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Facility Review Averaging

This Management Bulletin provides direction to sponsoring organizations for implementing facility review averaging. Sponsoring organizations must review each sponsored facility three times every year. The Second Interim Rule permits sponsors to conduct what is termed "review averaging" in meeting their monitoring requirements.

The review averaging requirements are:

1. If a sponsor conducts two unannounced reviews (one review during a meal service) of a facility in a year and finds no serious deficiencies, the sponsor may choose not to conduct a third review that year, provided that the sponsor conducts an average of three reviews of all of its facilities that year.
2. When the sponsor uses this averaging provision, and a specific facility receives two reviews in one review year, its first review in the next year must occur no more than nine months after the previous review.
3. Sponsors may not review a facility fewer than three times per year if the facility has submitted a block claim during the year.

The United States Department of Agriculture provided guidance for sponsoring organizations to assist them in their implementation of review averaging. Specifically, prior to implementing review averaging, sponsors are required to develop a written Review Averaging Plan that includes a Profile Chart and a Review Plan as follows:

1. Profile Chart
   The Profile Chart needs to include the following information:

• The fiscal year;
• All sponsored facilities by name or some other indicator;
• The sponsored facility's start date with the sponsor;
• If the facilities have been with the sponsor less than 12 months;
• If the facilities have been with the sponsor more than 12 months, but less than 24 months;
• Date of serious deficiency, if applicable; and,
• Other comments, such as minor problems, many problems, etc.
  

2. Review Plan
   The Review Plan needs to include the following information:

• The fiscal year;
• All sponsored facilities by name or some other indicator;
• The months of the year;
• Announced reviews;
• Unannounced reviews with no meal service;
• Unannounced reviews with meal service;
• Total number of reviews by month;
• Total number of reviews year to date;
• Total number of unannounced reviews;
• Total number of unannounced reviews with no meal service; and,
• Total number of unannounced reviews with meal service.
  
  

Sponsors are required to revise review plans as needed to ensure regulatory requirements are met. Completed Review Averaging Plans must be made available for State reviews.

Attachments

1. Sample Profile Chart
2. Sample Review Plan
3. Sample Revised Review Plan