/ Request for Waiver
HOME DELIVERED MEALS
Texas Department of Aging and Disability Services / Form / HDW
Aug 2008
Original Waiver Request
Waiver Amendment Request
Provider Name:
Address: / City: / State: / ZIP:
Federal Fiscal Year
Contract Period: / Proposed Waiver Implementation Date: / Funding Source: / Title III / Title XIX / Title XX
to / (Check all that apply)
Check if Common Provider:
Area Agency on Aging: / Definition – Common providers are those providers who contract with both DADS, to provide Title XX meals, and a AAA, to provide Older Americans Act Title III eligible home-delivered meals, to eligible individuals.
Name of Director:
Telephone Number:
LTSS Contract Number:
DADS Contract Manager:
Telephone Number:
Waiver Requested: / To serve hot meals only less than 5 days per week. No other meals provided.
(Check only one) / To serve hot meals in combination with frozen, chilled, shelf-stable or other meals.
To serve frozen, chilled, shelf-stable or other meals only. No hot meals provided.
To serve frozen, chilled, shelf-stable or other meals to a limited number of Title XIX or Title XX consumers, as approved by the Department’s case manager.
Number of individuals to be served under this waiver on the implementation date: / Maximum number of individuals to be served underthis waiver during the respective federal fiscal year:
Location of Meal Prep Site - / City: / County:
1. Describe the area(s) or delivery route(s) that will be affected by this proposed waiver. Include information such as the city and county (or portion thereof), distance from meal preparation site to distribution point(s) or route(s), or other geographically identifying information that supports the need for this proposed waiver.
2. Describe the circumstances necessitating this request for waiver.
3. Describe the pattern and type of meal delivery under this proposed waiver by including, at a minimum, the following information:
A. How frequently will a hot meal be delivered to each individual at their home?
B. For days when a hot meal will not be provided, what type of alternate meal (frozen, chilled, shelf-stable) will be delivered?
C. How many alternate meals will be provided to the individual each time a home delivery is made?
4. If one or more individuals are unable to safely store and prepare a frozen or shelf-stable meal in the area covered by this proposed waiver, describe the project’s plan to continue service to those individuals.
5. How will the provider notify each individual of the change in the pattern and type of meals to be served? Notification to each individual in the area affected by this proposed waiver must occur at least thirty (30) calendar days before initiation of the modified meal delivery schedule, unless otherwise requested by the provider and approved by the Department of Aging and Disability Services.
6. If delivery of a meal will occur less frequently than every other day, describe the provider’s method(s) for regularly scheduled contact with individuals receiving alternate meals. This description must illustrate how significant changes in the meal participant’s physical or mental condition and environment are reported, investigated and appropriate action is implemented within one (1) business day following identification of the change.
Assurances:
By submitting this waiver request to the Texas Department of Aging and Disability Services (DADS), Access and Intake Division, the entity requesting this waiver assures:
  1. When a provider contracts with both an Area Agency on Aging (AAA) and Long Term Services and Supports (LTSS) for the home delivery of meals, a waiver request has been submitted to both divisions of DADS Access and Intake.
  2. All parties will be informed of the approval or denial of the Waiver request(s) on a timely basis.
  3. The home delivered meals provider has established policies and/or procedures to ensure:
  4. Individuals eligible to receive home delivered meals are not denied services on the basis of the individual’s inability to safely store and prepare a frozen or shelf stable meal.
  5. Significant changes in an individual’s physical or mental condition or environment are reported in accordance with 40 TAC §§55.29 and 4.5(q)(4).
  6. The provider and every individual affected by the waiver has sanitary and safe conditions for storage, thawing, and preparation of the meal (40 TAC §§55.21(1) and 84.5(n)(1)).
  7. The meal can be safely handled by every individual affected by the waiver, or by another available person if the individual is unable to do so (40 TAC §§55.21(2) and 84.5(n)(2)).
  8. All frozen meals are safely packaged and transported (40 TAC §§55.23 and 84.5(o)) by the provider.
  9. Compliance with 25 TAC 229, Subchapter K, Texas Food Establishments Rules, Texas Department of State Health Services, to ensure all potentially hazardous foods are: properly frozen and stored (25 TAC §229.164(l) and (o)); prepared, stored, and clearly marked using calendar dates (25 TAC §229.164(o)(6)); cooled quickly within two hours to 70 degrees Fahrenheit, and to 41 degrees Fahrenheit in an additional four hours, not to exceed a total of six hours (25 TAC §229.164(o)(4)(A) and (B)); and remain frozen until ready for the thawing or cooking process (25 TAC §229.164(o)(1)-(3)).
  10. An annual waiver request(s) will be submitted to DADS for providers planning to continue serving hot meals less than five days per week at least sixty (60) days prior to the end of the federal fiscal year (September 30).
  11. An amended waiver request will be submitted to DADS prior to the end of the federal fiscal year for which a waiver has been granted when:
  12. The provider exceeds or projects to exceed the maximum number of individuals to be served as described in this proposed waiver, or
  13. The geographic service delivery area will be expanded during the contract period.
  14. In the event an individual becomes ineligible for the home delivered meals program for any reason (i.e., loss of eligibility, relocation, nursing home placement, death) and the provider has requested payment for meals delivered past the date of the consumer’s ineligibility, the provider will reimburse the AAA or DADS for all such meals for which it has received payment.