Name of Agency: St. Mary's Catholic School Date of off-site review: 02-09-17
Reviewer: Matthew Smith Date of on-site review: 03-27-17
Persons interviewed: Nancy Post and Date of exit conference: 03-27-17
This School Food Authority (SFA) operates the National School Lunch Program and the School Breakfast Program.
Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted February 9, 2017:
Local Wellness Policy: At the time of the Off-Site review the assessment and update to the local wellness policy had been completed but the updated policy was missing required elements. Your local wellness policy needs to have the following added:
- The name and title of the person(s) designated to assess St. Mary's Catholic School's local wellness policy and to ensure the policy's implementation. It is recommended no more than two people assess the policy. This is required to meet the requirements under 7 CFR Part 210.30 (c) (4) and 7 CFR Part 210.30 (e) (1).
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 and any other time the agency or committee identifies the need for updating. All policy updates need to be documented.
The policy provided at the time of the On-Site did not have the above changes made to it.
To demonstrate compliance with the local wellness policy:
- Add the name of the personnel who is designated to assess the local wellness policy and to ensure the policy implementation.
- Provide an updated copy of your local wellness policy along St. Mary's Catholic School's plan for corrective action to demonstrate compliance and understanding.
Procurement: At the time of the Off-Site portion of this Administrative Review (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 is 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.
During the On-Site portion of this AR the SFA provided a procurement plan that met federal requirements.
No further action is required regarding the procurement plan.
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.
The SFA provided an incomplete review of the school's revenue and expenses for school year 2015-2016 during the AR process. The SFA did not provide a review of the school's revenue and expenses that included revenue from adult meal sales. The non-profit school food services account must be reimburse for the costs of all adult meal sales (this must be documented). The review of revenue and expenses for the nonprofit school food services account cannot be considered complete without the revenue from adult meal sales being listed in the review. The SA reviewer cannot complete the comprehensive review of resource management at the time of this report. Also the AR cannot be closed until the comprehensive review of revenue and expenses is completed.
To demonstrate compliance with year-end income and expense review of the School Food Service Account requirement:
- Provide a review of revenue and expenses for school year 2015-2016 listing all revenue and expenses to the nonprofit school food services account. The revenue to the account must include revenue from adult meal sales.
- Provide the above as well as a plan for the annual review of the nonprofit school food services account and the proper maintenance of cash balances to demonstrate understanding and compliance.
Professional Standards: The SFA's food services director did not complete the eight hours of food safety training within 30 days of being hired or within five years of the date of hire as required by 7 CFR Part 210.30 (b) (v) and 7 CFR Part 210.30 (b) (2). 7 CFR 210.30 (b) (v) also requires all food services directors regardless of the date of hire are required to complete eight hours of food safety every five years.
To demonstrate compliance with professional standards requirements:
- Provide a plan for the SFA's school food services director to complete the required eight hours of food safety training.
- Provide the above along with St. Mary's Catholic School's plan for corrective action to demonstrate compliance and understanding.
Meal Patterns: A review of 01/23/17 through 01/27/17 indicated some insufficient portion sizes at breakfast and lunch meals.
The breakfast meal pattern 7 CFR Part 220.8 (c) requires the following minimum serving sizes; 1oz. by weight bread/grain daily and 8-10 oz. per week, 1 cup Fruit daily, and 1 cup fluid milk daily, 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.
- The weekly serving size for the bread/grain component was not met. The SFA served 6.50 oz
The lunch meal pattern 7 CFR 210.10 (c) requires the following minimum serving sizes; 1 oz. by weight meat/meat alternate daily and 9-10 oz. per week, 1oz. by weight bread/grain daily and 8-9 oz. per week, 1/2 cup fruit daily and 2 ½ cups per week, ¾ cup vegetables daily (dark green subgroup ½ cup/week, red/orange subgroup ¾ cup/week, legumes subgroup ½ cup/per week, starchy subgroup ½ cup/week, and other subgroup ½ cup/week) 3 ¾ cups/week, and 1 cup fluid milk daily, 5 cups weekly, offered as a choice between 1% and fat free.
- 01/27/17: the salad with tomato wedge only credited at 5/8 cup.
- The weekly starchy vegetable subgroup was not meet. The SFA did not serve any vegetable in the starchy vegetable subgroup.
- The weekly vegetable serving was not met. The SFA served 3 5/8 cups of vegetables during the week assessed.
- The weekly serving size for the bread/grain was not met. The SFA served 7 oz. during the week being assessed.
The above insufficient serving sizes were determined to be non-systemic in nature.
The above vegetable subgroup finding was a first violation. State agency (SA) is exercising its discretion to not apply fiscal action for the vegetable subgroup finding.
The SA is exercising its discretion to not apply fiscal action for the 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 K-8.
- Bring all insufficient serving sizes and missing components in compliance with the meal patterns for grades K-8.
- Submit your plan for corrective action to demonstrate understanding and compliance.
Whole Grain-Rich (WGR) Bread/Grain: For the reviewed menu week of January 23, 2017 through January 27, 2017; your agency did not meet the 100% Whole Grain-Rich (WGR) requirement for bread/grain products served at breakfast, 7 CFR Part 220.8 (c) (2) (iv) and 7 CFR Part 210.10 (c) (2) (iv). The percentage for meeting the whole grain rich requirement was 69%.
The following items were determined not to be WGR:
- The pancakes served on 01/24/17 and 03/28/17.
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.
To demonstrate compliance with Whole Grain Rich Bread/Grain Requirements:
- Evaluate your products to determine if they meet the whole grain rich requirement. Replace any products you determine don't meet the WGR requirement.
- Provide a copy of your corrective action plan to demonstrate understanding and compliance.
Findings and Recommendations Identified During the On-Site Portion of the Review Conducted March 28, 2017:
The SFA served non-creditable food item as part of the meal component. During the On-Site portion of this AR 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 meat balls served on 03/28/17.
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 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.
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.
Reviewer's Comments: Overall the staff members working within St. Mary's Catholic School's school nutrition program are doing a good job. Ms. Little being in her first year managing the program is doing an excellent job. She seeks out assistance from SA and applies the direction provided by SA. There is a lot to learn to administer these programs at a school.