Name of Agency: Bethesda Family Services Foundation Date of off-site review: 02/08/17
Reviewer: Matthew Smith Date of on-site review: 03/14/17
Persons interviewed: Rebecca Smith Date of exit conference: 03/14/17
This School Food Authority (SFA) operates the National School Lunch Program, the School Breakfast Program, and the After School Snack Program.
Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted February 8, 2017:
After School Snack Program Monitoring Checklist: At the time of the off-site review your agency completed the required Afterschool Snack Program Monitoring Checklist, for the 2016-2017 school year. An ASP monitoring review must be conducted by your staff twice a year, 7 CFR Part 210.9 (c) (7) and 7 CFR Part 210.10 (o). The first review should be conducted during the first four weeks of snack service and the second should be scheduled prior to the end of the school year as required by 7 CFR Part 210.9 (c) (7).
The designated personnel must review the After School Snack Program a minimum of two times a year using the DHS supplied monitoring checklist. Marking the review on a calendar may help your staff maintain a reoccurring ASP Administrative Review Summary Report review schedule. For each no answer on the form, you must take corrective action to ensure compliance. Keep the checklist and all supporting documentation for the snack program on file according to federal recordkeeping requirements.
The School Food Authority (SFA) conducted their first review on 10/17/16, which was more than four weeks after the school year started. The SFA completed the second review on 02/06/17. The SFA had a change of director of their school nutrition program in October 2016; the new director completed the After School Snack monitoring checklist soon after taking over the SFA's school nutrition program. The State Agency (SA) reviewer provided the SFA with technical assistance during this Administrative Review (AR) regarding the need to complete as required within the first four weeks of the school year starting.
No further action required regarding the After School Snack Program monitoring checklist.
Civil Rights: At the time of the Off-Site portion of this Administrative Review (AR) your agency had not completed the required annual civil rights training. The USDA requires that all staff who work with program applicants or participants receive annual Civil Rights training, FNS Instruction 113-1. Prior to the On-Site portion of this Administrative Review the SFA held its annual civil rights training.
No further action is required regarding the annual civil rights training.
The agency did not have a policy in place instructing staff on the proper handling of a civil rights complaint. Prior to the on-site portion of this administrative review the SFA adopted a policy for handling civil rights complaints. No further action is required.
Site Monitoring: At the time of the Off-Site visit of this AR the SFA had not completed the federally-required review of their sites. 7 CFR Part 210.9 (a) (1) requires each SFA to perform no less that one on-site review of the counting and claiming system and the readily observable areas of review cited under 7 CFR Part 210.18 (h), for each site under the SFA's jurisdiction by February 1 of each school year. If the SFA's site monitoring review discloses any problems with the sites counting and claiming procedures or general review the SFA will ensure the site implements corrective action. For sites with corrective action the SFA conduct a follow up review of the site(s) within 45 days to determine if the corrective action resolved the problems found during the initial on-site review conducted by the SFA.
Prior to the On-Site portion of this review the SFA conducted the site monitoring of both the SFA's sites and submitted the monitoring forms to the State Agency (SA).
No further action is required regarding site monitoring.
Professional Standards: At the time of the Off-Site visit the SFA did not have a tool to track training for their school nutrition program. USDA memo SP 39-2015 documents the training records must list the following: employee name, employer/school, training title, topic/objectives, training source, dates, and total training hours. During the Off-Site portion of this AR the SA reviewer provided the SFA with the SA training tracking tool which meets the requirements laid out in USDA memo SP 39-2015. The required documentation will demonstrate compliance with the training requirements documented in 7 CFR Part 210.30 (c), 7 CFR Part 210.30 (d), and 7 CFR Part 210.30 (e). The following are the training requirements documented in the preceding regulations:
|Job Category*||Annual Requirements|
|Staff (full time)||6 hours|
|Part-Time Staff (working less than 20 hours per week in the SFA's school nutrition program)||4 hours|
|Mid-year hires in all categories (January 1st or later)||One-half of training requirement for each job category.|
*Your SFA may not have all the job categories listed above. All SFA's have a director.
To demonstrate compliance with Professional Standards:
- Provide a copy of your agency's school nutrition program training tracking tool.
- Submit the above along with your agency's corrective action to demonstrate understanding and compliance.
Meal Patterns: A review of 01/14/17 through 01/20/17 indicated some insufficient portion sizes at breakfast and lunch.
The breakfast meal pattern 7 CFR Part 220.8 (c) requires the following minimum serving sizes; 1oz. by weight bread/grain daily and 12.5-14 oz. per week, 1 cup Fruit, and 1 cup fluid milk, offered as a choice between 1% and fat free. No more than 50% of the fruit components for a menu week can be met with 100% fruit juice.
- 01/14/17: The breakfast pita used to meet the bread/grain component was cut in half causing it to only credit at 0.50 oz.
- The above insufficient serving size was determined to be non-systemic in nature
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 bread used during this week only credits at 1.75 oz. for two slices. This caused there to be insufficient serving sizes for the bread/grain component on 01/16/17, 01/17/17, 01/18/17, and 01/20/17.
- 01/20/17 the grilled cheese sandwich credits 1.25 oz. toward the meat/meat alternative for this meal. Nothing else was served to bring the daily serving of the meat/meat alternative component up to 2 oz.
- The weekly meat/meat alternative minimum serving size was not met. This was due to the insufficient serving size for the daily meat/meat alternative on 01/20/17, and the SFA serving a chicken product that was non-creditable on 01/15/17 and 01/19/17.
- The insufficient serving sizes discovered during the week of 01/14/17 through 01/20/17 were determined to be non-systemic in nature.
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.
To demonstrate compliance with Meal Patterns:
- Review your menus for compliance with the meal patterns for grades 9-12.
- Bring all insufficient serving sizes and missing components in compliance with the meal patterns for grades 9-12.
- Submit your plan for corrective action 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 Tyson Grilled and Ready cooked chicken served on 01/15/17 and 01/19/17.
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 planning 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.
To demonstrate compliance with the CN label/product specification requirement:
- Obtain and provide a copy of the needed product formulation statements. Work with venders and sales representatives to obtain this documentation.
- If product formulation statement(s) or CN labeling is not available, provide a copy of the replacement creditable item's labels.
- Provide a copy of your corrective action plan along with the documentation list to demonstrate understanding and compliance.
Findings and Recommendations Identified During the On-Site Portion of the Review Conducted March 14, 2017:
Counting and Claiming: A review of the counting system demonstrates systemic counting errors for the review period (January 2017), 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 both the breakfast and lunch.
The errors were a result from the errors resulted from using a paper based edit check. The daily meal counts were not calculated correctly, which caused the meals to be under claimed for both breakfast and lunch.
Below are the differences, our reviewer identified, in your January lunch counts, when comparing the meal roster to the meals listed on your agency's claim:
Free meals were over under claimed by 16 meals.
Below are the differences, our reviewer identified, in your January breakfast counts, when comparing the meal roster to the meals listed on your agency's claim:
Free meals were over under claimed by 103 meals.
At the time of the On-Site portion of this AR the SA Reviewer strongly recommended the SFA use the electronic edit check. Technical assistance was given on how to use the electronic edit check to reduce human errors during the consolidation of the SFA meal counts for inclusion in the monthly claim. The SA recommended the SFA use the electronic edit check rather than using the a paper based edit check
7 CFR Part 201.8 (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. They result in Performance Standard 1 Violations and require fiscal action.
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 edit check daily to record meal counts instead of using paper based edit check.
- Provide copies of the following: your agency's meal rosters for March 2016, your agency's edit check forms, and the claim for March 2016.
- Provide the above copies, along with your corrective action plan to demonstrate understanding and compliance.
Reviewer's Comments: Overall your agency is doing a good job running its school nutrition program. I want to commend your staff working within the agency's school nutrition program. Keep in mind all programs being reviewed receive findings. The findings contained in this report are areas that need some work in order to bring your agency's school nutrition program into compliance with regulations.
I want to take the opportunity to provide a reminder of the end of school year (July 1 through June 30) review of revenue and expenses. This review is to ensure your agency's nonprofit school food services account to verify the account's nonprofit status. This review should be conducted after your agency receives the claim for June.