Administrative Review Summary Report
Date: 04-15-22
Name of Agency: First Lutheran School Date of off-site review: 02-10-22
Reviewer: Matthew Smith Date of on-site review: 03-31-22
Persons interviewed: Connie Erickson and Date of exit conference: 04-15-22
Sandi Lyons
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):
- Buy American Provision: During the menu week of breakfast and lunch menus assessed (for the week of 01/10/22 – 01/14/22), a food product was discovered that was not domestically produced [7 CFR Part 210.21 (d) and 7 CFR Part 220.16 (d)]. Prior to the completion of the on-site portion of this AR, First Lutheran School (FLS) provided documentation of the use of a limited exemption to the Buy American Provision [USDA Memo SP 24-2016]
- Local Wellness Policy: First Lutheran Schools’ (FLS) local wellness policy did not contain the following required areas:
- Guidelines and standards for the marketing of food and beverages on campus during the school day [7 CFR Part 210.31 (c) (3) (iii)]
- Designation of personnel responsible for the assessment of the policy [7 CFR Part 210.31 (e)].
- Description of how the public is provided with the opportunity to participate in the local wellness policy [7 CFR Part 210.31 (c) (5)].
Prior to the completion of the on-site portion of this AR, FLS updated their local wellness policy to include the above required areas.
- Meal Patterns: During the menu week assessed 01/10/22 – 01/14/22 there were some insufficient serving sizes for the lunch menus served [7 CFR Part 210.10 (c)]. Prior to the completion of this AR, FLS took corrective action by bringing all the insufficient serving sizes into compliance with the meal patterns.
- Whole Grain-Rich (WGR) Bread/Grain: During the week of breakfast and lunch menus (01/10/22 – 01/14/22), FLS did not meet the 100% Whole Grain-Rich (WGR) requirement for bread/grain products served at breakfast and lunch [7 CFR Part 210.10 (c) (2) (iv) and 7 CFR Part 220.8 (c) (2) (iv)]. Prior to the completion of the on-site portion of this AR, FLS took corrective actions replacing the non-WGR items with WGR items.
Corrective actions for the above findings were made prior to the completion to the On-Site portion of this AR. No further action is required for the above.
Findings and Recommendations Identified During the On-Site Portion of the Review Conducted March 31, 2022:
Counting and Claiming: A review of the counting system demonstrates systemic counting and claiming errors for the review period, January 2022, 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 and lunch monthly counts.
Below are the differences, our reviewer identified, in FLS’ November Lunch counts, when comparing the meal roster to the meals listed on FLS’ claim:
|
FLS Roster Counts |
FLS November Claim |
OKDHS School Nutrition Programs Count |
Difference |
Free |
2188 |
2078 |
2188 |
-110 |
Free lunch meals were under claimed by 110 meals.
The error for the monthly meal count occur when the monthly meal count was pulled from FLS’ electronic counting and claiming system. FLS only pulled those students who were listed as paid (this year all students not directly certified are list as paid, the system has a paid meal price of $0 due to FLS’ operation of SSO during school year 2021 – 2022) forgetting to add the free (directly certified students) into each daily meal count when conducting the daily edit checks. This caused the monthly meal counts to be off from FLS daily meal roster counts.
7 CFR Part 210.8 (a) (2) requires each SFA to review their claims for accuracy prior to submitting them to the State Agency (SA).
To demonstrate compliance with counting and claiming requirements:
- 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: meal rosters for March 2022, edit check forms for March 2022.
- Provide the above copies, along with FLS’ plan for corrective action to demonstrate understanding and compliance.
Reviewer’s Comments: I want to commend the Connie Erickson and Sandi Lyons on a job well done during this review! Keep up the good work.
Procurement Review Summary Report
Date: 04-15-22
Name of Agency: First Lutheran School Date of AR off-site review: 02-10-22
Reviewer: Matthew Smith Date of AR on-site review: 03-31-22
Persons interviewed: Connie Erickson and Date of exit conference: 04-13-22
Sandi Lyons
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):
- Buy American Provision: During the menu week of breakfast and lunch menus assessed (for the week of 01/10/22 – 01/14/22), a food product was discovered that was not domestically produced [7 CFR Part 210.21 (d) and 7 CFR Part 220.16 (d)]. Prior to the completion of the on-site portion of this AR, First Lutheran School (FLS) provided documentation of the use of a limited exemption to the Buy American Provision [USDA Memo SP 24-2016].
- Procurement Plan: The Procurement plan provided during the off-site portion of the AR was not compliant with federal regulations [2 CFR Part 200.318 and 2 CFR Part 200.323 (a)]. Prior to the completion of the on-site portion of the AR, FLS provided a procurement plan that was compliant with federal regulations.
Corrective actions for the above findings were made prior to the completion to the On-Site portion of this AR. No further action is required for the above.
There were no additional findings for the procurement review.
Reviewer’s Comments: I want to commend your school on the compliance with federal procurement requirements.
