Name of Agency: Goodland Academy Date of off-site review: 09-8-16
Reviewer: Matthew Smith Date of on-site review: 10-12-16
Persons interviewed: Charla Stephens Date of exit conference: 10-12-16
This agency participates in 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 September 8, 2016:
Civil Rights: At the time of the Off-Site portion of this Administrative Review Goodland was not able to provide a copy of their policy for handling civil rights complaints. Under FNS Instruction 113-1, each School Food Authority (SFA) is required to have this policy.
Your agency also had no means to collect racial and ethnic data for each resident, FNS Instruction 113-1. Racial and ethnic data should be collected and recorded on your yearly Civil Rights Worksheet.
To demonstrate compliance with the civil rights requirements:
- Provide the tool used to document collection of race and ethnicity data for residents.
- Provide a copy of Goodland Academy's policy for handling civil rights complaints.
- Provide copies of the above documentation along with Goodland Academy's plan for corrective action to demonstrate understanding and compliance.
Local Wellness Policy: At the time of the Off-Site review the assessment and update to the local wellness policy had not been completed. This is required under 7 CFR Part 210.30 (e) (2). Also, your agency did not provide documentation of the last update to the local wellness policy as required under 7 CFR Part 210.30 (e) (2). Your agency's local wellness policy needs to have the following added:
- Set specific goals for each of these three categories; nutrition promotion, physical activity, and school-based activities that promote student wellness. The goals must be reviewed by the SFAs and the SFAs must consider evidence based strategies and techniques, as required by 7 CFR Part 210.30 (b) (1).
Goodland Academy had not posted their local wellness policy and documentation of the update publicly at the time of the On-Site portion of this review. 7 CFR Part 210.30 (d) (2) and 7 CFR Part 210.30 (d) (3) require SFAs to inform the public about the content of the policy and inform the public of the updates to the local wellness policy.
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.
To demonstrate compliance with the local wellness policy:
- The meal served on 08/15/16, was served with an orange. The Food Buying Guide credits oranges at most at 5/8 of a cup.
- The meal served on 08/17/16 was served with ½ cup of grapes.
- The meal served on 08/18/16 was served with ½ cup of strawberries.
- The meal served on 08/19/16 was served with ½ cup of cantaloupe.
- The meal served on 08/21/16 was served with a banana for the fruit component. The Food Buying Guide credits bananas at ½ cup.
The weekly serving for fruit was insufficient due to the daily insufficient serving sizes. Goodland only served 4 5/8 cup of during the week of 08/15/16 through 08/21/16.
Missing Meal Component
On 08/16/16 this meal was served without the bread/grain meal component.
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 6 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) 6 cups/week, and 1 cup fluid milk daily, 6 cups weekly, offered as a choice between 1% and fat free.
The meal served on 08/15/16 this meal with a peanut butter sandwich that credited only 1 oz. toward the meat/meat alternative meal component.
- This meal was served with ¾ cup of celery.
- This meal was also served with bread that only credits at 1.75 oz. for two slices.
The meal served on 08/17/16, a banana was served for the fruit component. The Food Buying Guide credits bananas at ½ cup.
The meal served on 08/18/16, the cheddar cheese on the cheddar cheese grilled sandwich only credited at 1 oz.
- This meal was served with ¾ cup of cucumber slices for the vegetable component.
- The bread used for the sandwich only credits at 1.75 oz. for two slices.
- The meal was served with ¾ cup of carrots.
- This meal was served with ½ cup of romaine lettuce and ¼ cup of tomato slices. The vegetables in this meal credit at ½ cup.
The weekly vegetable minimum serving size was not met for the week of 08/15/16 through 08/21/16. Goodland Academy only served 3 ½ cups of vegetables.
The weekly serving size for the red/orange subgroup was not met (1 cup was served), the dark green subgroup was not met (1/4 cup was served), and the bean/peas subgroup was not met (none were served).
Missing Meal Component
- The meal served on 08/17/19 was served without the vegetable component.
The missing meal components are a Performance Standard 2 (PS2) violation that will require fiscal action, 7 CFR 210.18 (g) (2).
The State Agency (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).
The systemic errors in menu planning listed above reflect what the USDA considers severe noncompliance and identifies your agency as High-risk. Agencies identified as High-risk require a full breakfast and lunch nutrient analysis to be completed, before our office can close out the review.
Due to the violations described above; our office also has no choice but to remove the 6 cents, per lunch, performance-based reimbursement, beginning with November's claim. The performance-based cash assistance may resume beginning in the first full month your agency can demonstrate corrective action has taken place.
It is very important your staff 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 everything served as part of a reimbursable meal is documented.
Corrections for the insufficient quantities and missing meal components were made for the breakfast and lunch menus for the week of 08/15/16 through 08/21/16 prior to the nutrient analysis being conducted.
No further action is required regarding the insufficient quantities and missing meal components.
Nutrient Analysis: An analysis was conducted on the menu week previously assessed, August 15 through 21, 2016.
The nutrient analysis discovered errors for both the breakfast and lunch meals for the week of August 15 through 21, 2016.
The nutrient analysis for the breakfast meals showed the average calories for the week was at 607 calories. This exceeded the maximum average calories of 600 calories as established by 7 CFR Part 220 (c). The breakfast meals were found to have a sodium average for the week of 750 mg. This exceeded the maximum allowable average of 640 mg. as established by 7 CFR Part 220 (C).
Goodland Academy corrected both errors bringing both the average calories for the week and the average sodium for the week into compliance prior to this report being completed.
No further action is required regarding the errors found for the breakfast meals for the week of 08/15/16 through 08/21/16.
The nutrient analysis for the lunch meals were found to have a saturated fat percentage in excess of the maximum of 10% as established by 7 CFR Part 210.10 (c). Your saturated fat was at 10.71%.
To demonstrate compliance with Saturated fat Nutrient target:
- Submit a plan to correct the saturated fat percentage for the week exceeding 10% of the calories for the week.
- Review the rest of your menus for compliance with the meal patterns.
- 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 the AR both the code of conduct and the School Food Authority's (SFA) procurement policy were 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.
Each SFA must also 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 school'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 an items used in the school food service program. The school district can determine the extent of the plan. An SFA may implement a plan that applies to all schools under its jurisdiction, or allow each school to implement an individual plan. A new procurement plan does not need to be developed every year.
Prior to the On-Site portion of this Administrative Review Goodland provided copies of their procurement plan and code of conduct. No further action is required regarding procurement requirements.
Findings and Recommendations Identified During the On-Site Portion of the Review Conducted October 11 and 12, 2016:
Counting and Claiming: A review of the counting system demonstrates non-systemic counting errors for the review period (August 2016), which results in a Performance Standard Violation I (PSI), 7 CFR Part 210.18 (g) (1) (ii). The errors were non-systemic in nature and appeared to be human error when adding up the monthly totals for lunch meals on the paper based edit check.
Goodland Academy had an under claimed of seven lunch meals for the month of August. Goodland Academy claimed 224 lunches for the month of August. Upon review the State Agency (SA) reviewer discovered that Goodland Academy served 230 lunches during the month of August.
Goodland Academy also had an under claim for the snacks served in the month of August. Goodland Academy claimed 135 snacks on their August claim. During the review conducted by the SA reviewer it was discovered through the snack meal roster that 138 snacks were served to the residents in the month of August.
No errors were found for Goodland Academy's August claim for breakfast meals, 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 consolidation of daily meal counts.
- Begin using the electronic edit check daily to record meal counts instead of the paper edit check that YSBC is currently using.
- Provide copies of October 2016's completed meal rosters, a copy of October 2016's claim, and copies of October 2016's edit check forms, along with your corrective action plan to demonstrate understanding and compliance.