Management Plan for a



North Carolina Department of Health and Human ServicesDivision of Public HealthWomen’s & Children’s Health SectionNutrition Services BranchSpecial Nutrition ProgramsChild and Adult Care Food ProgramManagement Plan for an Independent InstitutionINSTITUTION PROFILEComplete the institution profile.Institution’s Legal Name: FORMTEXT ?????Agreement Number: FORMTEXT ?????Institution’s Business Name (if different from above): FORMTEXT ?????Institution Type: ? State Government ? Local Government ? Federal Government ? Private For-Profit? Private Non-ProfitBusiness Organization: ? Corporation? Limited Liability Company ? Sole Proprietorship? Partnership? Other: (Specify): FORMTEXT ?????FINANCIAL VIABILITY AND MANAGEMENT2. Identify all current revenue sources. Give the average amount received monthly and total length of time in years and/or months that this institution has received this revenue fund source, the type of revenue fund source, and the purpose. (Attach additional sheets, if necessary)Revenue Fund SourceLength of Time (Years and/or Months)Type (Federal, State, County Private, etc.)PurposeAverage Monthly Amount ($)CACFP FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Tuition (Parent Fees) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Department of Social Services (Subsidy) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Smart Start FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????More at Four FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other: (Specify) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3. Please list all other resources available to this institution: (Check all that apply)? Office space ? Desks? Office equipment ? Human Resources such as professional services, consultants, etc.? Computers? Printers? Motor vehicles? Other (Specify below): FORMTEXT ?????4.If this institution should experience a temporary interruption of CACFP funds, how would it continue to operate? (Check all that apply)? Line of credit/loans ? Tuition/Parent Fees ? Department of Social Services (subsidy) ? Sponsor’s Saving Account ? Grants? Other (Specify): FORMTEXT ?????5.If this institution must repay CACFP fund due to overclaim, how would this be done? (Check all that apply)? Line of credit/loans ? Tuition/Parent Fees ? Department of Social Services (subsidy) ? Sponsor’s Saving Account ? Grants? Other (Specify): FORMTEXT ?????Administrative Capability6.Does this institution’s bylaws available for review by the State agency? ? Yes ? No7.Attach an organizational chart reflecting employees with CACFP responsibilities.8.Please complete the chart on Supplemental Page 1, indicating the institution’s representative(s) responsible for each CACFP area requested. 9. Please check the method you will use to determine the effective date for this institution’s Income Eligibility Applications (IEAs). One of the boxes below must be checked. Whatever method this institution selects must be applied to all income eligibility forms submitted on behalf of all participants at this institution’s center?The date the adult participant or adult household member signs the IEA (Adult day cares only)?The date the parent or guardian signs the IEA (NOT applicable for schools)?The institution’s official (eligibility official) signs the IEA?The date the IEA is submitted (Only applicable for schools)?IEAs are not required (Check one below)? Head start ? At-Risk afterschool meal program ? Emergency shelterPROGRAM ACCOUNTABILITYQuestions 10., 11., 12. apply to private non-profit corporations and for-profit corporations that have a board of directors only. (If you are an institution, whose institution type is local, state, or federal government or a for-profit corporation without a board of directors, move to question 13.)10.What is the schedule for this institution’s board meetings? (Specify below) FORMTEXT ?????11.What oversight/supervision does the board of directors have for this institution’s participation in the CACFP? (Check all that apply)? Policy making ? Fiscal guidance? Ongoing governance ? Personnel decisions? Reviews the institution’s policies, programs, and budgets? Decision making on compensation and other areas of the institution’s operations? Other (Specify): FORMTEXT ?????12.Attach this institution’s governing board policies/procedures for oversight of this institution.13.How does this institution determine fiscal responsibility for the following topics? a.How is the fiscal integrity and accountability managed for all funds and property received, held, and disbursed?1. Does this institution have a separate bank account for CACFP? ? Yes ? NoList the name and address of the bank(s) where this institution’s CACFP reimbursement is deposited? FORMTEXT ?????What is this institution’s accounting method?? Cash ? Accrual ? Modified accrual CACFP transactions are recorded on? (Check all that apply)? Paper ledger? Accounting software (Provide the name of the software below)Provide the name of the software: FORMTEXT ?????? CACFP cash receipts and disbursement journal? Other (Specify): FORMTEXT ?????b.How is integrity and accountability of all expenses maintained? 1.What documentation is maintained on file to support CACFP expenditures? (Check all that apply)? Itemized receipts, invoices, and bills ? Bank records? Rental Agreement(s)? Timesheets? Payroll records? Contracts? Tax returns? Board minutes? Cost allocation plans? Depreciation schedule(s)? Travel records? Other (Specify): FORMTEXT ?????2.How frequently does your institution record fiscal transactions?? Daily? Weekly? Monthly? Other (Specify): FORMTEXT ?????3. How frequently does your institution compare their CACFP expenditures against their approved budget?? Daily? Weekly? Monthly? Other (Specify): FORMTEXT ?????c.How will this institution ensure that claims for reimbursement are processed accurately and in a timely manner? (All items in bold must be checked and add any other items that apply)?Meals/snacks are counted at the point of service to each participant at each meal service ?Claims are reviewed by a second party for accuracy prior to being submitted for reimbursement?Regulatory edit checks are performed prior to claim submission ?Claims are uploaded using an automated program (List the name of the automated program below)Provide the name of the automated program: FORMTEXT ??????Other (Specify): FORMTEXT ?????Question 13. (d) applies to for-profit institutions (If this institution is NOT a for-profit center(s), move to question 13. (e))d.How will this institution’s center ensure that eligibility requirements are met? (Check all that apply)?Verify that at least 25% of enrolled participants are eligible for free or reduced-price meals (child care) ?25% of enrolled participants receive Title XIX or Title XX and a claim for reimbursement is processed after the monthly reimbursement statement is reviewed?Other (Specify): FORMTEXT ?????e.How will this institution ensure that funds and property and expenses are incurred for authorized CACFP purposes only? 1.How does this institution ensure that their CACFP operates as a non-profit program? (Check all that apply)?Review year to date expenditures to ensure that no more than three (3) months operating balance is available for this institution?CACFP allowable costs exceed the CACFP reimbursement?The budget is amended as necessary to ensure all CACFP expenditures are approved prior to be incurred2.How is it ensured that CACFP funds are used only for necessary, reasonable, and allowable costs? (Check all that apply)?FNS Instructions 796-2, Rev. 4 is used as reference for determining allowable and unallowable costs?Cost allocation plans are used for costs shared between programs?Only costs included in the approved annual budget are expensed?Receipts are reviewed to ensure no unallowable costs are accounted for as a CACFP cost?Other (Specify): FORMTEXT ?????f.What system of safeguards and controls does this institution have in place to detect and prevent improper financial activities (fraud) by employees? (Check all that apply)? This institution separates CACFP duties/responsibilities between two or more employees? Different employees are responsible for receipt and expenditure of funds? Checks used to pay CACFP expenditures require more than one employees’ signature ? An accountant prepares monthly reports and yearly income tax returns? Annual audits are performed ? Board reviews CACFP expenditures and gives approval prior to purchases being made? Board makes fiscal decisions for CACFP ? CACFP duties/responsibilities are rotated periodically within the institution? The institution takes periodic inventory of items purchased using CACFP funds ? Other (Specify): FORMTEXT ?????14.Indicate this institution’s system for maintaining appropriate records to document CACFP requirements. (All items in bold must be checked and add any other items that apply)? Records are maintained at: (Provide the address where CACFP records are maintained below)Provide the complete physical address where this institution’s CACFP records are maintained: FORMTEXT ?????? Records are maintained for three (3) years plus the current year ? Records are maintained in accordance with 7 C.F.R. §.226.15(e)? Copies of the following records are maintained at the center (records stated below)Attendance records, point of service meal counts, menus, documentation of all CACFP costs, medical documentation for special dietary needsIf applicable, enrollment forms, income eligibility applications (IEAs), provision of breastmilk or infant formula and solid foods form? Other (Specify): FORMTEXT ?????FACILITY LEVEL OPERATIONS15.In addition to maintaining menus to document compliance with 7 C.F.R. § 226.20; serving meals that include creditable foods for all required components in appropriate quantities; and modifying meals to meet individuals required dietary modifications and special needs. How will this institution ensure that this institution will provide meals that meet the meal patterns set forth in 7 C.F.R. § 226.20? (Check all that apply)?Consults “Food Buying Guide”?Consults “Crediting Foods in the CACFP”?Menus are reviewed by Institution to ensure compliance?Provides training on meal pattern requirements ?Other (Specify): FORMTEXT ?????16.By what method will this institution ensure that it will comply with licensure or approval requirements set forth in 7 CFR § 226.6(d) and §226.6(e)? (Check all that apply)?Institution is licensed or approved by county, state, or federal agency?This institution will comply with alternative approval requirements as set forth by the State agency (if licensing is NOT required)?Other (Specify): FORMTEXT ?????17.How does this Institution ensure that it will have a food service that complies with applicable state and local health and sanitation requirements? (Check all that apply)?Center staff practice sanitary measures while preparing and serving meals?Provide sanitation training?Semi-annual or annual inspections by local sanitation?Other (Specify): FORMTEXT ?????18.Indicate how this Institution will ensure it will comply with Civil Rights requirements. (All items in bold must be checked and check any other items that apply)?Offers the CACFP and serves meals to all enrolled participants regardless of race, color, sex, age, disability, or national origin?Includes the nondiscrimination statement and complaint procedures in advertisements when referencing admissions and/or the CACFP?“And Justice for All” poster is on display in a prominent location for public viewing ?Racial/Ethnic data is collected annually based on currently enrolled participants ?Other (Specify): FORMTEXT ?????19.Indicate how this institution will ensure it will maintain complete and appropriate records on file. (All items in bold must be checked and check any other items that apply)?Institution maintains records for the required time period to document all required items including, but not limited to application materials, minutes from board meeting, procurement actions, food cost documentation, and all records to support the claim for reimbursement (including menus, enrollment, attendance, meal counts, meal substitutions, income eligibility applications, and Title XIX or XX status)?Records are on file for the past three years, plus the current year or until audit exceptions are satisfied?Attends training provided by the State agency on recordkeeping requirements ?Other (Specify): FORMTEXT ?????20.Indicate how this institution will ensure that it will claim reimbursement only for eligible meals. (All items in bold must be checked and check any other items that apply)?Meal counts taken at the point of service?Reimbursement does not exceed two meals and one snack or one meal and two snacks per child per day ?Each participant claimed is enrolled and attending the institution ?A dated menu that meets meal pattern requirements is available for each meal claimed?Reimbursement is not claimed for meals served to participants more than the center’s authorized capacity?Only approved meal types are claimed?Meals are only claimed for participants that are within the regulatory age limits?Title XIX and/or XX status is verified monthly and claims are only submitted in the months in which the center’s title XIX or title XX status is met (** This is required for for-profit corporations only**)?Other (Specify): FORMTEXT ?????21.Indicate this institution’s procurement (purchasing) policy. (Check all that apply)?Micro-Purchase $3,500?Small purchase procedures $3,501-149,999.99?Sealed bids $150,000?Competitive proposals (requires prior written State agency approval) ?Noncompetitive negotiation or sole source procurement (requires prior written State agency approval)Supplemental Page 18. Please complete the chart below, indicating the person(s) responsible for each CACFP area requested.CACFP AreaName(s) of Person(s) ResponsibleTitleQualificationsHrs./WeekEnsuring Meal Pattern Requirements are Met FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Ensuring Income Eligibility Applications (IEAs) are accurately classified FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Ensuring Point of Service Meal Counts are Taken FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Ensuring Fiscal Management FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Maintaining Proper Records FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Satisfying Training Requirements FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Sanitation FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Satisfying Civil Rights Requirements FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Other: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????CERTIFICATION AND SIGNATUREThe representations made herein on behalf of the Institution are true and correct to the best of my knowledge. I understand that these representations are being made in connection with the receipt of federal funds and that deliberate misrepresentation may subject me to prosecution under applicable state and federal criminal statutes. I certify that neither this institution nor any of it principals is disqualified from participating in the CACFP. Signature on Behalf of Institution: Authorized RepresentativeDatePrinted Name ................
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