RE: Finding 2023-004 - Significant Deficiency – Compliance with monitoring response
When completing the Monitor Review Reports there are times that the staff completing the documents is busy reviewing, teaching, re-directing the site server while being present at the facility to make use for extra training while present. This does not mean that the records should not be taken care of to the standards set forth by TDA. We just sometimes find ourselves in the moment trying to make each site better while we are there monitoring and the records on the monitoring report are missing a few items to complete. The reviewer needs to make sure that the documents of record, Monitor Review is filled out to its entirety at the end of the service time and by the end of the each month when records are turned in and give proper documentation for TDA standards and guidelines. There are times when the records of the Monitor Reviews need to be completed back at the office to ensure the five day reconciliation and meal production records are accurate. At this time the entire Monitor Review packet should be reviewed to ensure it is complete and accurate before turning it into the document binder.
See the following step-by-step policy and procedure that is in place effective today Feb. 1, 2024 as these policies were reviewed with staff responsible for these duties.
POLICY: Monitor Requirements (Updated Feb 2024)
• Being the eyes and ears
• Providing valuable feedback about how the sites are operating
• Visiting sites on a regular basis and observing the entire meal service
• Provide technical assistance to sites and serving staff while present for Monitor Review
PROCEDURE: Monitor Review Requirements
The monitoring review requirements for facilities participating in the SFSP are as follows:
• The Executive Director will conduct a pre-operational visit to every potential site;
• The next monitor visit will occur within the first week of operation at each site; and
• The minimum number of required visits is 1 within the first 4 weeks of operation, and
• A minimum number of required visits is 1 each additional 4 weeks of operation.
• If possible due to site approved meal times, he same meal type will not be monitored during each review.
• Monitor Review personnel will wear a badge for easy identification.
• The Monitor will be present before the meal service begins and stay until the meal service is over.
• Sites with findings during the monitor review will be documented and training will be conducted on site. Serious deficiency findings, a monitor review will be conducted within 4 weeks to ensure site is in compliance. If no corrective action is performed, TDA will be notified.
• All sites are required to allow access to WHH staff with proper identification and to provide all requested documents that support the Monitor Review. If any site does not comply, the meals will be disallowed for that day and another Monitor Review will be scheduled.
• All staff that are responsible for completing Monitor Review’s will attend Monitor Training annually provided by the Executive Director. This training will be given to discuss the importance of the monitor procedures, effective monitor technical assistance given, records completion, findings, training, follow up reviews, serious deficiencies, and procedures set forth by TDA.
• All trained monitors will complete the sections of the Monitor Review Documents at the time of the meal service being observed and finish completing the record with the proper documentation back at the office for the Monitor Review Binder.
• Each month the trained Monitors will turn in the Monitor Review Documents to the Executive Director for review of completion, status of each site, findings listed, technical assistance given, and for accuracy of the Monitor Review Document. If errors are noted on the Monitor Review Document the Executive Director and Monitor will correct them together to discuss the errors. This will completed at the end of each month before claim submission.
The annual monitoring review requirements are based upon the individual facility’s start date in the SFSP.