Administrative Review Summary Report

Date:  10-27-21

Name of Agency:  Murrow Indian Children’s Home            Date of off-site review: 07-20-20

Reviewer:  Matthew Smith                                                             Date of on-site review: 08-26-21

                                                                                                             and 10-01-21

Persons interviewed:  Betty Martin and                                  Date of exit conference: 10-20-21
                                      Georgia Davis

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):

• Fiscal Management:  A review of the Murrow Indian Children’s Home (MICH) food services account identified net cash resources (operating balance) totaled $3,640.41 for the review period.  This is $1.163.11 over the permitted balance of three months average operating expenses [7 CFR Part 210.14 (b)].  Prior to the completion of the on-site portion of this AR MICH took corrective action by providing a plan to spend down the excess balance
• Professional Standards – Tracking Annual Training Hours:  MICH did not keep training records and track training hours that could be credited toward annual training hours during school year 2020 – 2021 [7 CFR Part 210.30 (g) and USDA Memo SP 39-2015].

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 July 20, 2021:

Meal Patterns: A review of 06/14/21 through 06/20/21 indicated some insufficient portion sizes at lunch during this week, as well as on the day of review for lunch (10/01/21).

The lunch meal pattern 7 CFR 210.10 (c) requires the following minimum serving sizes for the grades 9-12 meal pattern:

• 2 oz. by weight meat/meat alternate daily and 14-17 oz. per week
•  2oz. by weight bread/grain daily and 14-17 oz. per week
•  1 cup fruit daily and 7 cups per week
• 1 cup vegetables daily, 7 cups weekly
  • Vegetable Subgroup Services:
    • Dark green subgroup ½ cup/week
    • Red/orange subgroup 1 ¼ cup/week
    • Legumes subgroup ½ cup/per week
    • Starchy subgroup ½ cup/week
    • Other subgroup ¾ cup/week) 7 cups/week.
• 1 cup fluid milk daily, 7 cups weekly, offered as a choice between 1% (unflavored) and fat free (flavored or unflavored). Two varieties must be offered daily.

 

Insufficient quantities

• The turkey and ham served with the lunch meal on 06/16/21, only credited 1.5 oz. toward the daily serving meat/meat alternative component.
• The bread served with the lunch meal on 06/18/21, only credited 1.75 oz. (for two slices) toward the daily serving for the bread/grain component.
• The weekly fruit component serving was insufficient.  Only 5 ½ cups could be credited toward the weekly fruit component serving.  This was due to two day’s daily fruit component serving be met with a non-creditable Jell-O with fruit items.
• The weekly minimum weekly meat/meat alternative component serving was not met.  Only 13 oz. could be credited toward the weekly serving for this component.  This insufficient serving was caused by non-creditable meat/meat alternative items being served to meet two day’s daily serving for this component.
• The weekly legume vegetable subgroup was not met.  No vegetables were served during the week that could credit toward this vegetable subgroup.
• The serving for the bread on the day of review was insufficient.  The serving only credited 0.25 oz. toward the minimum required daily bread/grain component.

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

 

The school served non-creditable food items as part of the meal component.  During the menu assessment for the week of 06/14/21 through 06/20/21 and the day of review for lunch (10/01/21) it was determined your school is serving non-creditable items. In order for the items to be creditable, they must contain a Child Nutrition (CN) label or an acceptable production formulation statement [Appendix C to 7 CFR Part 210].  Crediting information for USDA commodities can be found on the commodity fact sheets available on the USDA website (https://www.fns.usda.gov/usda-fis/usda-foods-product-information-sheets). The following items were identified as non-credible:

• The Jell-O with fruit served with the lunches on 06/14/20 and 06/20/21.  This recipe item will have to be replaced with one of the following:
  • A product that has either CN label or product formulation statement that credits 1 cup toward the daily fruit component serving.
  • Fruit (canned, dried, fresh, or frozen) that credits 1 cup toward the daily fruit serving.
• The chicken nugget product served with the lunch on 06/15/21 and the popcorn chicken served on 06/18/21.  These products will have to be replaced with one of the following:
  • Products that have either CN labels or product formulation statement.  The products must credit 2 oz. toward the daily meat/meat alternative component serving.
  • Recipe items that credit at least 2 oz. toward the daily meat/meat alternative component serving.
• The popcorn chicken product served with the lunch on the day of review (10/01/21) will have to be replaced with one of the following:
  • A product that has either a CN label or a product formulation statement that credits at 2 oz. toward the daily meat/meat alternative component serving.
  • A recipe item that credits at least 2 oz. toward the daily meat/meat alternative component serving.

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 as a 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 a copy of your corrective action plan along with the documentation list 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 Murrow Indian Children’s Home (MICH) school food services program.  Federal regulation [7 CFR Part 210.30 (g)] requires School Food Authorities (SFA) 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:

Job Category*	Annual Requirements
Directors	12 hours
Managers	10 hours
Staff (full time)	6 hours
Part-Time Staff (working less than 20 hours per week in the SFA's school nutrition program)	4 hours
Mid-year hires in all categories (January 1st or later)	One-half of training requirement for each job category.

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

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

OKDHS School Nutrition Programs recommends tracking training on an approved training tracking tool.  MICH began tracking training using a training tacking tool provided by OKDHS School Nutrition Programs during this AR.

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:

• Provided documentation of the director’s completion of eight hours of food safety training.
• Provide the above along with MICH’s plan for corrective action to demonstrate understanding and compliance.

Professional Standards – Eight Hour Food Safety Training:  MICH’s new school food services director did not complete eight hours of food safety within 30 days of starting in the position or within five years of starting in the position as required by federal regulation [7 CFR Part 210.30 (b) (1) (v)].  MICH was provided with information by email (on 06/08/21, and 08/23/21) on an online eight hour food safety training offered for free through the Institute of Child Nutrition’s (ICN) iLearn app. 

To demonstrate compliance with professional standard requirements:

• Have the school food services director complete eight hours of food safety training.
• Provided documentation of the director’s completion of eight hours of food safety training.
• Provide the above along with MICH’s plan for corrective action to demonstrate understanding and compliance.

Whole Grain-Rich (WGR) Bread/Grain: For the reviewed menu week of June 14 through 20, 2021; your agency did not meet the 100% Whole Grain-Rich (WGR) requirement for bread/grain products served at breakfast and lunch, 7 CFR Part 220.8 (c) (2) (iv) and 7 CFR Part 210.10 (c) (2) (iv).   The percentage for meeting the whole grain rich requirement for breakfast was 19%.  The percentage for the meeting the whole grain rich requirement for lunch was 39.4%.  Your agency has opted into the COVID-19 meal pattern flexibility waiver permitting at least half of the weekly serving being met by WGR items [as permitted by USDA Memo COVID-19: Child Nutrition Response #90].

The following items were determined not to be WGR:

• For Breakfast Menus:
  • The pancake mix used to make the pancakes served with the menu on 06/14/21.
  • The bread used to make the toast with the menus served on 06/15/21, 06/16/21, and 06/18/21.
  • The French toast served with the menu for 06/19/21.
  • The bread for the sandwiches served with the menu for 06/20/21.
• For Lunch  Menus:
  • The macaroni and cheese served with the menu for 06/15/21.
  • The bread sticks served with the menu on 06/16/21.
  • The rolls served with the menu for 06/17/21.
  • The bread served with the menu for 06/18/21.       

The percentage of the weekly servings met with WGR items must be brought up to 50% for both breakfast and lunch to be in compliance with the COVID-19 nationwide waiver your agency opted into.

In order for an item to be WGR it must contain 50% whole grains by weight. The easiest way to tell is to look at the ingredients on the label. If the first ingredient is a Whole Wheat Flour or a Whole Grain, you’re good. If a Whole Grain product is not listed first, you need to choose a different product that lists the correct grain first. The key is the word Whole.

To demonstrate compliance with Whole Grain Rich Bread/Grain Requirements:

• Evaluate your products to determine if they meet the whole grain rich requirement. Replace any products you determine don’t meet the WGR requirement.  
• Provide a copy of your corrective action plan to demonstrate understanding and compliance.

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted August 26, 2021 and October 1, 2021:

Counting and Claiming: A review of the counting system demonstrates systemic counting and claiming errors for the review period (January 2017), which results in a Performance Standard

Violation I (PSI), 7 CFR Part 210.18 (g) (1) (ii).  The error was systemic in nature and was found for breakfast, lunch, and snack monthly counts. 

The errors resulted from the manual consolidation of the daily meal counts into the monthly meal counts.  The monthly meal counts were not calculated correctly, which caused the meals to be under claimed for breakfast, lunch, and snack. 

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

	MICH	OKDHS SNP	Diff.
Free	195	217	-22

Free lunch meals were under claimed by 22 meals.

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

	MICH	OKDHS SNP	Diff.
Free	308	382	-74

	MICH	OKDHS SNP	Diff.
Free	219	236	17