Name of Agency: St. Anthony South Campus Date of off-site review: 01-11-17
Reviewer: Matthew Smith Date of on-site review: 02-13-17
Persons interviewed: Melissa Sheahart Date of exit conference: 02-13-17
This School Food Authority (SFA) operates the National School Lunch Program, School Breakfast Program, and After School Snack Program.
Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted January 11, 2017:
Civil Rights: The School Food Authority (SFA) did not have a policy for handling civil rights complaints, FNS Instruction 113-1. Prior to the On-Site portion of this Administrative Review (AR) the SFA, adopted a policy for handling civil rights complaints and provided the State Agency (SA) with a copy.
No further action is required regarding the policy for handling civil rights complaints.
The SFA also had no means to collect race and ethnic data for each resident, FNS Instruction 113-1. During the On-Site portion of the AR, the SFA provided documentation of how data on race and ethnicity are collected at the time of each resident's admission.
No further action is required regarding racial and ethnic data collection.
Local Wellness Policy: At the time of the Off-Site portion of this AR the SFA did not provide documentation of the most recent assessment and update to their local wellness policy. 2 CFR Part 210.30 requires the documentation of the assessment and update to be posted publicly.
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 [7 CFR Part 210.30 (e) (2)] and any other time the SFA or committee identifies a need. All policy updates need to be documented.
The policy update documentation should include; mention the policy was assessed, a brief statement of changes, who was present at the committee meeting, and the date of the meeting.
To demonstrate compliance with local wellness policy requirements:
- Provide documentation of the assessment and update to your agency's local wellness policy.
- Publicly post the documentation of the assessment and update with your agency's local wellness policy.
- Submit the above along with your plan for corrective action to demonstrate understanding and compliance.
Procurement: At the time of the Off-Site portion of this AR the SFA did not have a procurement policy or code of conduct available for review. Your staff failed to provide documents requested by our office to adequately review your procurement practices.
Each SFA is required to maintain a written code of conduct governing the employees engaged in the award and administration of contracts supported by program funds, 7 CFR Part 210.21(c) and 7 CFR Part 220.16 (c). This written code will eliminate any conflict of interests that might arise during the procurement process.
During this AR the SFA provided a code of conduct. The code of conduct provided to the SA reviewer met the federal requirements.
No further action required regarding the code of conduct.
Each SFA must have a written procurement plan on file, 7 CFR Part 210.21(c) and 7 CFR Part 220.16 (c). The plan must specify procurements procedures used by the SFA. All procedures must adhere to the federal requirements for procurement. The procurement plan identifies the agency's purchasing periods for the goods, equipment, and services related to the School Nutrition Programs and the various methods procurement being practiced.
The procurement plan provides an explanation for using certain procurement methods to obtain items used in the school food service program. Agencies can determine the extent of the plan. A new procurement plan does not need to be developed every year.
The procurement plan must include steps the SFA takes to assure that small, minority and women's businesses enterprises, and labor surplus firms when possible as required under 2 CFR Part 200.321. The procurement plan that was provided to the SA during the On-Site portion of the AR did not address this requirement. Also the procurement plan did not address the SFA performing a cost or price analysis in connection with every procurement action in excess of the simplified acquisition threshold (the US government sets this at $150,000) including contract modifications [2 CFR Part 200.323 (a)].
During the AR the reviewer determined only one price quotation was received for procurement of food. Your school lunch program participates in SSMHC Group Purchasing Organization. This GPO agreement may be one source when using small purchase procedures. 7 CFR Part 200.320 (b) and 7 CFR Part 3016.36 (d) (1) requires all SFAs to receive more than one price or rate quotation prior to making the decision to select a vendor.
To demonstrate compliance with the procurement requirements:
- Provide a copy of your agency's updated procurement plan to include the above required areas.
- Provide SA with a list of the vendors from school year 2015-2016, along with the amount spent with each vendor.
- Provide SA with contracts for procurements of $150,000 or above.
- Obtain a second rate quotation for the procurement of food, and provide a plan to ensure this is done in the future.
- Provide the above along with your corrective action plan demonstrate understanding and compliance.
Professional Standards: The SFA did not provide their training tracking tool for the hours completed by school food services employees. Each SFA's school food services program must have a means for tracking the hours completed by employees with duties within the school food service program as required by 7 CFR 210.15 (b) (8), USDA Memo SP38-2016, and the Administrative Review Manual for school year 2016-2107.
The SFA was provided with a SA developed training log during the Off-Site portion of the Administrative Review and asked to complete the log for all employees with duties within the school food service program. At the time of the On-Site portion of this AR, the SFA provided the completed training log for their school food service employees.
No further action required regarding professional standards requirements.
Year-end income and expense review: The SFA did not properly document the management of the school food service funds. Staff did not conduct a year-end (school year) review of total revenues and expenses to document and verify the school food service account's nonprofit status as required by 7 CFR Part 210.14 (a), 7 CFR Part 210.14 (b), and 7 CFR Part 210.19 (a) (1). This review allows the SFA to ensure costs incurred to the account are necessary, reasonable, and allowable. This caused the SA reviewer to conduct a comprehensive resource management review.
Prior to the On-Site portion of this AR, the SFA completed a review of the school's revenue and expenses for the previous year. The revenue and expense documentation you provided indicated cash resources did not exceed three months' average operating costs [7 CFR Part 210.14 (b)]. The year-end report indicated the SFA had a deficit of $7,339.51.
To demonstrate compliance with year-end income and expense review of the School Food Service Account requirement:
- Provide a plan for the annual review of account and the proper maintenance of cash balances to demonstrate understanding and compliance.
The SFA served non-creditable food item as part of the meal component. During the menu assessment it was determined your school is serving a non-creditable item. In order for the items to be creditable they must contain a CN label or an acceptable production formulation statement, 7 CFR 210 Appendix C. Crediting information for USDA commodities can be found on the commodity fact sheets available on the USDA website. The following item was identified as non-credible:
- The shredded pork served on 12/08/16.
Finding CN labeled products can be challenging. Remember; items similar to CN labeled products, but not the same, are not acceptable. Your ability to purchase food from suppliers with experience serving schools should allow your staff to obtain acceptable products. If all attempts fail and you are unable to obtain CN labels for the items you serve, your only choices are; discontinue serving the item or cook the item from scratch. When scratch cooking; we recommend using the USDA recipes because they will eliminate the panning needed when scratch cooking.
If a food is non-creditable and no other creditable foods are offered, the serving is considered insufficient. The USDA now considers insufficient serving sizes to be "missing components". Finding of missing components on subsequent reviews will be considered reoccurring and our office may have to access fiscal action.
Prior to the On-Site portion (on 02/01/17) of this AR the SFA replaced this non-creditable shredded pork product with a Child Nutrition (CN) labeled pork product.
No further action is required regarding the SFA serving a non-creditable item.
Meal Patterns: A review of 12/04/16 through 12/10/16 indicated an insufficient portion size at lunch.
The lunch meal pattern 7 CFR 210.10 (c) requires the following minimum serving sizes; 2 oz. by weight meat/meat alternate daily and 14-17 oz. per week, 2oz. by weight bread/grain daily and 14-17 oz. per week, 1 cup fruit daily and 7 cups per week, 1 cup vegetables daily (dark green subgroup ½ cup/week, red/orange subgroup 1 ¼ cup/week, legumes subgroup ½ cup/per week, starchy subgroup ½ cup/week, and other subgroup ¾ cup/week) 7 cups/week, and 1 cup fluid milk daily, 7 cups weekly, offered as a choice between 1% and fat free.
- The weekly minimum serving size for the meat/meat alternative was not met due to a non-creditable food item (shredded pork) being served on 12/08/16. The SFA only served 13 ounces during the week.
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.
The SFA, on 02/01/17, replaced the non-creditable shredded pork with a CN labeled pork product. This new product will bring the weekly serving of the meat/meat alternative component for this cycle menu week into compliance with meal pattern requirements.
No further action is required regarding meal pattern requirements.
Whole Grain-Rich (WGR) Bread/Grain: For the reviewed menu week of August 15 through 21, 2016; your agency did not meet the 100% Whole Grain-Rich (WGR) requirement for bread/grain products served at lunch, 7 CFR Part 210.10 (c) (2) (iv). The percentage for meeting the whole grain rich requirement was 93.9%.
The following items were determined not to be WGR:
- The cornbread served on 12/10/16.
In order for an item to be WGR it must contain 50% whole grains by weight. The easiest way to tell is to look at the ingredients on the label. If the first ingredient is a Whole Wheat Flour or a
Whole Grain, you're good. If a Whole Grain product is not listed first, you need to choose a different product that lists the correct grain first. The key is the word Whole.
Note: Findings for the whole grain-rich requirement may result in fiscal action for repeat violations on future reviews.
Prior to the On-Site portion of this AR the SFA stopped using the above item that was not WGR and as of 02/01/17, is making the cornbread that is being served in the program from a WGR recipe.
No further action is required regarding WGR requirements.
Buy American Provision: During the menu week assessment completed for this AR, a food product was found that was not domestically produced. 7 CFR Part 210.21 (d) requires SFAs when possible to buy domestically produced food products. Limited exceptions to the requirements to procure domestically produced food products are permitted. USDA memo SP-24-2016 documents the following exceptions to this requirement:
- The food product is not produced or manufactured within the United States
- The food product is not produced or manufactured domestically in sufficient quantities.
- The food product is not produced or manufactured domestically in satisfactory quality.
- The costs of domestically produced or manufactured food products are significantly higher in cost than non-domestic products.
If a SFA is going to use one of the above exceptions they must keep documentation justifying the exception. The following food products were found during the menu assessment that was not domestically produced or manufactured:
- Tilapia that was produced in China.
The SFA did not have documentation justifying the use of these products under one of the permitted exceptions. Work with your vendors to ensure the products used in your program are compliant with the buy American provision. When you determine it is necessary to use one of the permitted exceptions, make sure you keep documentation to justify its use.
Prior to the On-Site portion of this AR, the SFA replaced the foreign produced tilapia with a domestically produced Pollock.
No further action required regarding the buy American provision.
Reviewer's Comments: I want to commend Melissa Sheahart and her staff for doing a good job running the school nutrition program at St. Anthony South Campus. During the AR process it is not unusual for a SFA to have findings. This does not necessary reflect poorly on the job the people working in the program are doing. The school nutrition program at St. Anthony South Campus is operating well. The findings above indicate there are areas where some work needs to be done to bring the school nutrition program into compliance with federal requirements.
At the time of the On-Site, I observed how well the kitchen staff works together getting all the meal preparation done for the school nutrition program, as well as the rest of the campus. The staff never appeared stressed and the campus' kitchen is one of the better organized kitchens that I've observed.
Overall the program is running well and the people who work in the school nutrition program at St. Anthony's South Campus are doing a good job.