Date:  01-24-22

Name of Agency:  Positive Tomorrows                                                    Date of off-site review: 11-04-21

Reviewer:  Matthew Smith                                                                      Date of on-site review: 12-09-21

 

Persons interviewed:  Senaqua Hildreth                                                 Date of exit conference: 01-18-22
                               

This School Food Authority (SFA) operates the National School Lunch Program, the School Breakfast Program, and the After School Snack Program.

The following areas were corrected prior to the On-Site Portion of this Administrative Review (AR):

• Professional Standards – Training Tracking:  At the beginning of this AR, Positive Tomorrows was not using a State Agency (SA) approved training tracking tool to track training for employees with duties within their school food services program [USDA Memo SP 39-2015].  Prior to the completion of the off-site portion of this AR the SFA began using a SA approved training tracking tool.

• Whole Grain-Rich (WGR):  For the menu week of breakfast and lunch menus assessed (10/25/21 – 10/29/21), Positive Tomorrows did not meet the 100% WGR requirement for bread/grain products served with breakfast and lunch [7 CFR Part 210.10 (c) (2) (iv) and 7 CFR Part 220.8 (c) (2) (iv)].  Prior to the completion of the on-site portion of this AR, Positive Tomorrows opted into a nationwide COVID-19 waiver permitting at least half of the weekly serving being WGR.  This brought the menu week of breakfast and lunch menus into compliance with the meal patterns.

 

Prior to the completion of the On-Site portion or the AR, corrective actions for the above finding were completed.  No further action is required for the above. 

Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted November 4, 2021:

Buy American Provision: During the lunch menu week assessment (10/25/21 through 10/29/21), we discovered non-domestically produced food products. Federal regulation [7 CFR Part 210.21 (d)] requires School Food Authorities (SFA) when possible to buy domestically produced food products. Limited exceptions to the requirements to procure domestically produced food products are permitted. USDA memo SP 24-2016 documents the following exceptions to this requirement:

• The food product is not produced or manufactured within the United States
• The food product is not produced or manufactured domestically in sufficient quantities.
• The food product is not produced or manufactured domestically in satisfactory quality.
• The costs of domestically produced or manufactured food products are significantly higher in cost than non-domestic products.

We discovered the following non-domestically produced food products during the menu week assessment conducted as part of this AR:

• The Capri vegetable product served with the menu on 10/25/21 was a product of Canada and the United States.
• The mixed fruit cup served with the menu on 10/26/21 was a product of Thailand.
• The cherry mixed fruit cup served with the menu on 10/29/21 was a product of Thailand.

Positive Tomorrows did not have documentation justifying the use of these nondomestic products under one of the permitted exceptions. SFAs should work with their vendors to ensure the food products used in your school food services program are compliant with the Buy American Provision. When a SFA determines it is necessary to use one of the permitted exceptions, the SFA must ensure documentation is kept to justify its use.

 

To demonstrate compliance with the Buy American Provision:

• Review the food products used in your school food services program for compliance with the Buy American Provision.
• Provide Positive Tomorrows’ corrective action plan to demonstrate understanding and compliance.
   

Civil Rights – Data on Race and Ethnicity:  It was determined during the AR off-site portion; Positive Tomorrows was not gathering data on students’ ethnicity and race using a two-question format.  The USDA requires [FNS Instruction 113-1] SFAs gather data on students’ ethnicity and race using a two-question format.  One question gathers data on the students’ ethnicity.  The USDA defines ethnicity as Hispanic or non-Hispanic.  The second question gathers data on the students’ race.  The USDA has defines race as the following:

• American or Alaskan Native
• Asian
• Black or African American
• Native Hawaiian or Other Pacific Islander
• White

To demonstrate compliance with civil rights requirements for gathering data on ethnicity and race:

• Update Positive Tomorrows’ benefit issuance document to use the required two-question format to gather data on ethnicity and race.
• Provide an updated copy of the benefit issuance document, as well as Positive Tomorrows’ corrective action plan to demonstrate understanding and compliance.

Civil Rights – Written Procedure for Handling Civil Rights Complaints:  The procedure for handling civil rights complaints has incorrect USDA contact information for where to send civil rights complaints [FNS Instruction 113-1].  The current contact information for the USDA on where to send civil rights complaints is:

U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410, or faxed to (202) 690-7442 or emailed to program.intake@usda.gov. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339: additionally, program information may be made available in languages other than English.

To demonstrate compliance with civil rights complaints for the written procedure for handling civil rights complaints:

• Update Positive Tomorrows’ current written procedure for handling civil rights complaints.
• Provide a copy of the updated written procedure for handling civil rights complaints, as well as Positive Tomorrows’ corrective action plan to demonstrate understanding and compliance.

Meal Patterns:  During the week of breakfast and lunch menus (10/25/21 through 10/29/21) assessed as part of this review insufficient daily serving sizes were discovered.

The breakfast meal pattern 7 CFR Part 220.8 (c) requires the following minimum serving sizes for grades 9-12:

• 1 oz. by weight bread/grain daily and 8-10 oz. per week
• 1 cup of fruit daily and 5 cups per week
• 1 cup of fluid milk daily, 5 cups per week, offered as a choice between 1% (unflavored) and fat free (flavored or unflavored).  Two varieties must be offered daily.

Insufficient Quantities

• The menu served on 10/26/21 had an insufficient serving for the required daily bread/grain serving.  The pastry served with this menu only credited 0.75 oz. toward this required daily serving.

The lunch meal pattern 7 CFR 210.10 (c) requires the following minimum serving sizes for the grades K-8 meal pattern:

• 1 oz. by weight meat/meat alternate daily and 9-10 oz. per week
• 1 oz. by weight bread/grain daily and 8-9 oz. per week
• ½ cup fruit daily and 2 ½ cups per week
• ¾ cup vegetables daily, 2 ½ cups per week

Vegetable Subgroup Services:

• Dark green subgroup ½ cup/week
• Red/orange subgroup ¾ cup/week
• Legumes subgroup ½ cup/per week
• Starchy subgroup ½ cup/week
• Other subgroup ½ cup/week

o   1 cup fluid milk daily, 5 cups weekly, offered as a choice between 1% (unflavored) and fat free (flavored or unflavored).  Two varieties must be offered daily.

 

Insufficient Quantities

• No vegetables, for the dark green vegetable subgroup, during the week of 10/25/21 through 19/29/21 were served that could credit toward the weekly serving.  This insufficient vegetable subgroup serving for the dark green vegetables was determined to be a first violation.

The State Agency (SA) is exercising its discretion to not apply fiscal action for the above insufficient quantities as allowed for under 7 CFR Part 210.18 (g) (2).

It is very important for your staff to carefully review planned menus, product labels and recipes to ensure, the meal pattern requirements are met for every meal claimed for reimbursement. It is critical that your staff document everything served as part of a reimbursable meal.

To demonstrate compliance with Meal Patterns:

• Review menus for compliance with the meal patterns for grades K-8.
• Bring all insufficient serving sizes and missing components in compliance with the meal patterns for grades K-8.
• Submit Positive Tomorrows’ plan for corrective action to demonstrate understanding and compliance.    

 

Professional Standards – Annual Training Hours:  Records and documentation of training completed during school year 2020 – 2021 were not kept for employees with duties within Positive Tomorrows’ school food services program.  Federal regulation [7 CFR Part 210.30 (g)] requires SFAs to document compliance with the annual training requirements.  This required documentation will demonstrate compliance with the training requirements documented in 7 CFR Part 210.30 (b) (3), 7 CFR Part 210.30 (c), 7 CFR Part 210.30 (d), and 7 CFR Part 210.30 (e).

The following are the training requirements documented in the preceding regulations:

       *Your SFA may not have all the job categories listed above.  All SFA’s have a director.

The above training requirements must be completed every school year (July 1^st to June 30).  

Trainings that can be credited toward the professional standards annual training requirements include [7 CFR Part 210.30 (b) (3), 7 CFR Part 210.30 (c), and 7 CFR Part 210.30 (d)]:

• Meal counting and the reimbursement claim procedures
• Identification of reimbursable meals at the point of service
• Annual civil rights training
• Nutrition
• Health and safety standards

To demonstrate compliance with professional standard requirements:

• Provide Positive Tomorrows’ plan for corrective action to demonstrate understanding and compliance.

 

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted December 9, 2021:

Afterschool Snack Program – Meal Pattern:  During the review of five consecutive days’ worth of production records for the Afterschool Snack Program (11/29/21 through 12/03/21), insufficient servings were discovered and a non-creditable item was served.  Federal regulation [7 CFR Part 210.10 (o) (2)] has the following meal pattern for the Afterschool Snack Program for children ages 6 – 18:

•  Serve two of the following (must be from two different components):
  • Milk – Low-fat (1% or less, unflavored only) or fat free (flavored or unflavored) – 1 cup
  • Vegetables and Fruits – ¾ cup
  • Grains and Breads – 1 oz.
  • Meat/Meat Alternative – 1 oz.

The review discovered the following snack insufficient servings:

• For the snacks served on 11/30/21 and 12/02/21, the 100% fruit juice boxes served credited at ½ cup toward the fruit serving for the snack.

Positive Tomorrows served the following items that were non-creditable:

• The corndogs served with the snack on 11/29/21 were a non-creditable product.
• The pizza pockets served with the snack on 12/02/21 were also a non-creditable product. 

In order for these products to be creditable for the Afterschool Snack Program they would have to have a Child Nutrition (CN) label or a product formulation statement from the manufacturer [as required by federal regulation Appendix C to 7 CFR Part 210].  These products will have to be replaced with items that can be credited toward the Afterschool Snack Program.

To demonstrate compliance with Afterschool Snack – Meal Pattern requirements:

• Review snack menus for compliance with the Afterschool Snack Program meal pattern for ages 6 – 18 years old.
• Bring all insufficient serving sizes into compliance with the Afterschool Snack Program for ages 6 -18 years old.
• Replace the non-creditable items served with the snacks menus serve on 11/29/21 and 12/02/21 with a creditable items.
• Provide Positive Tomorrows’ plan for corrective action to demonstrate understanding and compliance.

Counting and Claiming: A review of the counting system demonstrates non-systemic counting and claiming errors for the review period (October of 2021), which results in a Performance Standard I violation (PSI), 7 CFR Part 210.18 (g) (1) (ii).  Errors were discovered for breakfast and lunch monthly counts for October of 2021. 

The errors resulted from the manual daily counts for four days (10/05/21, 10/08/21, 10/22/21, and 10/27/21).  This caused an over claim lunch meals for the month of October.  These errors were determined to be non-systemic in nature.

Below are the differences, our reviewer identified, in your October Lunch counts, when comparing the meal roster to the meals listed on your agency’s claim:

Free lunch meals were over claimed by 18 meals.

The errors for October’s breakfast monthly meal counts resulted from the manual daily counts for three days (10/06/21, 10/07/21, and 10/19/21).  This caused Positive Tomorrows to under claim lunch meals for the month of October.  These errors were determined to be non-systemic in nature.

Below are the differences, our reviewer identified, in your October breakfast counts, when comparing the meal roster to the meals listed on your agency’s claim:

Free breakfast meals were under claimed by nine meals.

7 CFR Part 210.8 (a) (2) requires each SFA to review their claims for accuracy prior to submitting them to the State Agency (SA).

To demonstrate compliance with counting and claiming:

• Review the counting and claiming system and create a plan to insure accurate daily meal counts are taken and recorded.
• Provide copies of the following: meal rosters for January 2022, edit check forms for January 2022.
• Provide the above copies, along with Positive Tomorrows’ corrective action plan to demonstrate understanding and compliance.   

Reviewer’s Comments:  I want to thank Positive Tomorrows staff members who work with the school food service program for their assistance with the reviews, as well as to commend them for a job well done. Keep up the good work!

Date:  01-24-22

Name of Agency:  Positive Tomorrows                                    Date of AR off-site review: 11-04-21

Reviewer:  Matthew Smith                                                       Date of AR on-site review: 12-09-21

Persons interviewed:  Senaqua Hildreth                                 Date of exit conference: 01-18-22

                                               

This School Food Authority (SFA) operates the National School Lunch Program, the School Breakfast Program, and the After School Snack Program.

The following areas were corrected during the Procurement Review (PR):

• Code of Conduct:  At the time of the Administrative Review (AR), off-site visit, Positive Tomorrows could not locate their code of conduct [2 CFR 200.318 (c) (1), 7 CFR Part 210.21 (c), 7 CFR Part 220.16 (c), and 7 CFR Part 3016.36 (3) (i-iv)].  Prior to the completion of the on-site portion of the AR, Positive Tomorrows took corrective action adopting a new code of conduct.
• Procurement Plan:  The procurement plan provided during the off-site portion of the AR had positions listed in the plan that no longer had responsibility for procurement for Positive Tomorrows’ school food services program [7 CFR Part 210.21(c) and 7 CFR Part 220.16 (c), 7 CFR Part 210.21(c), and 7 CFR Part 220.16 (c)].  Prior to the completion of the on-site portion of the AR, Positive Tomorrows took corrective action adopting a revised procurement plan.

Corrective actions were made prior to the completion to the On-Site portion of this AR.  No further action is required for the above.

Buy American Provision: During the lunch menu week assessment (10/25/21 through 10/29/21) conducted as part of the AR, food products were discovered that were not domestically produced. Federal regulation [7 CFR Part 210.21 (d)] requires SFAs when possible to buy domestically produced food products. Limited exceptions to the requirements are permitted. USDA memo SP 24-2016 documents the following exceptions to this requirement:

• The food product is not produced or manufactured within the United States
• The food product is not produced or manufactured domestically in sufficient quantities.
• The food product is not produced or manufactured domestically in satisfactory quality.
• The costs of domestically produced or manufactured food products are significantly higher in cost than non-domestic products. The following food products were discovered during the menu week assessment conducted as part of this AR that were not produced or manufactured domestically:

• The Capri vegetable product served with the menu on 10/25/21, was a product of Canada and the United States.
• The mixed fruit cup served with the menu on 10/26/21, was a product of Thailand.
• The cherry mixed fruit cup served with the menu on 10/29/21, was a product of Thailand.

Positive Tomorrows did not have documentation justifying the use of these nondomestic products under one of the permitted exceptions. SFAs should work with their vendors to ensure the food products used in your school food services program are compliant with the Buy American Provision. When a SFA determines it is necessary to use one of the permitted exceptions, the SFA must ensure documentation is kept to justify its use.

 

To demonstrate compliance with the Buy American Provision:

• Review the food products used in your school food services program for compliance with the Buy American Provision.
• Provide Positive Tomorrows’ corrective action plan to demonstrate understanding and compliance.