Administrative Review Summary Report

Date:  10-31-19

Name of Agency:  Bethesda Family Services Foundation

                                                                                                    Date of off-site review: 09-11-19

Reviewer:  Matthew Smith                                                    Date of on-site review: 10-22-19

Persons interviewed:  John Permantier                               Date of exit conference: 10-22-19

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

Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted September 11, 2019:

Local Wellness Policy:  The SFA's local wellness policy that was provided at the time of the Off-Site visit needs to have the following added:

• Guidelines and standards for all food and beverages sold on campus during school hours (school day is defined as 12:00 am to 30 minutes after school is dismissed) as required by 7 CFR Part 210.31 (3) (iii).  Even though your agency does not sell food and beverages you are still required to have guidelines.   The following is an example of language used to meet this requirement:
•  "The administration will ensure only foods meeting the Smart Snack standards will be marketed during the school day. Marketing of non-compliant food will not be permitted during the school day."
• A list of the members of the local wellness committee [7 CFR Part 210.31 (c) (5) and 7 CFR Part 210.31 (d) (1)].  Local wellness policies must document the committee membership within the policy.  The committee membership can be listed in a separate section within the policy, or simply listed at the bottom of the policy.  There is not a required format so long as the committee membership is listed within the policy.

The local wellness policy provided at the time of the Off-Site had not been assessed and updated since February of 2016.  7 CFR Part 210.31 (e) (2) requires local wellness polices to be assessed at least once every three years.    USDA Memo SP24-2017 requires School Food Authorities (SFA) to document the assessment and update to local wellness policies using a triennial wellness assessment report.  The triennial wellness assessment report is required to be posted publicly [7 CFR Part 210.31 (e)].  It is recommended the triennial wellness policy be posted publicly with the local wellness policy.

To demonstrate compliance with the local wellness policy:

• Add the following to the local wellness policy:
• Guidelines and standards for food and beverages sold on campus.
• List the members of the local wellness policy in the policy.
• Assess and update the local wellness policy.
• Provide a copy of the triennial wellness assessment report for the most recent assessment and update to the policy.
• Provide a copy of the updated local wellness policy with the required changes listed above.
• Publicly post the updated local wellness policy and the triennial wellness assessment report.
• Provide the above requested documentation along with a plan for corrective action to demonstrate compliance and understanding.

Meal Patterns:During a review of the menu week records of 08/10/19 through 08/16/19, conducted as part of this Administrative Review, indicated some insufficient portion sizes at both breakfast and lunch.


The breakfast meal pattern requires the following minimum serving sizes; 1oz. by weight bread/grain daily and 12.5-14 oz. per week, 1 cup Fruit, and 1 cup fluid milk, offered as a choice between 1% and fat free.   No more than 50% of the fruit components for a menu week can be met with 100% fruit juice [7 CFR Part 220.8 (c)].

Insufficient quantities

• On 08/16/19, the meal had an entrée that only credited at 0.25 oz. toward the bread/grain required daily serving size.
• During the week all of the required weekly fruit serving size was met by serving 100% fruit juice. 

The lunch meal pattern requires the following minimum serving sizes; 2 oz. by weight meat/meat alternate daily and 10-12 oz. per week, 2oz. by weight bread/grain daily and 10-12 oz. per week, 1 cup fruit daily and 5 cups per week, 1 cup vegetables daily (dark green subgroup ½ cup/week, red/orange subgroup 1 ¼ cup/week, legumes subgroup ½ cup/per week, starchy subgroup ½ cup/week, and other subgroup ¾ cup/week) 5 cups/week, and 1 cup fluid milk, offered as a choice between 1% and fat free [7 CFR Part 210.10 (c)]. 

Insufficient quantities

• On 08/10/19, the meal was served with an entrée that only credited 1.5 oz. toward the meat/meat alternative component.

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. 

To demonstrate compliance with Meal Patterns:

• Review menus for compliance with the meal patterns for grades 9-12.
• Bring all insufficient serving sizes in compliance with the meal patterns with grades 9-12.
• Submit a plan for corrective action to demonstrate understanding and compliance.    

Professional Standards:  During the Off-Site portion of this review it was discovered a few staff members did not complete their annual training hours for school year 2018-2019.  The following are the training requirements contained in 7 CFR Part 210.30 (b) (3), 7 CFR Part 210.30 (c), and 7 CFR Part 210.30 (d):

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

The director of school nutrition programs for the SFA was one hour short of meeting the required 12 hours for school year 2018-2019.

There was one full time employee with duties in the SFA's school nutrition programs who did not complete six hours of training during school year 2018-2019.  The employee completed three hours of training during school year 2018-2019. 

One part time employee with duties in the SFA's school nutrition programs who did not complete four hours of training during school year 2018-2019.  This employee only completed three hours of training during school year 2018-2019.

To demonstrate compliance with Professional Standards: 

• Submit a plan for corrective action to demonstrate understanding and compliance.

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted October 22, 2019:

Counting and Claiming: A review of the counting system demonstrates non-systemic counting errors for the review period (August 2019) as well as for the Afterschool Snack review period (August 2019), which results in a Performance Standard Violation I (PSI), 7 CFR Part 210.18 (g) (1) (ii).   

The errors for the lunch meal counts were due to addition errors when adding the meal counts up for the month due to the use of a paper based edit check.  This caused an under claim for lunch meals. 

Below are the differences identified in Bethesda Family Services Foundation (BFSF) August lunch counts, when comparing the meal roster to the meals listed on the claim:

Free meals were under claimed by 13 meals.

The errors with the snack meal counts appears to be due to BFSF claiming snacks on days when school was not in session after the school year began (on weekend days).  This caused an over claim of snacks for the month of August.

Below are the differences identified in BFSF's August Afterschool Snack Program counts, when comparing the meal roster to the meals listed on the claim:

Free snacks were over claimed by 42 snacks.

At the time of the On-Site portion of this AR the State Agency (SA) Reviewer strongly recommended BFSF use the electronic edit check.   Technical assistance was given on how to use the electronic edit check to reduce human errors during the consolidation of BFSF's meal counts for inclusion in the monthly claim.  

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

These are serious, systemic errors in the counting and claiming system. They result in Performance Standard 1 Violations and require fiscal action.

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.
• Begin using the electronic edit check daily to record meal counts instead of using paper based edit check.
• Provide copies of the following: your agency's meal rosters for November 2019, your agency's edit check forms, and the claim for November 2019.
• Provide the above copies, along with your corrective action plan to demonstrate understanding and compliance.

Health Inspections:  During school year 2018-2019, BFSF failed to request a second health inspection.   7 CFR Part 210.13 (b) requires School Food Authorities (SFA) to receive at least two health inspections during the school year. If two are not received during a school year the SFA must call their local health department and request a second inspection.  The SFA must document their local health department's response if they decline to conduct the second health inspection.

To demonstrate compliance with health inspection requirements:

• Provide BFSF's corrective action plan to demonstrate understanding and compliance with health inspection requirements.

Reviewer's Comments:  The staff members with duties within BFSF's school nutrition programs are doing a good job.  I want to encourage BFSF to contact our office as questions regarding school nutrition programs come up.  Keep up the good work.

Procurement Review Summary Report

Date:  10-31-19

Name of Agency:  Bethesda Family Services Foundation

                                                                                                    Date of AR off-site review: 09-11-19

Reviewer:  Matthew Smith                                                    Date of AR on-site review: 10-22-19

Persons interviewed:  John Permantier                               Date of exit conference: 10-22-19

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

There were no findings for the procurement review.

Reviewer's Comments:  Bethesda Family Services Foundation is doing a good job with being compliant with procurement regulations.