If the CAP is acceptable, the serious deficiency determination for the provider is temporarily deferred.

Transcription

1 Pat McCrry Gvernr Sent Via TO: FROM: Nrth Carlina Department f Health and Human Services Divisin f Public Health May Spnsring Organizatins f Day Care Hmes Arnette Cwan, MS, RD, LDN Supervisr, Special Nutritin Prgrams Aldna Z. Ws, M.D. Ambassadr (Ret.) Secretary DHHS Penelpe Slade-Sawyer Divisin Directr CACFP SUBJECT: Child and Adult Care Fd Prgram Guidance n the Serius Deficiency Prcess and Acceptable Crrective Actin Plans, Natinal Disqualified List Prcedures and Debt Cllectin The purpse f this memrandum is t prvide guidance n the regulatry serius deficiency, terminatin, and disqualificatin prcesses fr the Child and Adult Care Fd Prgram (CACFP). By prviding this guidance, ur bjective is t assist spnsring rganizatins in ensuring unifrmity and prgram integrity thrughut the CACFP. T achieve this bjective, this memrandum will: Review the serius deficiency prcess; Clarify Fd and Nutritin Service (FNS) expectatins fr acceptable crrective actin plans (CAP); Review the terminatin and disqualificatin prcess; Prvide guidance n what is required fr submissins t the Natinal Disqualified List (NDL); Prvide guidance n what is needed t request remval frm the NDL; and Prvide clarificatin n the cllectin f debts, including interest. This mem is intended t assist spnsring rganizatins t cme int cmpliance with CACFP requirements by stressing that the initiatin f the serius deficiency prcess is the first step in successfully addressing a prvider s nn-cmpliance with ne r mre aspects f its peratin f the Prgram. Prper implementatin f the serius deficiency prcess includes develpment f a CAP. This allws the prvider t cntinue Prgram participatin and t receive technical assistance frm the spnsring rganizatin. It is critical t the integrity f the Prgram and the effectiveness f the serius deficiency prcess and the NDL that these prcedures are cnsistently applied Tel Fax Lcatin: 5601 Six Frks Rad Raleigh, NC Mailing Address: 1914 Mail Service Center Raleigh, NC An Equal Opprtunity / Affirmative Actin Emplyer

2 Page 2 The Serius Deficiency Prcess During fiscal years (FY) 2010 and 2011, the CACFP Targeted Management Evaluatin (TME) prcess, as well as investigatins assciated with Office f Inspectr General (OIG) htline cmplaints, disclsed a pattern f regulatry nn-cmpliance with the serius deficiency prcess. It has been revealed that, ften when areas f nn-cmpliance rise t the level f serius deficiency, many spnsring rganizatins are wrking with prviders t achieve cmpliance utside f the regulatry serius deficiency prcess. Once a prvider is declared seriusly deficient, the fllwing prcedures must be fllwed: The spnsring rganizatin must ntify the day care hme that it has been determined t be seriusly deficient. The serius deficiency ntice must identify all serius deficiencies (as defined in 7 CFR (l)(2) fr prviders). The ntice must als specify: Actins t be taken t crrect the serius deficiencies; The time alltted t crrect the serius deficiencies; That the serius deficiency determinatin is nt appealable; That failure t fully and permanently crrect the serius deficiencies within the alltted time will result in issuance f a Ntice f Prpsed Terminatin and Disqualificatin and; That vluntary terminatin f the agreement after being determined seriusly deficient will result in issuance f a Ntice f Terminatin and Disqualificatin and placement n the Natinal Disqualified List. The name(s) f the prvider and/r Respnsible Principals r Individuals (RPIs) will be placed n the State agency s list (nting the basis fr the serius deficiency determinatin); In respnse t the serius deficiency ntice, the prvider must submit a CAP that details the internal cntrls implemented t ensure that the serius deficiencies are fully and permanently crrected. A successful CAP includes: Name(s) f the prvider and ther RPIs assciated with the serius deficiencies; Lcatin f the prvider; Dates f birth fr all RPIs r the prvider assciated with the serius deficiencies; Plicies and prcedures r ther fficial dcumentatin which ensures the serius deficiencies have been fully and permanently crrected. (See mre details n CAP guidance in the next sectin.) Family day care hme spnsring rganizatins must prvide the serius deficiency ntice and supprting dcumentatin t the State agency (7 CFR (l)(3)(i)). If the CAP is acceptable, the serius deficiency determinatin fr the prvider is temprarily deferred. If a timely CAP is nt submitted, r n CAP is submitted, a Ntice f Prpsed Terminatin and Disqualificatin, with appeal rights, must be sent t the prvider and RPIs. If an appeal is filed, and the actin taken by the spnsring rganizatin is upheld, the prvider and all RPIs will be sent a Ntice f Terminatin and Disqualificatin and placed n the NDL with the full amunt f any determined debt assciated with bth the institutin and/r RPIs. When a spnsring rganizatin declares a prvider and/r RPI seriusly deficient, the Spnsring Organizatin must hld the prvider and/r RPI accuntable fr the serius deficiencies and cntinue the serius deficiency prcess thrugh its cmpletin. The intent f the CACFP regulatins is that a prvider

3 Page 3 as well as RPIs wh were invlved in causing r failing t crrect the serius deficiencies, will be disqualified and placed n the NDL. A prvider can never be seriusly deficient withut sme imprper actin by the prvider and/r RPIs. A prvider and/r RPI are always respnsible fr the prvider s failing t cmply with regulatry requirements. If the prvider and/r RPI fail t cmplete crrective actin, bth the prvider and/r RPI will be terminated and placed n the NDL, thus ntifying ther State agencies that these RPIs are currently ineligible t participate in CACFP as part f a different institutin, as institutin principals, a spnsred center, r as day care hme prviders. If this des nt ccur, the prvider and /r RPI respnsible fr the serius deficiencies in ne family day care hme may, because they have nt been disqualified, simply re-incrprate under a new name and be admitted t participate in the Prgram in anther State. Crrective Actin Plans Guidance Prviders are required t submit crrective actins taken t fully and permanently crrect each serius deficiency t the spnsring rganizatin (7 CFR (l)(3)(F)(ii)). If the spnsring rganizatin determines that the crrective actins fully and permanently crrect each serius deficiency, then the spnsring rganizatin will temprarily defer its serius deficiency determinatin. The submissin f the CAP must include the prvider s fficial dcumentatin demnstrating that the serius deficiencies have been fully and permanently crrected. The spnsring rganizatin will rely n the submissin f this infrmatin t determine whether the prvider has internal cntrls in place t ensure accuntability. Therefre, the CAP must include the fllwing infrmatin: What are the serius deficiency(ies) and the prcedures that will be implemented t address the serius deficiency(ies)? Wh will address the serius deficiency? List persnnel respnsible fr this task. When will the prcedure fr addressing the serius deficiency be implemented? Prvide a timeline fr implementing the prcedure (i.e., will the prcedure be dne daily, weekly, mnthly, r annually, and when will it begin?) Where will the CAP dcumentatin be retained? Hw will the staff and facilities r prviders be infrmed f the new plicies and prcedures (e.g., Handbk, training, website, etc.)? Additinal supprting dcumentatin must be submitted with the CAP. This might include cpies f incme eligibility frms, enrllment frms, enrllment rsters, staff training dcumentatin, site mnitring reprts, menus, Child Nutritin Labels r manufacturers prduct analysis sheets r recipes, attendance recrds, meal cunt frms, itemized fd receipts, etc. Sample Crrective Actin Plan fr a Prvider During an administrative review, a spnsring rganizatin discvers that a day care hme prvider fails t maintain adequate Prgram recrds (i.e., enrllment frms, attendance recrds, meal cunts, menus, etc.). The spnsring rganizatin sends a ntice f serius deficiency t the prvider. The prvider respnds t the serius deficiency ntice and indicates that she will cmply with CACFP requirements in relatin t the maintenance f Prgram administrative recrds. The spnsring rganizatin accepts the letter and temprarily defers the serius deficiency. This is nt an acceptable CAP. In this situatin, the prvider must submit a CAP t the spnsring rganizatin which includes at a minimum the fllwing infrmatin: The prvider s full name, address, and date f birth; Each serius deficiency and the prcedures t be implemented t crrect the issue;

4 Page 4 The timeframe fr implementatin f the prcedures t crrect the issue; The lcatin where recrds will be kept assciated with crrecting the issue; and Supprting dcumentatin as described in the CAP Guidance sectin. The State agency will be evaluating CAP s that are submitted by prviders t spnsring rganizatins. If a spnsring rganizatin temprary defers a serius deficiency based n an unacceptable CAP; than the spnsring rganizatin may be declared seriusly deficient. Submitting Terminated and Disqualified Institutins/Prviders and Individuals t the NDL All NDL submissin request sent t the FNS Natinal Office will be sent by the State agency. NDL submissin requests sent t the State Agency must cntain all required infrmatin as indicated in the Prviders sectin belw. If a required piece f infrmatin is nt available, the Spnsring Organizatin shuld include an explanatin f why the missing infrmatin is unbtainable. Incmplete infrmatin which des nt have an explanatin fr the missing data element will be returned t the Spnsring Organizatin fr cmpletin. The fllwing infrmatin is required when submitting day care hme prviders t be placed n the NDL: Name(s) f the prvider; Address (including city, State and zip cde); Date f birth; Terminatin date; Amunt f debt wed, if any; Name f the individual s spnsring rganizatin; and Reasn/s fr the disqualificatin (if ther is checked, an explanatin shuld be included). Remval frm the NDL Please nte that prviders and RPIs that fail t repay debts wed under the Prgram will remain n the NDL until the debt has been paid in full. Once it has been determined by the State that the prvider has paid the debt in full (including any interest, if applicable) and dcumentatin is n file, the State may request remval f the prvider frm the NDL. In additin, the effective date f NDL remvals will be the date n which the FNS Natinal Office prcesses the remval request. The Spnsring Organizatin will be ntified that the remval has been cmpleted. Day Care Hme Prviders Accrding t 7 CFR 226.6(c)(7)(vi), nce included n the NDL, a prvider will remain n the list until the FNS Natinal Office in cnsultatin with the state agency determines that the serius deficiency(ies) that led t its placement n the list has(ve) been crrected, r until 7 years have elapsed since its agreement was terminated fr cause. Hwever, if the prvider has failed t repay debt wed under the Prgram, the prvider will remain n the list until the debt has been repaid. Even thugh the CACFP regulatins give the States authrity t remve prviders frm the NDL, this des nt relinquish FNS respnsibility t hld the States accuntable fr their decisins in terms f remving prviders frm the NDL. The FNS Reginal Office will review the dcumentatin t ensure State agencies are perating in accrdance with CACFP requirements and that dcumentatin supprts remval f the prvider frm the list.

5 Page 5 Debt Cllectin Assciated with Terminated and Disqualified Institutins/RPIs/Prviders The Spnsring Organizatin must cnsult with the State agency if it is determined that the debt is uncllectible. Day care hme prviders will als remain n the NDL until the debt is repaid; hwever interest is nt applied t debts assciated with prviders. A sample CAP frm has been attached t this plicy mem. Please cntact yur reginal cnsultant if yu have questins. Attachment cc: SNP Staff