Administrative Review Summary Report
Date: 04-19-23
Name of Agency: St. Anthony Hospital – Behavioral Medicine Center
Date of off-site review: 11-03-22
Reviewer: Matthew Smith Date of on-site review: 12-15-22
Persons interviewed: Rebecca Laprarie and Date of exit conference: 04-18-23
Angela Harrison
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):
· Meal Patterns: During the week of lunch menus assessed, 10/24/22 – 10/30/22 there were some insufficient serving sizes for the lunch menus served [7 CFR Part 210.10 (c)]. Prior to the completion of on-site portion of this AR, St. Anthony Hospital – Behavioral Medicine Center (SAHBMC) took corrective action bringing all of the insufficient servings into compliance with the meal patterns.
· Non-Creditable Food Item Served as Part of the Meal Component: During the week of lunch menus assessed, 10/24/22 – 10/30/22 a non-creditable item was served. Prior to the completion of the on-site portion of this AR. SAHBMC took corrective action by replacing the non-creditable item with a product that could be credited.
· Whole Grain Rich – Percentage of Weekly Serving Under 80%: During the assessment of breakfast menus for the week of 10/24/22 through 10/30/22 it was discovered the percentage of the bread/grain component weekly serving for the breakfast menus was under 80% [as required by federal regulations 7 CFR Part 210.10 (c) (2) (iv) (B) and 7 CFR Part 220.8 (c) (2) (iv) (B)]. Prior to the completion of the on-site portion of this AR, SAHBMC took corrective action by bringing the WGR percentage of the weekly bread/grain serving to at least 80%.
No further action is required for the above.
Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted November 3, 2022:
Local Wellness Policy: The most recent documentation of the assessment and update to the local wellness policies for both sites (triennial wellness assessment reports) do not document the policies being compared to the model school local wellness policy. Federal regulation [7 CFR Part 210.31 (e) (2) (ii)] requires School Food Authorities (SFA) to compare their local wellness policies to the model local school wellness policy.
To demonstrate compliance with local wellness policy requirements:
· Provide St. Anthony Hospital – Behavioral Medicine Center’s (SAHBMC) plan for corrective action to demonstrate understanding and compliance.
Findings and Recommendations Identified During the On-Site Portion of the Review Conducted December 15, 2022:
Counting and Claiming: A review of the counting and claiming system demonstrates non-systemic counting and claiming errors for the review period (October 2022), which resulted in a Performance Stander I (PSI) violation [as required by federal regulation 7 CFR Part 210.18 (g) (1) (ii)]. Errors were found with the School Breakfast Program (SBP) and the Afterschool Snack Program monthly counts claimed on the reimbursement claim.
Below are the differences the Oklahoma Human Services School Nutrition Programs (OHS SNP) identified in SAHBMC’s claim for October (comparing the meal rosters and the edit check with OHS SNP’s meal count):
|
SAHBMC’s Meal Roster count |
SAHBMC’s Claim |
OHS SNP’s Meal Count |
Difference |
Free |
2905 |
2905 |
2905 |
0 |
Reduced |
0 |
0 |
0 |
0 |
Paid |
289 |
289 |
219 |
+70 |
Paid lunch meals were over claimed by 70 lunches.
Below are the differences the OHS SNP identified in SAHBMC claim for October 2022 comparing the meal rosters and the edit check with OHS SNP’s meal count):
|
SAHBMC’s Meal Roster count |
SAHBMC’s Claim |
OHS SNP’s Meal Count |
Difference |
Free |
1422 |
1422 |
949 |
-473 |
Free snacks were under claimed by 473 snacks.
Federal regulation [7 CFR Part 210.8 (a) (2)] requires each SFA to review their claims for accuracy prior to submitted them to the State Agency (SA).
To demonstrate compliance with counting and claiming requirements:
· Revie the counting and claiming system and create a plan to ensure the meal counts are combined accurately, and then submitted to the OHS SNP’s online claiming system.
· Provide the following:
o Meal rosters for the SBP and the Afterschool Snack Program for both of SAHBMC sites for April 2023.
o The edit checks for the SBP and the Afterschool Snack Program for April 2023
· Provide copies of the above documentation along with SAHBMC’s plan for corrective action to demonstrate understanding and compliance.
Procurement Review Summary Report
Date: 04-19-23
Name of Agency: St. Anthony Hospital – Behavioral Medicine Center
Date of AR off-site review: 11-03-22
Reviewer: Matthew Smith Date of AR on-site review: 12-15-22
Persons interviewed: Rebecca Laprarie Date of exit conference: 04-18-23
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 for St. Anthony Hospital – Behavioral Medicine Center.
