Name of Agency: Integris Mental Health Date of off-site review: 03-03-17
Reviewer: Matthew Smith Date of on-site review: 04-04-17
Persons interviewed: Tracey Williams Date of exit conference: 04-04-17
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 March 3, 2017:
Local Wellness Policy: At the time of the Off-Site review the assessment and update to the local wellness policy had not been completed. Also, your agency did not provide documentation of the last update to the local wellness policy. Your agency's local wellness policy needs to have the following added, 7CFR Part 210.30:
- The name and title of the person(s) assessing the policy. It is recommended no more than two people assess the policy.
- Names and titles of the wellness committee's members.
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. This documentation should include; mention the policy was assessed, state briefly what changes were made, who was present at the committee meeting, and the date of the meeting. The documentation of the most recent evaluation of the agency's local wellness policy was not provided to the State Agency (SA) reviewer during this Administrative Review (AR).
To compliance with local wellness policy requirements:
- Provide an updated copy of your agency's local wellness policy with the areas listed above added to the policy.
- Provide a copy of the documentation of the most recent evaluation of your agency's local wellness policy.
- Submit the above along with your corrective action plan to demonstrate understanding and compliance.
Procurement: At the time of the off-site portion of the Administrative Review (AR) the School Food Authority's (SFA) code of conduct was not provided. The 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 the procurement review the State Agency (SA) determined the SFA only received one price quotation for the procurement of food and supplies for the school year (2015-2016). The procurements fell under the small purchase procedure. When using the small purchase procedure to procure goods and services under $150,000, 2 CFR Part 200.320 (b) and 7 CFR Part 3016.36 (d) (1) requires SFA's to obtain quotations from an adequate number of sources (more than one).
The SFA also failed to provide a list of vendors and the amount spent with each vendor for school year 2015-2016 (using funds from the nonprofit school food services account) during this AR. The required documentation has yet to be provided as of the date of this report. This AR cannot be closed without this information.
To demonstrate compliance with Procurement:
- Write and approve a code of conduct.
- Provide your plan to ensure that price quotations from an adequate number of sources are obtained [2 CFR Part 200.320 (b) and 7 CFR Part 3016.36 (d) (1)].
- Provide a list of vendors with the amount spent with each out of the non-profit school food services account for school year 2015-2016.
- Provide copies of the above along with your plan for corrective action to demonstrate understanding and compliance.
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 (SFA informed of this review on 03/03/17).
The end of school year review revenue and expenses needs to be conducted for school year 2015-2016. The SFA will need to provide documentation of this review of revenue and expense to the SA in order for the comprehensive resource management review to be completed. The SFA will also need to provide the statements for the non-profit school food services account for the months of May and June of 2016. The SFA also only provided the invoices for US Foods for the month of June 2016; the SA reviewer will also need the requested invoices for the month of May 2016 for US Foods. The SA review received all other requested invoices. The comprehensive resource management review cannot be completed until this documentation is received. This AR cannot be completed until the comprehensive resource management review is completed.
To demonstrate compliance with year-end income and expense review of the School Food Service Account requirement:
- Provide a copy of the end of school year revenue and expense report for the non-profit school food services account.
- Provide copies of the account statement for the non-profit school food services account for the months of May and June of 2016.
- Provide copies of the invoices for the month of May 2016 for US Foods.
- Provide the above along with a plan for the annual review of the non-profit school food services account and the proper maintenance of cash balances to demonstrate understanding and compliance.
Meal Patterns: A review of 02/05/17—02/11/17 indicated some insufficient portion sizes 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.
- 02/09/17: the SFA only served one slice of bread that credits at 1 ounce toward the bread/grain component.
- This insufficient serving caused the weekly serving for the bread/grain component to be one ounce short of the minimum weekly serving.
The above insufficient serving sizes were determined to be non-systemic. 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.
Production Records: A review of the productions records, conducted during the Off-Site, indicated some issues with documentation. The production records for the salad bar did not contain the daily carrots and vegetable offerings. The salad bar production records only document the fruit offerings. The salad bar production records should document everything offered to children on the salad bar. 7 CRF Part 210.10 (a) (3) requires SFAs to keep productions records that document how the meals offered contribute toward the meal patterns to support the claim for reimbursement.
For serving sizes, document the serving sizes planned and served. For meats and meat entrees list the number of pieces, one slice, one burger, one sandwich, or serving in ounces (ex. 5 nuggets or 2 ounces slice). Unless fresh fruit is being served, fruits and vegetable are primarily list by cup size (ex. 1 whole banana, ½ Cup diced pears or ¾ Cup green beans). Using standardized recipes will help the agency in planning for the correct serving size.
For the total amount prepared, use actual weights. For meats or fresh vegetables, list the weight (ex. 10 lbs., 5 ounces) or total number of pieces prepared. For canned vegetables and fruits, document the weight of the can or specify the can size (ex. 2, 108 oz. cans or 1, # 10 can). For breads, pastas and grains, document the total weight or number of slices. For milk, document the number of gallons or pints used.
For the planned number of servings, documentation of food production should accurately note the amount of servings planned (including adults and second servings).
To demonstrate compliance with Production Documentation:
- Staff should begin immediately completing the daily salad bar production records by; listing all items served, listing components in the proper categories and documenting actual serving sizes.
- Ensure salad bar production records are complete.
- Provide a copy of one salad bar production records along with your corrective action plan to demonstrate understanding and compliance.
Record Keeping: The benefit issuance document provided at the time of the on-site did not document the date of certification and method of certification. The benefit issuance document is required by 7 CFR Part 245.6 (e) and the USDA Administrative Review Manual to have the method of certification and date of certification for each student. This allows you to track student eligibility for claiming purposes and for yearly verification reporting.
The SA provided your agency with an electronic version of a benefit issuance document that meets USDA requirements on 03/06/17.
To demonstrate compliance with record keeping:
- Immediately add the required columns to your benefit issuance document (date of certification and method of certification) or start using the SA provided benefit issuance document for RCCIs.
- Have a plan and document in place to begin gathering this data for each student.
- Please provide a copy of your updated benefit issuance document along with your corrective action plan to demonstrate understanding and compliance.
Findings and Recommendations Identified During the On-Site Portion of the Review Conducted April 4, 2017:
Buy American Provision: During the On-Site visit, food products were found that were 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 On-Site visit that were not domestically produced or manufactured:
- Dole diced peach cups produced in Thailand.
- Cherry tomatoes grown in Mexico.
- Strawberries grown in Mexico.
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.
To demonstrate compliance with the buy American provision:
- Review the products that are used in your school nutrition program for compliance with the buy American provision.
- Provide your corrective action plan to demonstrate understanding and compliance.
Counting and Claiming: A review of the counting system demonstrates a non-systemic counting error for the review period (February 2017). The error resulted in an under claim for the after school snack program for the month of February 2017, which caused a Performance Standard Violation I (PSI), 7 CFR Part 210.18 (g) (1) (ii). The error was non-systemic in nature and was an under claim for after school snack program count.
The error appeared to be a result of the February after school snack program count being entered into the claim form incorrectly. This incorrect entry caused the snacks to be under claimed.
Below are the differences, our reviewer identified, in your February snack count, when comparing the electronically generated edit check to the snacks listed on your agency's claim:
Free snacks were under claimed by 2 snacks.
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).
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.
- Provide copies of the following: your agency's edit checks for the meals claimed for March 2017 and the claim for March 2017.
- Provide the above copies, along with your corrective action plan to demonstrate understanding and compliance.
HACCP food safety plan: A required HACCP (Hazard Analysis Critical Control Points) food safety plan could not be found at the time of the On-Site visit [7 CFR Part 210.13 (c) requires each SFA to have a HACCP plan]. Your staff will need to develop and implement a comprehensive food safety plan. This process approach for preparing food must be used to insure that foods are stored and prepared properly. The plan should include all the appropriate documentation forms for monitoring and review.
A HACCP plan template was emailed to your agency on 04/05/17. This template contains everything needed to easily develop the missing plan.
Keeping foods safe is a vital part of healthy eating. When properly implemented, HACCP-based food safety programs help to ensure the safety of all meals. Agencies must routinely monitor and document food safety procedures.
To demonstrate compliance with HACCP food safety requirements:
- Use the sample HACCP plan provided as a guide and develop your plan.
- Provide a copy of; your HACCP plan's cover sheet, along with your corrective action plan to demonstrate understanding and compliance.
Reviewer's Comments: Overall the staff members for your agency are doing a good job running your agency's school nutrition programs. Keep in mind the employees who have the responsibility for the administration of the National School Lunch and School Breakfast Program have to have a large knowledge base in order to properly implement both programs. . Ms. Williams is doing a good job of maintaining a good understanding of the knowledge required to run these programs, as well as running the day to day operation of the SFA's school food service programs.
After observing your agency's kitchen in action I would like to commend Ms. Williams for operating well organized meal preparation and meal service for the meals that I observed. The employees all work well together and work as a team to get the residents of your facility feed in a calm and orderly fashion.