Administrative Review Summary Report

Date: 04-24-19

Name of Agency: Tulsa Adventist Academy

Date of off-site review: 02-21-19

Reviewer: Matthew Smith Date of on-site review: 03/28/19 and

04-04-19

Persons interviewed: Jennifer Cross Date of exit conference: 10-20-19

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

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

Meal Patterns: During the menu week assessment for the lunch menus for the week of 01/07/19—01/10/19, systemic insufficient serving sizes were discovered. The USDA considers SFAs with these types of systemic errors high-risk, triggering a nutrient analysis for the menu week [7 CFR Part 210.18 (g) (2) (ii)]. Prior to the nutrient analysis the SFA took corrective action for all issues of non-compliance found during the week [7CFR Part 210.10 (c)]. Due to the violations described above; our office has no choice but to remove the 6 cents, per lunch, performance-based reimbursement, beginning with March's claim [as required by 7 CFR Part 210.18 (g) and the Administrative Review Manual].
Nutrient Analysis triggered and Dietary Specifications not met. A nutrient analysis was completed for grades K-5, 6-8, and 9-12.

The average calories for the week were exceeded for all grade levels [K-5 722 average calories, 6-8 725, and 9-12 998 average calories, 7 CFR Part 210.10 (f) (1)]. The average saturated fat percentage exceeded the requirement for <10% [K-5 12.22%, 6-8 12.39%, and 9-12 12.90%, 7 CFR Part 210.10 (f) (2)].

Prior to the conclusion of the On-Site portion of this AR the SFA took corrective action that reduced the average calories and saturated fat percentages for all grades for the week analyzed.

The School served non-creditable food items as part of the meal component. During the menu week assessment it was determined the school was serving a non-creditable hummus (7 CFR Part 210 Appendix C). Prior to the On-Site portion of this AR the school replaced the hummus with a creditable item (cottage cheese).
Resource Management Findings:

Cash resources exceed three months' average operating costs [7 CFR Part 210.14 (b)]. In the summer of 2018, the SFA spent down the excess on kitchen equipment repairs and on food for the beginning of the school year.

Adult meal pricing: During the Off-Site portion of this AR it was discovered the SFA was not charging enough for adult meals. SFAs must charge adults an amount at least equal to the reimbursement for a free meal and the value of USDA donated food [7 CFR Part 210.14 (e) (6) (iii) (2) (i) and (ii)]. Prior to the conclusion of the On-Site portion of this AR the SFA raised their adult meal price (to $3.65 on 03/01/19) enough to meet the meal pricing requirement.

Corrective action for the above was made prior to the conclusion of 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 February 21, 2019:

Civil Rights: During the Off-Site portion of the review it was determined the SFA was not complying with the USDA's Civil Rights requirements.

The SFA's public release was done through a post on their Facebook page. The post on Facebook just notified the public of their participation in the National School Lunch Program (NSLP). This attempted public release failed to have the required information. The public release is required to have the non-discrimination statement, income eligibility guidelines, and other methods to determine eligibility for free meals (as required by FNS Instruction 113-1 and 7 CFR Part 245.5). OKDHS School Nutrition Programs released a prototype public release prior to the beginning of the school year. It is recommended SFA's use this prototype public release.

7 CFR Part 245.5 requires SFAs to issue their public release statement at the beginning of the school year. The public release should be sent to local media (newspaper).

7 CFR Part 245.5 (b) requires SFAs to provide copies of the public release to any interested persons upon their request.

The SFA failed to provide documentation on how data is collected on race and ethnicity for the students as required by FNS Instruction 113-1. Most schools collect this data at the time each student is enrolled. This data is usually gathered on the school's enrollment application.

To demonstrate compliance with Civil Rights public release requirements:

Technical assistance was provided regarding the public release.
Please provide your corrective action plan regarding the public releases requirement to demonstrate compliance and understanding.
Please provide your corrective action plan regarding how your school will gather data on race and ethnicity as required by FNS Instruction 113-1 to demonstrate compliance and understanding.

Local Wellness Policy: The SFA's local wellness policy needs to have the following added:

The policy provided at the time of the Off-Site visit did not contain any of the required goal areas. Local wellness policies are required to contain goals for the following [7 CFR Part 210.31 (c) (1)]: nutrition education, nutrition promotion, physical activity, and other school based activities.

The SFA's local wellness policy does not contain nutrition guidelines and standards for all food and beverages sold on campus during school hours. 7 CFR Part 210.31 (c) (1) and 7 CFR Part 210.31 (c) (2) requires local wellness policies to contain nutrition guidelines. 7 CFR Part 210.31 (3) requires wellness policies to contain standards for foods and beverages provided to the students during school hours.

The local wellness policy provided at the time of the Off-Site visit also did not contain guidelines for the marketing food and beverages on campus during the school day. SFAs are required to have guidelines for marketing of food and beverages in their wellness policy [7 CFR Part 210.31 (3) (iii)].

The SFA's local wellness policy did not contain a description for measuring the implementation of the policy. Local wellness policies are required to have a description of how the SFA is going to measure the implementation of the policy [7 CFR Part 210.31 (e)].

Prior to the On-Site the SFA provided a new local wellness policy that contained all of the above areas. No further action is required for the above local wellness findings.

The SFA's new policy needs to have the following added:

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 210.30 (c) (4) and 7 CFR Part 210.30 (e) (1).
The SFA's wellness policy also did not have a description of when the policy would be assessed. Wellness policies are required to document the how frequently the policy is to be assessed, at a minimum once every three years [7 CFR Part 210.31 (e) (2)]. The best practice is to assess the policy annually.

When changes to the local wellness policy occur review them with the committee and post the policy changes where you publicly post the policy. Once you review and update your policy, consider the policy updated for this program year. An evaluation of program requirements must occur once during a 3-year cycle and any other time the agency or committee identifies the need for updating. All policy updates need to be documented in a wellness assessment report, USDA Memo SP24-2017. The wellness report needs to be posted publicly as required by

To demonstrate compliance with local wellness policy requirements:

Add the name(s) of the personnel designated with the responsibility for the assessment of the local wellness policy.
Add a description of how frequent the local wellness policy is to be assessed.
Provide a copy of the policy with the above added along for corrective action to demonstrate compliance and understanding.

Meal Pattern Findings:The SFA was grouping grades 9-12 serving sizes with lower grades on their production records. The meal pattern requirements' calorie limits for lunch meals [7 CFR Part 210.10 (c)] do not allow for serving the same serving sizes to both elementary and high school students. You can serve the same serving sizes to the prekindergarten through eighth graders as long as you keep your average weekly calories between 600-650 calories. Ninth through twelfth grades must have a weekly average between 750-850 calories. The weekly required serving sizes for each age/grade group is designed to capture the differences in calories.

When serving K-12 students in a single school, one way to ease menu planning for these two grade groups is to start with a menu that is appropriate for grades 6-8, then add in a few additional foods to serve to the older grade group. For grades 9-12, the fruit and vegetable minimums must be met. Therefore, on top of the requirements for the grades 6-8, schools must make available to the older children: ½ cup more fruit daily, ¼ cup more vegetables daily and across the week ½ cup more red/orange, ¼ cup other, ½ cup additional (any subgroup) vegetables.

To demonstrate compliance with Meal Patterns:

Immediately checked your planned menu to ensure serving sizes are the required size for each grad group (grades K-8 and grades 9-12).
Provide your plan for corrective action to demonstrate understanding and compliance.

Record Keeping: A review of the production records conducted during this AR indicated some issues with documentation on the production records. Several production records were incomplete. The following issues were noted:

Grades 6-8 were grouped with grades 9-12 using the same serving sizes.
Serving sizes were not written for all items served on more than one production record.
Serving sizes were written in the wrong place on the production records.
The planned menu section of the production record was not fully filled out on more than one production record.
The meals served section on the production record was not filled out on more than one production record.
The adult meals planned and served are not being recorded on the planned meals section and the meals served section.

To insure proper integrity, documentation of food production should accurately note the amount of servings planned (including adults and second servings), the actual serving sizes for each item and the total amount of food product used to prepare the meal.

For serving sizes, document the serving sizes planned and served. For meats and meat entrees list the number of pieces, one slice, one burger, one sandwich, or serving in ounces

(ex. 5 nuggets or 2 ounces slice). Ounces should reflect only the actual serving size and will be rarely used. Unless fresh fruit is being served, fruits and vegetable are primarily list by cup size (ex. 1 whole banana, ½ Cup diced pears or ¾ Cup green beans). Using standardized recipes will help the agency in planning for the correct serving size.

For the total amount prepared, use actual weights. For meats or fresh vegetables, list the weight (ex. 10 lbs., 5 ounces) or total number of pieces prepared. For canned vegetables and fruits, document the weight of the can or specify the can size (ex. 2, 108 oz. cans or 1, # 10 can). For breads, pastas and grains, document the total weight or number of slices. For milk, document the number of gallons or pints used.

For the planned number of servings, documentation of food production should accurately note the amount of servings planned (including adults and second servings).

SFAs are required to keep production records for all the meals that are produced and claimed for reimbursement [7 CFR Part 210 (a) (3)]. Federal regulation 7 CFR Part 210.10 (a) (3) requires the production record show:

"…how the meal offered contributes to the required food components and food quantities for each grade served every day."

The production records are a part of the documents supporting a SFA's reimbursement claim and are required to be kept for at least three school years [7 CFR Part 210.20 (b) (14)].

To demonstrate compliance with Production Documentation:

Staff should begin immediately completing the daily production records by; listing all items served, listing components in the proper categories and documenting actual serving sizes.
Ensure production records are complete.
Provide a copy of one lunch production record along with your corrective action plan to demonstrate understanding and compliance.

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted March 28, 2019 and April 4, 2019:

Failure to Provide Requested Records: The SFA failed to provide documentation as required by their agreement with the State Agency (SA) and as required by 7 CFR Part 210.9 (b) (17). This federal regulation requires SFAs to:

"Upon request make all accounts and records pertaining to its school food service available to the State Agency, and to the USDA Food and Nutrition Service (FNS)"

The SFA failed to provide several documents during the Off-Site portion of this AR. The SA reviewer made several requests before all of the requested documentation was provided prior to

the completion of the On-Site portion of this AR. No further action is required regarding the documentation requested during the Off-Site portion of this AR.

The SA reviewer made several requests to the SFA to provide records for the On-Site Portion of this AR starting on March 28, 2019 through April 22, 2019. The SA requested the following records:

Lunch meal count for 03/28/19.

Failure to provide the above documentation and failure to submit a complete corrective action plan will result in the withholding of future payments (7 CFR Part 210.24).

To demonstrate compliance with providing requested records:

Provide the meal count by eligibility category for the lunch meal served on 03/28/19.
Provide the requested lunch meal count along with a copy of your agency's plan for corrective action to demonstrate understanding and compliance.

Procurement Review Summary Report

Date: 04-24-19

Name of Agency: Tulsa Adventist Academy

                                                                                                   Date of AR off-site review: 02-21-19

Reviewer: Matthew Smith                                                    Date of AR on-site review: 03-28-19
                                                                                                                                            and 04/04/19

Persons interviewed: Jennifer Cross                                     Date of exit conference: 03-28-19

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

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

Failure to provide Records: The SFA failed to provide documentation need to complete the PR [7 CFR Part 210.9 (b) (17). Prior to the completion of the On-Site portion of the AR the SFA provided all the requested documentation for the PR.
Procurement: At the time of the PR was commenced, your agency did not provide a procurement plan and did not provide the code of conduct [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)]. During the PR your agency provide copies of both documents that were compliance with federal regulations.

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

There were no additional findings for the procurement review.