Date:  04-28-21

Name of Agency:  Sacred Heart Catholic School                   Date of off-site review: 01-05-21

Reviewer:  Matthew Smith                                                       Date of on-site review: 03-24-21 and 04-07-21

Persons interviewed:  Joanna Camacho                                  Date of exit conference: 04-28-21                                            

This School Food Authority (SFA) operates the National School Lunch Program , the School Breakfast Program, and the After School Snack Program (due to the outbreak of COVID-19 the SFA is not operating their snack program during school year 2020-2021).

Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted January 5, 2021:

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

• The name and title of the person(s) designated to assess the SFA's local wellness policy [7 CFR Part 210.31 (c) (4) and 7 CFR Part 210.31 (e) (1)].  It is recommended no more than two people assess the policy.
• The policy does not list the local wellness policy committed membership [7 CFR Part 210.31 (c) (5) and 7 CFR Part 210.31 (d) (1)].

When the local wellness policy was assessed and updated in October of 2020, this assessment and update was not documented in a triennial wellness assessment [as required by 7 CFR Part 210.31 (e) (2), 7 CFR Part 210.31 (f) (3), and USDA Memo SP24-2017].   During the off-site portion of this AR, SHCS provided a triennial wellness assessment report dated 09/17/18.

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 federal regulation [7 CFR Part 210.30 (E) (2)].   

To demonstrate compliance with the local wellness policy:

• Add the following to Sacred Heart Catholic School’s (SHCS) local wellness policy: 
  • Add the name of the person designated to assess the local wellness policy.
  • Add the local wellness committee membership.
• Provide a copy of the updated local wellness policy with the required changes listed above.
• Provide the above requested documentation along SHCS’ plan for corrective action to demonstrate compliance and understanding.   

Meal Patterns: A review of 12/07/20 through 12/11/20 indicated some insufficient portion sizes at breakfast and lunch.

The breakfast meal pattern: 7 CFR Part 220.8 (c) requires the following minimum serving sizes for grades K-8:

• 1oz. by weight bread/grain daily and 8 – 9 oz. per week
• 1 cup Fruit daily and 5 cups per week. No more than 50% of the fruit components for a menu week can be met with 100% fruit juice.
• 1 cup fluid milk daily and 5 cups per week, offered as a choice between 1% (unflavored) and fat free (flavored or unflavored)  

Insufficient quantities

• For the breakfast, meal served on 12/09/20 was served with a muffin that only credited at 0.75 oz. (the muffins weighed 43 grams each).  In order for a muffin to credit at one ounce, it must weigh at least 55 grams or more.
• For the week (12/07/20 – 12/11/20) the required minimum weekly bread/grain serving was insufficient.  Only 6.5 oz. could be credited toward this weekly serving. 

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 7 cups per week,
• ¾ cup vegetables daily and 3 ¾ cup per week
  • Vegetable Subgroup Servings: 
    • 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
• 1 cup fluid milk daily and 5 cups weekly, offered as a choice between 1% (unflavored) and fat free (flavored or unflavored).

Insufficient quantities

• During the week of 12/07/20 through 12/11/20 only ½ cup of vegetables were served that could be credited toward the red/orange vegetable subgroup. 

Insufficient serving sizes are a Performance Standard 2 (PS2) violation which requires fiscal action.  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 your plan for corrective action to demonstrate understanding and compliance.    

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted March 24, 2021 and April 7, 2021:

Counting and Claiming:  A review of the counting and calming system demonstrated errors for the review period (December 2020).  These non-systemic errors were found for breakfast and lunch.

The errors appear to have been data entry errors when the point of service paper, meal rosters were entered into the SHCS’ electronic meal counting system.

Below are the differences identified in SHCS’ December breakfast meal rosters and the daily edit checks generated by the electronic meal counting system:

Free meals and reduced priced meals were under claimed by one meal each.

Below are the differenced identified in SCHS’ December lunch meal rosters and the daily edit checks generated by the electronic meal counting system.

Free meals were under claimed by six meals.

Federal regulation [7 CFR Part 210.8 (a) (2)] requires SFAs to review their claims for accuracy prior to submitting the claim to the State Agency (SA).

To demonstrate compliance with counting and claiming requirements:

• Review the counting and claiming system and create a plan to ensure accurate meal counts are taken and recorded.
• Provide copies of SHCS’ meal rosters (breakfast and lunch) for April 2021, and the edit checks (breakfast and lunch) for April 2020.
• Provide copies of the above along with SHCS’ corrective action plan to demonstrate understanding and compliance.

Eligibility Certification:  During a review of the household applications it was determined one household application was certified in error.  The error resulted in one child receiving free meals with eligible for reduced priced meals.  The error was due to not all the sources being used when the household’s income was determined.  This caused the household to be miss categorized in the wrong benefits category [7 CFR Part 245.6].  This error resulted in a Performance Standard I (PSI) which requires fiscal action as required by federal regulation [7 CFR Part 210.18 (g) (1)]. 

During the on-site portion of this AR the household application with the error was brought to SHCS’ attention,  Federal regulation [7 CFR Part 245.6 (c) (3) (iii)] requires SFAs to send notification to households in writing when a reduction of benefits is being made, 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 completed application.  If the application is complete, the official must determine whether the household is income eligible for benefits or 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.

SHCS provided the household with a letter notifying the household of the reduction in benefits on 04/08/21.  The household submitted a new household application prior to the expiration of the 10 day period for a possible hearing request.  The household has had a reduction in household income since the initial application was submitted.  This reduction in household income caused the household to be eligible for free meal benefits.  Prior to the 10 days allowing for a possible hearing request, SHCS was able to make a determination on the new household application determining the household was eligible to receive free meals.

To demonstrate compliance and understanding with eligibility certification requirements:

• Provide a copy of the letter sent along with SHCS’ written corrective action plan to demonstrate understanding and compliance.

Reviewer’s Comments:  I want to commend the staff members who work with the SHCS’ school nutrition programs on a job well done during this review.   Keep up the good work

Federal regulation [7 CFR Part 210.8 (a) (2)] requires SFAs to review their claims for accuracy prior to submitting the claim to the State Agency (SA).

To demonstrate compliance with counting and claiming requirements:

• Review the counting and claiming system and create a plan to ensure accurate meal counts are taken and recorded.
• Provide copies of SHCS’ meal rosters (breakfast and lunch) for April 2021, and the edit checks (breakfast and lunch) for April 2020.
• Provide copies of the above along with SHCS’ corrective action plan to demonstrate understanding and compliance.

Eligibility Certification:  During a review of the household applications it was determined one household application was certified in error.  The error resulted in one child receiving free meals with eligible for reduced priced meals.  The error was due to not all the sources being used when the household’s income was determined.  This caused the household to be miss categorized in the wrong benefits category [7 CFR Part 245.6].  This error resulted in a Performance Standard I (PSI) which requires fiscal action as required by federal regulation [7 CFR Part 210.18 (g) (1)]. 

During the on-site portion of this AR the household application with the error was brought to SHCS’ attention,  Federal regulation [7 CFR Part 245.6 (c) (3) (iii)] requires SFAs to send notification to households in writing when a reduction of benefits is being made, 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 completed application.  If the application is complete, the official must determine whether the household is income eligible for benefits or 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.

SHCS provided the household with a letter notifying the household of the reduction in benefits on 04/08/21.  The household submitted a new household application prior to the expiration of the 10 day period for a possible hearing request.  The household has had a reduction in household income since the initial application was submitted.  This reduction in household income caused the household to be eligible for free meal benefits.  Prior to the 10 days allowing for a possible hearing request, SHCS was able to make a determination on the new household application determining the household was eligible to receive free meals.

To demonstrate compliance and understanding with eligibility certification requirements:

• Provide a copy of the letter sent along with SHCS’ written corrective action plan to demonstrate understanding and compliance.

Reviewer’s Comments:  I want to commend the staff members who work with the SHCS’ school nutrition programs on a job well done during this review.   Keep up the good work