ATTACHMENT C: NCDAAS CLIENT RECORD REVIEW AND UNIT VERIFICATION WORKSHEET Page of CONGREGATE NUTRITION NSIP ONLY – DATE OF ASSESSMENT__________________ AGENCY__________________________________ AND YEAR REVIEWED_________________________________ Reviewer should select a random sample of clients from each Site/Route/Worker Code and include one or more special eligibility clients (if any). Attach to this worksheet the Units of Service Verification Report used to select the sample of clients and units. Identify on this report the persons sampled and the month(s) reviewed. Also attach copies of other worksheets, such as copies of the ZGA-903 or comparable document. List on the reverse side of this worksheet the clients and specific dates for which units could not be verified, if applicable. Provide a copy to the agency during the exit interview of both of this completed worksheet if unverified units are found. Eligible client? CRF Date of DOA-101 updated # units If special eligibility, most CRF is at least to be S/R/W state documentation recent complete every 12 # units # units adjusted CLIENT NAME Code reviewed. CRF? ? months? reported verified in ARMS UNITS NOT VERIFIED = THIS REPRESENTS % OF TOTAL UNITS REPORTED FOR THE MONTH Total units reported for all clients in month reviewed = REVIEWED. If 10% or more, expand sample and select another month to review. Signature of reviewer(s) Date________________________
ATTACHMENT C: NCDAAS CLIENT RECORD REVIEW AND UNIT VERIFICATION WORKSHEET Page of CONGREGATE NUTRITION – NSIP ONLY DATE OF ASSESSMENT__________________ AGENCY__________________________________ AND YEAR REVIEWED_________________________________ Reviewer should select a random sample of clients from each Site/Route/Worker Code and include one or more special eligibility clients (if any). Attach to this worksheet the Units of Service Verification Report used to select the sample of clients and units. Identify on this report the persons sampled and the month(s) reviewed. Also attach copies of other worksheets, such as copies of the ZGA-903 or comparable document. List on the reverse side of this worksheet the clients and specific dates for which units could not be verified, if applicable. Provide a copy to the agency during the exit interview of both of this completed worksheet if unverified units are found. CLIENT NAME S/R/W Code Eligible client? If special eligibility, state documentation reviewed. Date of most recent CRF? DOA-101 CRF is complete ? CRF updated at least every 12 months? # units reported # units verified # units to be adjusted in ARMS UNITS NOT VERIFIED = Total units reported for all clients in month reviewed = THIS REPRESENTS % OF TOTAL UNITS REPORTED FOR THE MONTH REVIEWED. If 10% or more, expand sample and select another month to review. Signature of reviewer(s) Date________________________
Nutrition_MonitoringToolae-i_0.docx