Administrative Review Summary Report

Date:  04-6-20

Name of Agency:  St. Mary's Catholic School

                                                                                               Date of off-site review: 01-14-20

Reviewer:  Matthew Smith                                               Date of on-site review: 03-06-20

Persons interviewed:  Jamie Gonzalez and                    Date of exit conference: 03-06-20

                                        Elizabeth Little

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

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

• Civil Rights: The School Food Authority (SFA) did not provide records of the last annual civil rights training that was conducted.  FNS Instruction 113-1 requires staff members who work with program applicants or participants to receive annual civil rights training.  Prior to the On-Site visit, this training was conducted and documentation was provided to the State Agency (SA) reviewer.
• Failure to Provide Records: The SFA failed to provide documentation [7 CFR Part 210.9 (b) (17)].  Prior to the completion of the On-Site portion of this AR the SFA provided the requested documentation.
• Resource Management:  The SFA failed to conduct the end of year revenue and expense report for school year 2018-2019 [7 CFR Part 210.14 (a), 7 CFR Part 210.14 (b), and 7 CFR Part 210.19 (a) (1)].  Prior to the completion of the On-Site portion of this AR the SFA provided a revenue and expense report for school year 2018-2019.

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

Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted January 14, 2020:

Local Wellness Policy: The St. Mary's Catholic School's (SMCS) local wellness policy needs to have the following added:

• Standards and guidelines for the marketing of food and beverages sold on campus during the school day as required by 7 CFR Part 210.31 (c) (3) (iii).

• A description for the measuring of the implementation of the policy as required by 7 CFR Part 210.10 (c) (6).
• A description of how and when the policy is to be assessed as required by 7 CFR Part 210.31 (c) (4) and 7 CFR Part 210.31 (e) (1).  Local wellness policies are required to be assessed at least once every three years [7 CFR Part 210.31 (e) (2)].
• The name and title of the person(s) designated to assess the SFA's local wellness policy and to ensure the policy's implementation.  It is recommended no more than two people assess the policy. This is required to meet the requirements under 7 CFR Part 210.31 (c) (4) and 7 CFR Part 210.31 (e) (1).

SMCS' web site has an old version of the local wellness policy posted on it.   7 CFR Part 210.31 (d) (2) requires SFAs to publicly post the most current version of their policy.  Two examples of how this can be done are: posting the policy on the SFA's web site, and, or posting the policy on a bulletin board that the public has access to.  

SMCS did not have their triennial wellness assessment report posted publicly as required by 7 CFR Part 210.31 (d) (2) and 7 CFR Part 210.31 (d) (3).  This requirement can be met by posting the triennial wellness assessment report on SMCS' website where the local wellness policy is posted.  

To demonstrate compliance with the local wellness policy:

• Add the following to the local wellness policy

• The name(s) of the person/people (no more than two) designated to assess the local wellness policy and to ensure the policy is implemented.
• Guidelines and standards for the marketing of food and beverages during the school day on campus.
• A description of the measurement of the implementation of the local wellness policy.
• A description of how and when the policy is to be assessed.

• Publicly post the updated local wellness policy, as well as the most recent triennial wellness assessment report.
• Provide a copy of the updated local wellness policy with the required changes listed above.
• Provide the above requested documentation along SMCS' plan for corrective action to demonstrate compliance and understanding.   

Meal Patterns:A review of 12/09/19 through 12/13/19 indicated some insufficient portion sizes at lunch. 

The lunch meal pattern 7 CFR 210.10 (c) requires the following minimum serving sizes for grades K-8; 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 (dark green subgroup ½ cup/week, red/orange subgroup ¾ cup/week, legumes subgroup ½ cup/per week, starchy subgroup ½ cup/week, and other subgroup ½ cup/week) 3 ¾ cups/week, and 1 cup fluid milk daily, 5 cups weekly, offered as a choice between 1% and fat free. 

Insufficient quantities

• The required weekly serving for the legume vegetable subgroup was not met.   No vegetables served during this week could be credited toward this subgroup.
• The required weekly serving of the bread/grain component was not met. Only 7.5 oz. could be credited toward this weekly serving.

The above insufficient serving sizes were determined to be non-systemic in nature.

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 that is served as part of a reimbursable meal. 

To demonstrate compliance with Meal Patterns:

• Review your 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 SMCS' plan for corrective action to demonstrate understanding and compliance.    

The SFA served non-creditable food item as part of the meal component.  During the menu assessment it was determined your school is serving a non-creditable items. In order for the items to be creditable they must contain a CN label or an acceptable production formulation statement, 7 CFR 210 Appendix C.  Crediting information for USDA commodities can be found on the commodity fact sheets available on the USDA website. The following items were identified as non-credible:

• The meatballs served with the lunch menu for 12/09/19.
• The chicken tenders served with the lunch menu for 12/10/19.
• The steak finger served with the lunch menu for 12/12/19.

Finding CN labeled products can be challenging. Remember; items similar to CN labeled products, but not the same, are not acceptable. Your ability to purchase food from suppliers with experience serving schools should allow your staff to obtain acceptable products. If all attempts fail and you are unable to obtain CN labels for the items you serve, your only choices are; discontinue serving the item or cook the item from scratch. When scratch cooking; we recommend using the USDA recipes because they will eliminate the planning needed when scratch cooking.

If a food is non-creditable and no other creditable foods are offered, the serving is considered insufficient.  The USDA now considers insufficient serving sizes to be "missing components". Finding of missing components on subsequent reviews will be considered reoccurring and our office may have to access fiscal action.

To demonstrate compliance with the CN label/product specification requirement:

• Obtain and provide a copy of the needed product formulation statements. Work with venders and sales representatives to obtain this documentation. 
• If product formulation statement(s) or CN labeling is not available, provide a copy of the replacement creditable item's labels.
• Provide SMCS' corrective action plan to demonstrate understanding and compliance.  

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted March 6, 2020:

Counting and Claiming: A review of the counting system demonstrates systemic counting errors for the review period (December 2019), which results in Performance Standard Violations I (PSI), 7 CFR Part 210.18 (g) (1) (ii). 

The errors appear to have occurred with the counts were entered into RenWeb from the point of service documents.  Errors occurred with the lunch, breakfast, and snack counts. 

Below are the differences identified in St. Mary's Catholic School's (SMCS) December lunch counts, when comparing the meal roster to the meals listed on the claim:

Free meals were over claimed by 26 meals, reduced priced meals were over claimed by 36 meals and paid meals were over claimed by 34 meals.

Below are the differences identified in SMCS' December school breakfast counts, when comparing the meal roster to the meals listed on the claim:

Free meals were over claimed by 24 meals and reduced priced meals were over claimed by 3 meals.

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

Free snacks were over claimed by 12 snacks and paid snacks were under claimed by 2 snacks.

7 CFR Part 210.8 (a) (2) requires each SFA to review their claims for accuracy prior to submitting them to the 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: SMCS' meal rosters for March 2020, SMCS' edit check forms, and the claim for March 2020.
• Provide the above copies, along with SMCS' corrective action plan to demonstrate understanding and compliance.

Eligibility Certification:  During review it was determined that one application was certified in error. The error resulted in one child receiving free meals when eligible for reduced price meals. The errors were due to miss-categorizing the households' income in the wrong benefits category (7 CFR Part 245.6). This error resulted in a Performance Standard I (PSI) Violations. 

During the On-Site portion of the AR the SFA the application with the error was brought to the SFA's attention.   7CFR Part 245.6 (c) (3) (iii) requires the SFA to send notification to the households in writing, and allow 10 calendar days for a possible hearing request.

The school-reviewing official must review each incoming application to ensure that the household submitted a complete application. If the application is complete, the official must then determine whether the household is categorically eligible or income eligible for benefits. It is recommended that someone come behind the determining official and double check the math and benefit category.  A space is provided on the application for a second person to sign off on the determination.

This is a Performance Standard 1 (PS 1) violation which requires fiscal action, 7 CFR Part 210.18 (g) (1).

To demonstrate compliance with eligibility certification requirements:

• Inform the households in writing of their change in benefits status, allow 10 days for a possible hearing request
• Once the 10 calendar day timeframe has past, change the benefits status from free to reduced meal eligibility.
• Provide copy of the letter sent, date changes were made and SMCS's written corrective action plan to demonstrate understanding and compliance.  

HACCP food safety plan: A required HACCP (Hazard Analysis Critical Control Points) food safety plan could not be found at the time of the On-Site visit [7 CFR Part 210.13 (c) requires each SFA to have a HACCP plan]. Your staff will need to develop and implement a comprehensive food safety plan. This process approach for preparing food must be used to
insure that foods are stored and prepared properly. The plan should include all the appropriate documentation forms for monitoring and review.

A HACCP plan template was emailed to SMCS on 03/06/20. This template contains everything needed to easily develop the missing plan. 

Keeping foods safe is a vital part of healthy eating.  When properly implemented, HACCP-based food safety programs help to ensure the safety of all meals.  Agencies must routinely monitor and document food safety procedures. 

To demonstrate compliance with HACCP food safety requirements:

• Use the sample HACCP plan provided as a guide and develop your plan.
• Provide a copy of your HACCP plan's cover sheet, along with your corrective action plan to demonstrate understanding and compliance. 

Procurement Review Summary Report

 

Date:  04-6-20

Name of Agency:  St. Mary's Catholic School

                                                                                                    Date of AR off-site review: 01-14-20

Reviewer:  Matthew Smith                                                    Date of AR on-site review: 03-06-20

Persons interviewed:  Jamie Gonzalez and                         Date of exit conference: 03-06-20
                                       Elizabeth Little 

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

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

• Code of Conduct: The code of conduct provided had the former principal's name listed as being the person responsible for interpreting the code.  Prior to the completion of the AR On-Site the SFA provided an updated code of conduct without the former principal's name listed.
• Failure to Provide Records:The SFA failed to provide documentation [as required by their agreement with State Agency (SA) and 7 CFR Part 210.9 (b) (17).  Prior to the completion of the On-Site the SFA provided a list of their vendors.
• Procurement Plan: The procurement plan provided at the time of the AR Off-Site visit did not address the performance of a price analysis for every procurement conducted in excess of the simplified acquisition threshold ($150,000 set by the SFA's plan) including contract modifications as required by 2 CFR Part 200.323 (a).  Prior to the completion of the AR On-Site the SFA took corrective action by adopting a plan that addressed this finding.

Corrective action for the above was made during the PR.  No further action is required for the above.

There were no additional findings regarding the procurement review.