Administrative Review Summary Report
Administrative Review Summary Report
Date: 11-23-22
Name of Agency: Marie Detty Youth and Family Service Centers, Inc.
Date of off-site review: 09-06-22
Reviewer: Matthew Smith Date of on-site review: 10-18-22
Persons interviewed: Rita Colomb, Dwight Shegog, Date of exit conference: 11-09-22
and Kelly Walton
This School Food Authority (SFA) operates the National School Lunch Program, the School Breakfast Program, and the After School Snack Program.
The following areas were corrected prior to the On-Site Portion of this Administrative Review (AR):
· Professional Standards – Eight Hour Food Safety Training: The school food services director (Kelly Walton) did not complete eight hours of food safety training within 30 days of starting in the position or within five years of starting in the position [as required by federal regulation 7 CFR Part 210.30 (b) (1) (v)]. Prior to the beginning of the Administrative Review, Mr. Walton completed eight hours of food safety.
No further action is required for the above.
Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted September 6, 2022:
Local Wellness Policy: The local wellness policy provided by Marie Detty Youth and Family Service Centers, Inc. (MDYFSC) did not contain the following required areas:
· The policy does not have an area of the policy for the goals for nutrition promotion. Federal regulation [7 CFR Part 210.31 (c) (1)] requires local wellness policies to contain goals for nutrition promotion.
· The policy does not contain the guidelines and standards for marketing of food and beverages on campus during the school day [as required by federal regulation 7 CFR Part 210.31 (c) (3) (iii)].
· The policy does not contain a description of how and when the policy is to be assessed as required by federal regulation [7 CFR Part 210.31 (c) (5)]. Federal regulation [7 CFR Part 210.31 (e) (2)] requires local wellness policies to be assessed at least once per every three years.
· The policy does not designate personnel with the responsibility for assessing the policy [as required by federal regulation 7 CFR Part 210.31 (e) (1)].
· The policy does not list the local wellness committee membership [as required by federal regulations 7 CFR Part 210.31 (c) and 7 CFR Part 210.31 (d) (1)].
· The policy does not contain a description of the manner in which the public is provided with the opportunity to participate in the local wellness policy process [as required by 7 CFR Part 210.31 (c) (5)]. The description should include those things your agency is doing to encourage public involvement with the local wellness policy process.
Update MDYFSC’s local wellness policy to include all required areas.
To demonstrate compliance with local wellness policy requirements:
· Update MDYFSC’s local wellness policy to include the above required areas.
· Publicly post the updated local wellness policy at both sites.
· Provide a copy of the updated local wellness policy along with MDYFSC’ plan for corrective action to demonstrate understanding and compliance.
Meal Patterns: During the menu week assessed 08/22/22 – 08/28/22 there were some insufficient serving sizes for the lunch menus served.
The lunch meal pattern 7 CFR 210.10 (c) requires the following minimum serving sizes for the grades 9 – 12 meal pattern:
Meal Component |
Required Serving |
Bread/Grain |
2 oz. by weight daily and 14 – 17 oz. per week |
*All items used to meet the daily and weekly bread/grain servings must be Whole Grain-Rich. |
Fruit |
1 cup daily and 7 cups per week |
*Up to half of the weekly serving can be met with the use of 100% fruit juice. |
Meat/Meat Alternative |
2 oz. by weight daily and 14 – 17 oz. per week |
Milk |
1 cup daily and 7 cups per week |
*Residents must be given a choice of milk from fat free unflavored, fat free flavored, and 1% unflavored. **One of the choices must be unflavored. |
Vegetable |
1 cup daily and 7 cups per week |
Vegetable Subgroups to be offered throughout the week |
|
-Dark Green ½ cup -Red/Orange 1 ¼ cup -Legume ½ cup per week -Starchy ½ cup -Other ¾ cup |
|
Insufficient Quantities for the Menu Week 08/22/22 – 08/28/22
§ The menu served on 08/25/22 had an insufficient daily serving size for the meat/meat alternative component. The fish sticks served only credited 1.5 oz. toward this component’s daily serving.
§ The menu served on 08/25/22 had an insufficient daily serving size for the vegetable component. The salad served only credited at ½ cup toward this component’s daily serving.
§ The minimum required weekly serving for the red/orange vegetable subgroup was not met. The menus served during the week could only credit 1 1/8 cups of vegetables toward this subgroup.
§ The minimum required weekly serving for the meat/meat alternative component was not met. The menus served during the week only credited 13.5 oz. toward this components weekly serving.
The above insufficient serving sizes were determined to be non-systemic in nature.
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).
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 MDYFSC’s plan for corrective action to demonstrate understanding and compliance.
The weekly amount of fruit served exceeded the allowable amount of fruit juice used to meet meal pattern requirement: The breakfast and lunch menu week assessed (08/22/22—08/28/22) MDYFSC met part of the weekly fruit serving requirement by using 100% fruit juice. For the menu week assessed both breakfast and lunch exceeded the maximum percentage of 100% fruit juice used to meet the weekly serving. Federal regulations [7 CFR Part 210.10 (c) (2) (ii) and 7 CFR Part 220.8 (c) (2) (ii)] require no more than half of the weekly serving of the fruit component may be met using 100% fruit juice for both the breakfast and lunch meal patterns. The following are the percentage of the weekly serving for the percentage of the weekly servings met by the use of 100% fruit juice for the week of 08/22/22 – 08/28/22:
- Breakfast: The percentage of the weekly serving met using 100% fruit juice was 63.64%.
- Lunch: The percentage of the weekly serving met using 100% fruit juice was 61.11%.
It is recommended if 100% fruit juice is used to meet the daily serving requirements for the fruit component of a meal, that only half of the daily serving be met using 100% fruit juice (half cup), and the other half cup be met using canned, fresh, or frozen fruit.
To demonstrate compliance with fruit juice weekly serving requirements:
- Review your menus for compliance with weekly fruit juice serving requirements
- Submit MDYFSC’s plan for corrective action to demonstrate understanding and compliance.
Findings and Recommendations Identified During the On-Site Portion of the Review Conducted October 18, 2022:
Counting and Claiming: A review of the counting system demonstrates systemic counting and claiming errors for the review period, August 2022, 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 was found for breakfast and lunch monthly counts.
Below are the differences, our reviewer identified, in MDYFSC’s August lunch counts, when comparing the meal roster to the meals listed on MDYFSC’s claim:
|
MDYFSC Roster Counts |
MDYFSC’s August Claim |
OKDHS School Nutrition Programs Count |
Difference |
Free |
353 |
353 |
345 |
+8 |
Free lunch meals were over claimed by eight meals.
Below are the differences, our reviewer identified, in MDYFSC’s August breakfast counts, when comparing the meal roster to the meals listed on MDYFSC’s claim:
|
MDYFSC Roster Counts |
MDYFSC’s August Claim |
OKDHS School Nutrition Programs Count |
Difference |
Free |
468 |
468 |
470 |
-2 |
Free breakfast meals were under claimed by two meals.
The errors for the lunch over claim appears to be from five days (08/10/22, 08/12/22, 08/19/22, and 08/22/22) during the month where MDYFSC had data entry errors in the edit check that carried over into the reimbursement claim. The errors for the breakfast under claim appears to be from two days where MDYFSC under counted the meals by one (on 08/18/22 and 08/20/22).
7 CFR Part 210.8 (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 requirements:
- 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: meal rosters for November 2022, edit check forms for November 2022.
- Provide the above copies, along with MDYFSC’s plan for corrective action to demonstrate understanding and compliance.
Procurement Review Summary Report
Date: 11-23-22
Name of Agency: Marie Detty Youth and Family Service Center, Inc.
Date of AR off-site review: 09-06-22
Reviewer: Matthew Smith Date of AR on-site review: 10-18-22
Persons interviewed: Rita Colomb Date of exit conference: 11-09-22
This School Food Authority (SFA) operates the National School Lunch Program, the School Breakfast Program, and the After School Snack Program.
Procurement Plan: The procurement plan provided does not address the use of the micro-purchase method of procurement. Federal regulation [2 CFR Part 200.318 (a)] requires School Food Authorities (SFA) to have a procurement plan documenting the procurement practices the SFA uses.
To demonstrate compliance with procurement plan requirements:
- Update Marie Detty Youth and Family Service Centers, Inc.’s (MDYFSC) procurement plan to address the use of the micro-purchase method of procurement.
- Provide documentation of the update to MDYFSC’s procurement plan along with MDYFS’s plan for corrective action demonstrating understanding and compliance.
