Date:  03-16-22

Name of Agency:  Holy Trinity Catholic School                            Date of off-site review: 10-14-21

Reviewer:  Matthew Smith                                                             Date of on-site review: 01-12-22

Persons interviewed:  Jamie Jenkins and                                    Date of exit conference: 03-10-22

                                    Kim Annuschat

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):

·       Civil Right – Annual Training: The School Food Authority (SFA) did not conduct the annual civil rights training during school year 2021-2022 as required by FNS Instruction 113-1.  Prior to the completion of the on-site portion of the AR, Holy Trinity Catholic School (HTCS) conducted the annual civil rights training.

·       Failure to Provide Requested Records:  HTCS failed provide requested records [7 CFR Part 210.9 (b) (17)].  Prior to the completion of the on-site portion of the AR, HTCS provided the requested records.

·       Resource Management – Adult Meal Pricing:  At beginning of the off-site portion of this AR, HTCS had an insufficient adult lunch meal charge [FNS Instruction 782-5 Rev. 1]. 

Holy Trinity Catholic School (HTCS) took corrective actions for the above findings prior to the completion to the On-Site portion of this AR.  No further action is required for the above findings. 

 

Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted October 14, 2021:

Local Wellness Policy: HTCS’ local wellness policy needs to have the following added:

·    The guidelines and standards for the marketing of food and beverages on campus during the school day as required by federal regulation [7 CFR Part 210.31 (c) (3) (iii)]. 

·    The policy does not contain the local wellness committee membership as required by federal regulations [7 CFR Part 210.31 (c) (5) and 7 CFR Part 210.31 (d) (1)].

During the AR, HTCS failed to provide documentation of the most recent assessment and update to their local wellness policy (triennial wellness assessment report) as required by Federal regulation [7 CFR Part 210.31 (e) (2) and USDA Memo SP 24-2017].

To demonstrate compliance with local wellness policy requirements:

• Add the following to HTCS’ local wellness policy:  guidelines and standards for the marketing of food and beverages on campus during the school day, and local wellness committee membership.
• Provide a copy of the most recent triennial wellness assessment report.
• Provide a copy of HTCS’ local wellness policy, along with HTCS’ plan for corrective action to demonstrate understanding and compliance.

Meal Patterns: A review of 09/20/21 through 09/24/21 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 meal pattern:

Meal Component	Required Serving
Bread/Grain	1 oz. by weight daily and 8 – 9 oz. per week

*All items used to meet the daily and weekly bread/grain servings must be Whole Grain-Rich.

Fruit	½ cup daily and 2 ½ cups per week
Meat/Meat Alternative	1 oz. by weight daily and 9 – 10 oz. per week
Milk	1 cup daily and 5 cups per week
Vegetable	¾ cup daily 3 ¾ cups per week
Vegetable Subgroups to be offered throughout the week
-Dark Green ½ cup     -Red/Orange ¾ cup     -Legume ½ cup per week -Starchy ½ cup           -Other ½ cup

 

Insufficient quantities

·       The lunch menu served on 09/24/21, had an insufficient daily serving size for the vegetable component.  The menu only credited ½ cup to this daily serving size.

·       The required weekly minimum serving for the meat/meat alternative component was not met.  The menus served during the week only credited 8.25 oz. toward the weekly serving for the meat/meat alternative component.

Insufficient serving sizes are a Performance Standard 2 (PS2) violation that 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).

To demonstrate compliance with meal pattern requirements:

·       Review HTCS’ menus for compliance with the meal patterns for grades K-8.

·       Bring all insufficient serving sizes into compliance with the grades K-8 meal pattern.

·       Submit HTCS’ plan for corrective action to demonstrate understanding and compliance.

Professional Standards – Annual Training Hours:  Records and documentation of training completed during school year 2020 – 2021 and for school year 2021 – 2022, were not kept for employees with duties within HTCS’ school food services program [as required by  Federal regulation 7 CFR Part 210.30 (g)].

To demonstrate compliance with professional standard requirements:

·     Begin keeping training records and tracking the training for school food service employees.

·     Provide HTCS’ plan for corrective action to demonstrate understanding and compliance.

Resource Management – Equipment Purchase over $5,000:  During school year 2020 – 2021, HTCS purchased a two door commercial freezer that was in excess of $5,000 ($5,399.00).  HTCS failed to obtain approval from OKDHS School Nutrition Programs (SNP) prior to making the purchase with funds from HTCS’ Nonprofit School Food Services Account (NSFSA) as required by Federal regulation [2 CFR Part 200.439 (a) (2)].

To demonstrate compliance with requirements for equipment purchases over $5,000:

• Provide HTCS’ plan for corrective action demonstrating understanding and compliance.

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted January 12, 2022:

Counting and Claiming: A review of the counting system demonstrates systemic counting and claiming errors for the review period (September 2021), which results in a Performance Standard Violation I (PSI), 7 CFR Part 210.18 (g) (1) (ii).  The error was systemic in nature. 

The errors appear to have resulted from the manual consolidation of the daily meal counts into the monthly meal counts.  The monthly meal counts were not calculated correctly, and then the wrong meal count number was entered into OKDHS School Nutrition Programs’ (SNP) online claiming system.  These errors caused lunch meals to be under claimed for the month of September. 

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

	HTCS Sept. Claim	OKDHS SNP	Difference
Free	1688	1754	-86

Free lunch meals were under claimed by 86 meals.

Federal regulation [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).

These are serious, systemic errors in the counting and claiming system.   

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.
• Begin using the electronic meal roster with edit check spreadsheet daily to record meal counts.
• Provide copies of the following: meal rosters for March 2022, edit check for March 2022.
• Provide the above copies, along with HTCS’ corrective action plan to demonstrate understanding and compliance.

HACCP Food Safety Inspection:  HTCS did not received two health inspections for school year 2020 – 2021.  HTCS did not have documentation of a request being made to health department to conduct a second inspection.  Federal regulation [7 CFR Part 210.13 (b)] requires SFAs receive two food safety inspections for each site that the SFA operates. 

To demonstrate compliance with HACCP food safety inspection requirements:

• Provide HTCS’ corrective action plan to demonstrate compliance and understanding.

Procurement Review Summary Report

Date:  03-16-22

Name of Agency:  Holy Trinity Catholic School                            Date of AR off-site review: 10-14-21

Reviewer:  Matthew Smith                                                              Date of AR on-site review: 01-12-22

Persons interviewed:  Jami Jenkins and                                      Date of exit conference: 03-10-22

                                    Kim Annuschat

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

Code of Conduct:  HTCS’ code of conduct had personnel listed with the responsibility for interpretation of the code who are no longer employed by HTCS.  School Food Authorities (SFA) are required to have a written code of conduct for procurement [as required by federal regulation 2 CFR Part 200.318].  The code is required to cover conflicts of interests and governing employees conduct who have procurement duties. 

To demonstrate compliance with code of conduct requirements:

·       Update HTCS’ code of conduct with the current personnel’s title who has the responsibility for interpretation of the code.

·       Provide an updated copy of HTCS’ code of conduct along with HTCS’ plan for corrective action demonstrating understanding and compliance.

Procurement Plan:  HTCS’ procurement plan has personnel listed with procurement responsibilities who is no longer employed by HTCS.  SFAs are required to have written procurement plan documenting the SFA’s procurement procedures [as required by 2 CFR Part 200.318 (a)].

To demonstrate compliance with procurement plan requirements:

• Review and update HTCS’ procurement plan to reflect the current personnel who responsible for each procurement responsibility listed in the plan.
• Provide a copy of the updated procurement plan along with HTCS’ plan for corrective action demonstrating understanding and compliance.