Administrative Review Summary Report
Name of Agency: St. Anthony Hospital BMC Date of off-site review: 11-10-16
Reviewer: Matthew Smith Date of on-site review: 12-13-16
Persons interviewed: Ashlei Graham and Date of exit conference: 12-13-16
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 November 10, 2016:
Civil Rights: St. Anthony Hospital Behavioral Medicine Center (BMC) did not have a policy for handling civil rights complaints. FNS Instruction 113-1 requires each SFA to have a policy for handling civil rights complaints. The State Agency (SA) reviewer emailed a prototype policy for handling civil rights complaints on 11/14/16.
To demonstrate compliance with Civil Right:
- Provide a copy of St. Anthony Hospital BMC's policy for handling civil rights complaints.
- Submit the above along with your 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 local wellness policy needs to have the following added:
- The goals for school based activities. This is required to meet the requirements under 7 CFR Part 210.30 (c) (1).
- The name and title of the person(s) designated to assess St. Anthony Hospital BMC's local wellness policy and to ensure the policy's implementation and that your agency is compliant with your local wellness policy. 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.
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.
No further action is required regarding the local wellness policy.
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 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 your school to ensure costs incurred to the account are necessary, reasonable, and allowable.
Prior to the On-Site visit St. Anthony Hospital BMC completed a review of the school's revenue and expenses for the previous year. The revenue and expense documentation you provided indicated cash resources did not exceed three months' average operating costs [7 CFR Part 210.14 (b)]. The year-end report indicated St. Anthony Hospital BMC had a deficit of $23,233.51.
To demonstrate compliance with year-end income and expense review of the School Food Service Account requirement:
- Provide a plan for the annual review of account and the proper maintenance of cash balances to demonstrate understanding and compliance.
Procurement: Your agency did not have a procurement policy available for review, the code of conduct provided failed to meet requirements, and documents our office requested to adequately review your procurement practices were not provided.
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 did not prohibit employees from soliciting or accepting gratuities, favors, or anything of monetary value from contractors or parties of subcontracts [as required by 2 CFR 200.318 (c) (1) and 7 CFR Part 3016.36 (3) (1-1v)].
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 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 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. 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.
Your agency failed to provide all the documentation requested for our office to adequately review your procurement practices. Copies of your contract(s) for procurement of goods and services were not provided. The reviewer requested the contract(s) for the procurement documentation throughout this AR. The SFA also failed to provide a list of vendors and the amount spent with each vendor for school year 2015-2016. The required documentation has yet to be provided as of the date of this report.
To demonstrate compliance with the procurement requirements:
- Provide a copy of your agency's procurement plan.
- Provide a copy of your agency's code of conduct that addressees employees not accepting or soliciting gratuities, favors, or anything of monetary value from contractors or parties of subcontractors, as required by 2 CFR 200.318 (c) (1) and 7 CFR Part 3016.36 (3) (1-1v).
- Provide a plan for providing SA requested procurement documentation and information.
- Provide SA with a list of the vendors from school year 2015-2016, along with the amount spent with each vendor.
- Provide SA with contracts for procurements of $150,000 or above.
- Provide the above along with your corrective action plan demonstrate understanding and compliance.
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, 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 63%.
The following items were determined not to be WGR:
- The raisin toast served with breakfast meals on 10/14/16 and 10/15/16.
- The blue berry muffins served at breakfast on 10/13/16.
- The banana muffins served with the breakfast meal on 10/16/16.
- During the On-Site visit biscuits that were in a freezer were being used for the SFA's school nutrition program. The labeling on the box indicated the biscuits were not WGR, the SFA claimed they were using the box due to it being easier to store.
- At the time of On-Site Apple Jacks cereal used by the SFA was determined to not be WGR.
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.
Trans-Fat requirement: A review of product nutrition information indicated you're serving a product containing trans-fats. The gravy served for lunch on 10-12-16 contained 1.5 grams of trans-fats. 7 CFR Part 210.10 (f) (4) and 7 CFR Part 220.8 (f) (4) requires food products and ingredients used to prepare school meals must contain zero grams of trans-fat (less than 0.5 grams) per serving.
Schools must indicate the need for trans-fat free products when relaying product specifications to potential vendor during the procurement process. Cafeteria staff should review documentation for food products and ingredients (nutrition label or manufacturer specifications) to ensure all products contain zero grams of trans-fat per serving.
To demonstrate compliance with the Trans-Fat requirement:
- Staff should begin regularly reviewing nutrition labels and other product documentation to ensure all items are trans-fat free.
- If your staff identifies items containing trans-fats, their use should be discontinued and they should work with suppliers to procure suitable trans-fat free replacements.
- Provide a copy of your corrective action plan 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 sliced brisket served on 10/10/16.
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.
Findings and Recommendations Identified During the On-Site Portion of the Review Conducted December 13, 2016:
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:
- Pineapple that was produced in the Philippines.
- Mandarin oranges that were produced in China.
- Ardmore Farms 100% fruit juice that had concentrates from the United States, China, Chile, and Argentina.
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.
HACCP: During the review several poor food safety practices and HACCP violations were observed. The reviewer observed food debris on the floor, several sinks in the kitchen that were backed up with food, observed no sanitizer buckets in use during lunch preparation. An employee was observed placing a thermometer on a visibly unclean prep surface just prior to use. This thermometer was then rinsed in the sink and not sanitized prior to being returned to its storage sheath. The miss use of the thermometer is particularly troubling because it is a text book example of how food borne illnesses are spread through cross contamination.
During the On-Site visit it was discovered that there were issues with a couple of the freezers and one of the refrigeration units. The first issue was one of the freezers (on the temperature log designated St. A-p sm wlk in frz-1002226) was reading a temperature range of 11.3 degrees to 25.8 degrees. On 11/33/16, another freezer (St. A-p lg wlk in frz-1002224) had a reading of 11.3 degrees for over six hours. Also one of the refrigeration units (St. A-P meat wlk in-1002227) had a reading of 46.3 degrees. When you monitoring activities indicate that cold storage units are out specified temperature ranges, maintenance should be called so the problems can be quickly remedied.
Sodexo has documentation showing completion of the monthly food safety inspections, as required by your agency's HACCP plan [which keep your agency in compliance with 7 CFR Part 210.13 (c) (2) (iv)]. The proper use of monthly self-inspections should eliminate these findings before our office or the Health Department ever arrives on site. The appearance of the kitchen and the observation of employee practices, indicates that your staff is not following your own food safety procedures and is putting the customers you serve at undue risk.
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 on HACCP best practices.
- Provide a copy of the training log to demonstrate food service staff received the above training along with your corrective action plan to demonstrate understanding and compliance.
Fluid Milk Substitute: During the On-Site visit it was discovered the SFA was serving a fluid milk substitute that did not meet the requirements documented in 7 CFR Part 210.10 (c) (ii) (3). The SFA was serving Silk Soy Milk that only had 6 grams of protein. 7 CFR Part 210.10 (c) (ii) (3) requires fluid milk substitutes to have 8 grams of protein.
Keep in mind the requirements listed below when selecting a fluid milk substitute to ensure the product meets 7 CFR Part 210.10 (c) (ii) (3).
7 CFR Part 210.10 (c) (ii) (3) has the following requirements for fluid milk substitutes:
(8 fl oz)
|Vitamin A||500 IU.|
|Vitamin D||100 IU.|
|Vitamin B-12||1.1 mcg.|
To demonstrate compliance with fluid milk substitute requirements:
- Replace the Silk Soy Milk that does not meet program requirements with a product that meets the requirements in 7 CRF Part 210.10 (c) (ii) (3).
- Provide your corrective action plan to demonstrate understanding and compliance.
Reviewer's Comments: Overall, the staff members at St. Anthony Hospital BMC are doing a good job with the school nutrition program. The counting and claiming system look good.
The storage of the food products for the school nutrition program is a bit confusing for an outsider or new staff members working in the kitchen. The school nutrition program's food products are stored with products used for other programs at the hospital. While there were no storage violations, I recommend more labeling of the areas where school nutrition program food products are stored. I further recommend not storing other food products in those areas designated for the school nutrition program food products. I observed other products being stored in areas designated for the school nutrition program during the On-Site visit on 12/13/16.
Again I want to commend your agency on all the good work that is being done in your school