Date:  01-31-24

Name of Agency:  Saints Peter and Paul Catholic School

            Date of off-site review: 10-05-23

Reviewer:  Matthew Smith                                                       Date of on-site review: 11-09-23,

 11/14/23, and 11-29-23

Fiscal Action: Yes, fiscal action amount will be assessed in the fiscal action and closure letter.     

Persons interviewed:  Jennifer Mullins and                                 Date of exit conference: 01-25-24

                                    Cody McDonald

Programs Operated by the School Food Authority (SFA): This 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):

·       Local Wellness Policy: The local wellness policy provided at the time of the off-site visit did not contain the local wellness committee membership as required by federal regulation [7 CFR 210.31 (c) (5) and 7 CFR Part 210.31 (d) (1)]. 

Prior to the completion of the on-site portion of this AR, Saints Peter and Paul Catholic School (SPPCS) took corrective action by adding the local wellness committee membership to the policy.

No further action is required for the above. 

Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted October 5, 2023:

Resource Management – Indirect Costs:  SPPCS charged indirect costs to the Nonprofit School Food Services Account (NSFSA) without an approved State Agency (Oklahoma Human Services) Indirect Cost Rate Agreement (ICRA) as required by federal regulations [2 CFR Part 200.414 and 7 CFR Part 200.14 (g)] and the USDA Indirect Cost Guidance for State Agencies and School Food Authorities.

To demonstrate compliance with Indirect costs requirements:

• Cease charging indirect costs to the NSFSA without an ICRA approved by Oklahoma Human Services.
• Provide SPPCS’ plan for corrective action to demonstrate understanding and compliance.

Resource Management – Internal Controls:  A review of SPPCS’ resource management practices, identified insufficient internal controls to ensure only allowable costs are charged to the NSFSA.  Federal regulation [2 CFR Part 200.303] requires SFAs to ensure only allowable costs are charged to the NSFSA.  Indirect costs without an approved ICRA by OKHS are unallowable costs.

To demonstrate compliance with internal control requirements:

·       Develop internal controls to ensure only allowable costs are expenses to the NSFSA.

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

Resource Management – Revenue NSFSA:  It was discovered SPPCS was not providing a complete breakdown for the revenue for the NSFSA on the end of school year revenue and expense report (or accounting code for the NSFSA) for SY23.  Federal regulations [2 CFR Part 200.414 and 7 CFR Part 210.14 (g)] require non-program foods revenue to be tracked separately from the other revenue for the NSFSA. 

Specifically, the revenue portion of the report did not show the revenue for the non-program foods.  The non-program foods revenue must be further broken down into:

·       revenue from adult meal sales

·       and all the other revenue from non-program foods

To demonstrate compliance with revenue reporting requirements:

·       Begin separating out the revenue sources when tracking revenue for the NSFSA. Be sure to separate the non-program food revenue as described above.

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

Whole Grain Rich – Percentage of Weekly Serving Under 80%:  An assessment of breakfast menus for the week of 09/11/23 through 09/15/23 identified the percentage of weekly servings of bread/grain components were under 80%.  The percentage was 43.24%. 

Federal regulations [7 CFR Part 220.8 (c) (2) (iv) (B)] require the percentage of the breakfast weekly serving for the bread/grain components be at least 80% WGR.  Corrective action will have to be taken to bring up weekly servings of bread/grain components to at least 80%.

To demonstrate compliance with WGR requirements:

·      Review the breakfast menus for the menu week assessed.  Determine where changes can be made to bring the percentage of the weekly serving into compliance with the meal pattern.

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

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted November 9, 2023, November 14, 2023, and November 29, 2023:

Counting and Claiming:  A review of the counting and claiming system demonstrates systemic Performance Standard I (PSI) claiming errors for the review period (September 2023), requiring fiscal action [per federal regulation 7 CFR Part 210.18 (g) (1) (ii)].  These systemic errors were found for both the breakfast and lunch monthly meal counts.

The errors appear to be due to SPPCS not fully accounting for all the changes in eligibility that occurred throughout the month of September.

Below are the differences OKHS SNP has identified in your lunch meal counts claimed for September 2023:

	OKHS SNP Count	SPPCS Meal Roster Count	SPPCS Edit Check	SPPCS Claim	Difference
Free	2006	2029	2029	2023	17
Reduced	293	293	293	293	0
Paid	225	202	202	208	-17

·       Free lunches meals were over claimed by 17 meals. 

·       Paid lunch meals were under claimed by 17 meals.

Below are the differences OKHS SNP has identified in your breakfast meal counts claimed for September 2023:

	OKHS SNP Count	SPPCS Meal Roster Count	SPPCS Edit Check	SPPCS Claim	Difference
Free	1664	1680	1680	1678	14
Reduced	353	355	355	355	2
Paid	212	194	194	196	-16

Errors were identified for breakfast eligibility categories:

• Free breakfast meals were over claimed by 14 meals.
• Reduced priced breakfast meals were over claimed by two meals.
• Paid breakfast meal were under claimed by 16 meals.

Federal regulation [7 CFR Part 2108 (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 requirements:

• Review the counting and claiming system and create a plan to ensure accurate meal counts are claimed.
• Complete the edit check process for breakfast and lunch meals daily.
• Provide copies of the breakfast and lunch meal rosters for December 2024.
• Provide copies of December 2024 edit checks for breakfast and lunch.
• Provide the above along with your plan for corrective action to demonstrate understanding and compliance.

Verification SY23 – Appeal Process Notification:  SPPCS failed to provide a household having their benefit reduced with 10 days to appeal [as required by federal regulation 7 CFR Part 245.6a (j)].  The household notification letter only gave three days to appeal.

Future verification notification letter must provide households with 10 days to appeal when benefits are reduced.

To demonstrate compliance with notification of the appeal process requirement:

·       Provide a copy of the adverse effects notification letter to this household.

·       Provide the above documentation along with SPPCS’ plan for corrective action to demonstrate understanding and compliance.

Verification – Incorrect or Insufficient Income Documentation:  A review of the SY24 verification process identified two household applications not properly verified. 

One application was originally determined to be categorically eligible.  SPPCS failed to obtain household income documentation from the last 180 days as required by federal regulation [7 CFR Part 245.6a (g)] and the USDA Eligibility Determination Manual. 

The SFA documented the household had a case with OKHS.  After being notified of this finding SPPCS contacted OKHS SNP and directly verified this application.

On the second application, SPPCS used income tax documentation for 2022 to verify a household’s income.  Federal regulation federal regulation [7 CFR Part 245.6a (g)] and the USDA Eligibility Determination Manual, require documentation of income for the verification process be no older than 180 days.

To demonstrate compliance with Insufficient Income documentation requirements:

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

Verification – Record Retention:  A review of the SY23 verification process indicated SPPCS did not retain all documentation for the process as required by federal regulation [7 CFR Part 245.6a (h)].  SPPCS did not have the household notification of verification results letters when the original eligibility determination was confirmed.

To demonstrate compliance with record retention requirements:

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

Reviewer’s Comments:  Overall this review demonstrated your school’s good work in administering its school nutrition programs.  OKHS SNP would like to take the opportunity to commend Jennifer Mullins for all the hard work she does to make your school’s program so successful.

Procurement Review Summary Report

Date:  01-31-24

Name of Agency:  Saints Peter and Paul Catholic School

            Date of AR off-site review: 10-05-23

Reviewer:  Matthew Smith                                                       Date of AR on-site review: 11-09-23,

11/14/23, and 11-29-23

Persons interviewed:  Jennifer Mullins                           Date of exit conference: 01-25-24

Programs Operated by the School Food Authority (SFA):  This SFA operates the National School Lunch Program, the School Breakfast Program, and the After School Snack Program.

Congratulations! Saints Peter and Paul had no procurement review findings.

Reviewer’s Comments:  I want to commend Jennifer Mullins for all her hard work on the school food services program procurement activities.  Keep up the good work!

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

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

For school year 2020-2021, the school food services director has completed seven hours of training. The school food services director will need to complete an additional five hours of creditable training to meet the 12 hours required prior to June 30, 2021.

Your food services full time employees all have seven hours of training that could be credited toward the annual training requirements, thus completing the required training hours for school year 2020-2021. 

To demonstrate compliance with professional standard requirements:

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

Resource Management – Unpaid Meal Charge Policy:  The unpaid meal charge policy does not address the steps leading up to the households unpaid meal charges being charged as bad debt and being paid for by funds not from the nonprofit school food services account.  USDA Memos SP46-2016 and USDA Memo SP23-2017 requires SFAs to have an unpaid meal charge policy that communicates how the funds will be collected to pay the unpaid meal charges.

To demonstrate compliance with unpaid meal charge policy requirements:

• Develop an unpaid meal charge policy that addresses the steps leading up to the endowment paying households unpaid meal charges.
• Provide a copy of the update meal charge policy along with SPPCS’ corrective action plan to demonstrate understanding and compliance.

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted November 12, 2020:

Benefit Issuance Document:  Errors were discovered on the Benefit Issuance Document (BID) during the review of household applications and direct certification documentation.

Three students were listed on the SPPCS’ BID as being approved for reducedo8 priced meals (as of 01/22/21), when all three students were listed on direct certification documentation received by SPPCS. 

Federal regulation [7 CFR Part 245.6 (b)] requires SFAs to make adjustments in eligibility determinations when direct certification lists are received throughout the school year.  When receiving each direct certification list SFAs should compare the list to their BID and make updates and changes as needed.

SPPCS made the changes in their point of service system and on their BID on 01/22/21, changing all the affected students from reduced priced meals to free meals, as well as to send letters to the affected households on 01/25/21.

To demonstrate compliance with Benefit Issuance Document (BID) requirements:

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

Reviewer’s Comments:  I want to commend all the staff members who work with the SPPCS’ school food services program on the good work they are doing with their programs.  Keep up the good work

Date:  02-23-21

Name of Agency:  Saints Peter and Paul Catholic School                  Date of AR off-site review: 10-01-20

Reviewer:  Matthew Smith                                                                       Date of AR on-site review: 11-12-20

Persons interviewed:  Joanne Brown and                                               Date of exit conference: 02-19-21
                                      Jennifer Mullins

This School Food Authority (SFA) operates the National School Lunch Program, the School Breakfast Program, and the After School Snack Program.

There were no findings for the procurement review.

Reviewer’s Comments:  I want to commend Jennifer Mullins on a job well done on Saints Peter and Paul Catholic School’s compliance with federal procurement regulations.