Name of Agency: Youth Services of Bryan County (YSBC) Date of off-site review: 09-06-16
Reviewer: Matthew Smith Date of on-site review: 10-10-16
Persons interviewed: Petra Watson and Date of exit conference: 10-11-16
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 6, 2016:
After School Snack Program Monitoring Checklist: At off-site review, your agency did not have documentation the monitoring review of your After School Snack Program was completed. Agencies must ensure staff responsible for the operation of the program comply with USDA requirements. Agencies must designate a person to review the After School Snack Program a minimum of two times a year as required by . Agencies should use the monitoring checklist supplied by our office. The first review must be conducted during the first four weeks of snack service.
Your agency needs to conduct the first review immediately. For each no answer on the form, you must take corrective action to ensure compliance. Keep the checklist and all supporting documentation on file according to federal recordkeeping requirements. The second review will need to be conducted prior to the end of the school year (June 30, 2017).
To demonstrate compliance with After School Snack Monitoring requirements:
- Conduct the first snack review and document any corrective action taken.
- Provide a copy of the completed monitoring checklist, along with your corrective action plan to demonstrate understanding and compliance.
Civil Rights: Youth Services of Bryan County (YSBC) did not have a policy for handling civil rights complaints, FNS Instruction 113-1. Prior to the On-Site portion of this Administrative Review YSBC, adopted a policy for handling civil rights complaints and provided the SA with a copy.
No further action is required regarding YSBC's policy for handling civil rights complaints.
YSBC also had no means to collect race and ethnic data for each resident, FNS Instruction 113-1. Prior to the On-Site portion of the AR, YSBC added questions to their intake and enrollment paperwork collecting each student's race and ethnicity.
No further action is required regarding racial and ethnic data collection.
Also your agency had not completed the required annual staff civil rights training. Upon review of YSBC's training documentation it does not appear as if YSBC has held the annual civil rights training for a few years. 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 YSBC held its annual civil rights training. The training sign in sheet, provided, only documented staff at the shelter completed the training. There was no documentation, of training, for staff members at the Bryan County Juvenile Detention Center.
To demonstrate compliance with the civil rights requirements:
- Conduct the civil rights training with the staff members who work at the Bryan County Juvenile Detention Center and have duties within YSBC's school food service program.
- Provide documentation that this training was conducted with the staff members at the Bryan County Juvenile Detention Center who have duties within YSBC's school food service program.
- Submit the requested documentation along with YSBC's plan for corrective action to demonstrate understanding and compliance.
Fiscal Management: A review of the YSBC's food services account identified net cash resources (operating balance) totaled $6,185.43 for the review period. 7 CFR Part 210.14 (b) requires schools to limit their net cash resources to an amount that does not exceed 3-months' worth of average expenditures for its nonprofit school food service account.
Based on school year 2015-2016's year ending expenditures of $8,729.11. This means the allowable carryover would be $2,182.29, based on 3 months' average of your expenditures. Your program was $4,003.14 over the allowable amount. The overage will have to be spent down to no more than the allowable amount of $2,182.29.
To demonstrate compliance with Fiscal Management:
- Create and provide a copy of YSBC's plan to spend down the excess balance ($4,003.014) in the food services account.
- Submit your 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 local wellness policy needs to have the following added:
- The name and title of the person(s) designated to assess YSBC'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).
Names and titles of the wellness committee's members. This is required to meet the requirements set up under 7 CFR Part 210.30 (c) (5) and 7 CFR Part 210.30 (d) (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.
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.
Prior to the On-Site your agency updated the local wellness policy and posted it publicly, but it was still missing the required entries list above.
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 YSBC's plan for corrective action to demonstrate compliance and understanding.
Meal Patterns: A review of 08/15/16 through 08/21/16 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 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.
- The meal on 08/15/16 was served with an orange. The Food Buying Guide credits oranges at 5/8 of a cup at most.
- The meal on 08/16/16 was served with only ½ cup of 100% apple juice.
- The meal on 08/17/16 was served with only ½ cup of 100% orange juice.
- The meal on 08/18/16 was served with a banana. The Food Buying Guide credits bananas at a maximum of ½ cup.
- The meal on 08/19/16 was served with only ½ cup of 100% grape juice.
- The meal on 08/20/16 was served with only ½ cup of 100% orange juice.
- The meal on 08/21/16 was served with only ½ cup of 100% apple juice.
YSBC only served 3 5/8 cup of fruit during this week.
The weekly fruit component was 68.97% met with 100% fruit juice. This will need to be brought down to no more than 50% of the weekly fruit component met by using 100% fruit juice.
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 meal served on 08/15/16 was served with a banana. The Food Buying Guide credits bananas at a maximum of ½ cup.
- The meal served on 08/18/16 was served with a banana. The Food Buying Guide credits bananas at a maximum of ½ cup.
- The bread served with this meal only can only be credited at 1.75 oz. for two slices.
- The meal served on 08/20/16 was served with pasta and a slice of bread that credited at 1.75 oz. toward the bread/grain component.
- The weekly fruit component serving size was not met. YSBC served 5 ½ cups of fruit.
- The weekly serving size for the bread/grain component was not met. YSBC served 13.50 oz.
The weekly serving size for the red/orange vegetable subgroup was not met. YSBC only served ¾ cup of red/orange vegetables.
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.
A nutrient analysis was conducted on the menu week previously assessed, August 15 through 21, 2016.
Corrections for the insufficient quantities were made for the breakfast and lunch meals for the week of 08/15/16 through 08/21/16 prior to the nutrient analysis being conducted. YSBC made the necessary corrections for the nutritional deficiencies found during the nutrient analysis bringing the week assessed into compliance with the meal pattern requirements.
No further action is required regarding meal patterns and the nutrient analysis. However we recommended you review all breakfast and lunch menus for meal pattern compliance.
Due to the violations described above; our office has no choice but to remove the 6 cents, per lunch, performance-based reimbursement, beginning with November's claim. The performance-based cash assistance will resume beginning in the first full month your agency can demonstrate corrective action has taken place.
We have also chosen to exercise our discretion and not apply fiscal action for the above insufficient quantities as allowed for under 7 CFR Part 210.18 (g) (2).
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 breakfast and lunch, 7 CFR Part 220.8 (c) (2) (iv) and 7 CFR Part 210.10 (c) (2) (iv). For breakfast the percentage for meeting the whole grain rich requirement was 90%. For the lunch the percentage for meeting the whole grain rich requirement was at 78%.
- The biscuits served on 08/16/16 and 08/19/16 were not WGR and will have to be replaced. During the nutrient analysis the use of the biscuits was replaced with bread. YSBC has an exemption for bread for this school year. It is recommended that a WGR bread be found that weighs at least 28 grams per slice.
- The Texas toast used to make the French toast strips on 08/17/16 was not WGR. YSBC has an exemption for bread. Keep in mind this exemption will expire at the end of this school year. Alternative bread that is WGR will have to be found to substitute in for the Texas Toast when the exemption expires.
- The pancake recipe used to make the pancakes served on 08/20/16 was not WGR. The recipe was replaced with an USDA recipe that is WGR prior to the nutrient analysis being conducted.
- The tortilla used for the breakfast burrito served on 08/21/16 was not WGR. This tortilla was replaced with a WGR tortilla prior to the nutrient analysis being conducted.
- The rice used in the Spanish rice recipe served on 08/15/16 was not WGR. The rice was replaced in this recipe with a WGR brown rice prior to the nutrient analysis being conducted.
- The tortilla used for the beef taco pie serve on 08/15/16 was not WGR.
- The Italian bread recipe used to make bread served on 08/16/16 was not WGR. This was replaced with a WGR USDA Italian bread recipe prior to the nutrient analysis being conducted.
- The corn bread recipe used to make the bread served on 08/17/16 and 08/19/16 was not WGR. This recipe was replaced with a WGR USDA recipe for cornbread prior to the nutrient analysis being conducted.
- The bread used to make the toast turkey, ham, and cheese sandwich served on 08/18/19 was not WGR. YSBC has exemption for bread. Keep in mind this exemption will expire at the end of this school year. Alternative bread that is WGR will have to be found to substitute in for the non WGR bread when the exemption expires.
- The pasta used in the chicken tomato bake recipe was not WGR that was served on 08/20/16 is not WGR. This pasta was replaced with WGR pasta prior to the nutrient analysis being conducted.
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 State Agency (SA) conducting a nutrient analysis of the menu week being assessed all WGR findings were corrected.
No further action is required regarding Whole Grain Rich Bread/Grain requirements. However it is recommended that you evaluate all the products you use to ensure they are WGR.
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 procurement procedures used by the SFA. All procedures must adhere to the federal requirements. 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. Agencies can determine the extent of the plan. A new procurement plan does not need to be developed every year.
Prior to the On-Site portion of this Administrative Review, YSBC provided their procurement plan and code of conduct.
No further action is required regarding procurement.
Professional Standards: YSBC does not have a school food services training tracking tool for the hours completed by employees with duties within the school food service program as required in the 7 CFR 210.15 (b) (8), USDA Memo SP38-2016, and the Administrative Review Manual for school year 2016-2107. The Administrative review manual requires the tracking tool to cover the following key areas:
- Training topic
- Learning objectives
- USDA Training codes
YSBC was given a SA developed training tool during the Off-Site portion of the Administrative Review and asked to complete the tool for all employees with duties within the school food service program.
To demonstrate compliance with professional standards requirements:
- Ensure all training is entered correctly into the SA provided tracking log (TA was provided by the reviewer, by completing the log using training information provided on 10/24/16).
- Submit your corrective action plan to demonstrate understanding and compliance.
Findings and Recommendations Identified During the On-Site Portion of the Review Conducted October 10 and 11, 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 error was non-systemic in nature and appeared to be human error when adding up the daily and monthly totals for breakfast meals.
The error resulted in an under claimed of 1 breakfast meal. YSBC claimed 201 breakfasts for the month of August, 202 meal was the actual number verified by the reviewer. No errors were found for YSBC claim for the lunch meals and snacks in the month of August (2016). 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.
HACCP food safety plan: At the time of the on-site review your agency had not conducted the monthly self-inspections as required by your agency's HACCP plan. The monthly self-inspections keep your agency in compliance with 7 CFR 210.13 (C) (2) (iv) which requires SFA's HACCP plan to have monitoring procedures in place to ensure compliance with their plans. The last self-inspection was completed in December 17, 2015.
Monthly self-inspections are required for both kitchens. It is important the person in charge of the inspections takes them seriously, so your staff can swiftly rectify any problems before they become more serious issues.
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:
- Review your HACCP/food safety plan.
- Train food service staff on proper food safety procedures and instruct them on properly completing the logs and self-inspection forms.
- Conduct the monthly review of both kitchens.
- Provide a copy of the completed monthly review for both kitchens, along with your corrective action plan to demonstrate understanding and compliance.