-1-01 of the Administrative Code.

(b) “Restaurant” has the same meaning as “food service operation” in rule 3717-1-01 of the Administrative Code.

Effective: 03/05/2009

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

Promulgated Under: 119.03

Statutory Authority: 173.02; 173.392; Section 305 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; Section 213.20 of Am. Sub. H.B. No. 119 (127th G.A.); Section 305 of the Older Americans Act of 1965, 79 Stat. 210, 42 U.S.C. 3001, as amended in 2006

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;

(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 �g No less than 234 �g Vitamin B6 0.57 mg No less than 0.5 mg

Vitamin B12 0.8 �g No less than 0.7 �g Vitamin C 30 mg No less than 25 mg

Vitamin D 3.33 �g No less than 2.5 �g 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.

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.

(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/nutritionguidelinesandresources.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 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.

(f) Milk or milk alternates:

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

(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.

(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;

(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,

(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.

(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/nutritionguidelinesandresources.to plan a meal using carbohydrate choices.

(d) Modified meals:

(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;

(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.

(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.

(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.

(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);

(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.

(iv) Examples of food for special dietary are:

(a) Thickened liquids used for dysphasia;

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

(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.

(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.

(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.

(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.

Effective: 03/23/2009

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

Promulgated Under: 119.03

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

173-4-06 Nutrition consultation service.

(A) Definitions:

(1) “Nutrition consultation service” (i.e., “medical nutritional therapy”) means a service that provides individualized guidance on appropriate food and nutrient intakes for consumers who require disease management. The service includes nutrition assessment, intervention, education, and counseling.

(2) “Consultant” means a person who performs a nutrition consultation service.

(B) Minimum requirements for a nutrition consultation service:

(1) In general:

(a) Authorization: The consultant shall not provide the service to a consumer unless a physician (or another healthcare professional with prescriptive authority) has authorized it for the consumer.

(b) Face-to-face: The consultant shall provide the service to the consumer or family caregiver (on behalf of the consumer) on a face-to-face basis or by means of a telecommunications system. As used in this paragraph, “telecommunications” means technologies that exchange health information and provide health care services across geographic, time, social, and cultural barriers.

(c) Records: For each service performed, the provider shall document the consumer’s name; service date and duration of service; service description, including a description of follow-up plans; consultant’s name, consultant’s signature; and consumer’s signature.

(2) Nutrition assessment:

(a) The consultant shall conduct an initial individualized nutrition assessment of the consumer’s nutritional needs and, when necessary, subsequent nutrition assessments by assessing:

(i) Nutrient intake;

(ii) Anthropometic measurements;

(iii) Biochemical values;

(iv) Physical and metabolic parameters;

(v) Socio-economic factors;

(vi) Current medical diagnosis and medications;

(vii) Pathophysiological processes; and,

(viii) Access to food and food-assistance programs.

(b) No later than seven calendar days after the assessment, the consultant shall furnish the results of the assessment to the consumer’s case manager, if the consumer has a case manager, and physician (or other healthcare professional with prescriptive authority).

(3) Nutrition intervention plan:

(a) Based upon the results of the nutrition assessment, the consultant shall develop a nutrition intervention plan that includes:

(i) Clinical and behavioral goals and a care plan;

(ii) Intervention planning, including nutrients required, feeding modality, and method of nutrition education and consultation, with expected measurable outcomes;

(iii) Consideration for input from the consumer, physician, case manager, and, when applicable, any family caregiver or relevant service providers; and,

(iv) The scheduling of any follow-up nutrition consultation service.

(b) No later than seven calendar days after the nutrition assessment, the consultant shall furnish the intervention plan to the consumer’s case manager and physician (or other healthcare professional with prescriptive authority).

(c) The consultant shall furnish documentation of the plan’s implementation and the consumer’s outcomes to the case manager and the physician (or other healthcare professional with prescriptive authority).

(d) The consultant shall provide a plan to the consumer.

(4) Consultant qualifications and limitations:

(a) The provider shall furnish evidence to the AAA that the consultant holds a current, valid license to practice as a LD under Chapter 4759. of the Revised Code or a current, valid license to practice another profession in which the license-holder may perform a nutrition consultation service as part of their profession’s scope of practice.

(b) The consultant shall not provide a service that exceeds the limitations of the provider agreement with the AAA.

Effective: 03/05/2009

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

Promulgated Under: 119.03

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 214, 336, and 339 of the Older Americans Act of 1965, 79 Stat. 210, 42 U.S.C. 3001, as amended in 2006

173-4-07 Nutrition education service.

(A) “Nutrition education service” means a service that promotes better health by providing accurate and culturally-sensitive information and instruction to consumers or family caregivers on nutrition, physical activity, or disease prevention, whether provided in a group or an individual setting.

(B) Minimum requirements for a nutrition education service:

(1) In general:

(a) Education materials: The provider may only provide the service if the provider maintains documentation that the AAA’s LD determines that the educational materials that the provider plans to distribute:

(i) Are tailored to the consumers’ needs, interests, and abilities, including literacy levels;

(ii) Contain accurate and relevant information; and,

(iii) Are written at an appropriate literacy level for the target population, with appropriate font sizes.

(b) Evaluation: The provider shall establish a methodology for evaluating the effectiveness of its nutrition education service and shall maintain records of the evaluations.

(c) The provider who is reimbursed with Older Americans Act funds shall offer to congregate nutrition programs, home-delivered nutrition programs, and providers of a restaurant and grocery meal service:

(i) A nutrition education service two times per year;

(ii) A system for providing a nutrition consultation service under rule 173-4-06 of the Administrative Code within an individual county; or,

(iii) A combination of paragraphs (B)(1)(c)(i) and (B)(1)(c)(ii) of this rule.

(2) Congregate nutrition programs:

(a) Group setting: If the provider provides the service through a congregate nutrition program, the provider shall do so in a group setting.

(b) Records: For each service performed, the provider shall document each consumer’s name (e.g., attendance sheet); service date and duration of service; service topic; service units; instructor’s name; and instructor’s signature.

(c) Instructor qualifications: The provider may only provide the service if the AAA’s LD determines that the provider meets the minimum credentials for an instructor of nutrition education based upon regulations regarding the practice of dietetics found in Chapter 4759. of the Revised Code.

(3) Home-delivered nutrition programs and restaurant and grocery meal services: For each service provided, the provider shall document the number of consumers who received the educational materials, service date, topic of materials, and provider’s signature.

Effective: 03/05/2009

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

Promulgated Under: 119.03

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

173-4-08 Nutrition health screening.

(A) Definitions:

(1) “Determine Your Own Nutritional Health” checklist means form ODA0010 (http://www.aging.ohio.gov/information/rules/forms.aspx), which is a health screening instrument issued by ODA that indicates a person’s level of nutritional risk.

(2) “Nutrition health screening” means using the “Determine Your Own Nutritional Health” checklist to screen consumers for nutritional risks.

(3) “High nutritional risk” means the status of a consumer whose score on the “Determine Your Own Nutritional Health” checklist is six or above.

(B) Minimum requirements for a nutrition health screening:

(1) Frequency:

(a) For each consumer enrolled in a congregate nutrition program or restaurant and grocery meal service, the provider shall screen no later than two months after the consumer’s enrollment into the program and at least annually thereafter.

(b) For each consumer enrolled in a home-delivered nutrition program, the provider shall screen no later than two months after the first meal is delivered to the consumer’s home and at least annually thereafter.

(2) Referrals:

(a) The provider shall establish a referral system that allows for potential interventions for consumers with a high nutritional risk, unless the AAA has already established a referral system.

(b) The provider shall use the referral system to refer any consumer who is determined to have a high nutritional risk.

(c) On a monthly basis, the provider shall document the number of consumers who were referred to community-based services through screening.

Effective: 03/05/2009

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

Promulgated Under: 119.03

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

173-4-09 Grocery shopping assistance service.

(A) Definitions:

(1) “Grocery shopping assistance service” means a service that provides transportation to and from a grocery store or grocery ordering and delivery for a consumer who needs assistance to shop for groceries. The service is only reimbursed with funds from Title III, Part B or Title III, Part E of the Older Americans Act (or any source used to match those funds) or senior community services funds.

(2) “Groceries” mean foods for a household to eat, such as breads and cereals; fruits and vegetables; meats, fish, and poultry; and dairy products.

(B) Minimum requirements for a grocery shopping assistance service:

(1) Introductory packet: Upon enrollment in the service, the provider shall provide the consumer with a packet of introductory information that explains how the service works, defines eligible foods, lists eligible grocery stores, and explains how to safely store and handle groceries

(2) Transportation to and from a grocery store: As part of transporting a consumer to and from a grocery store, the provider may help the consumer transfer groceries from the store/shopping cart to the vehicle and from the vehicle to the consumer’s home.

(3) Grocery ordering and delivery:

(a) As part of grocery ordering and delivery, the provider shall carry the groceries into the consumer’s home.

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

(4) Records: For each service performed, the provider shall document the consumer’s name; service date; pick-up time and location (if transportation was provided); drop-off time and location (if transportation was provided); service units; provider’s signature; and consumer’s signature.

(1) One-way transportation to or from a grocery store; or,

(2) One episode of grocery ordering and delivery.

Effective: 03/05/2009

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

Promulgated Under: 119.03

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