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Administrative Review Summary Report

Administrative Review Summary Report

Date:  05-19-20

Name of Agency:  Marie Detty Youth and Family Services, Inc.

            Date of off-site review: 03-03-20

Reviewer:  Matthew Smith                                                     Date of on-site review: 05-05-20

Persons interviewed:  Rita Colomb                                        Date of exit conference: 05-11-20

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):

        • Civil Rights: At the time of the Off-Site visit the written procedure for handling civil rights complaints was not provided. FNS Instruction 113-1 requires SFAs to have a written procedure for handling civil rights complaints.  During the Off-Site portion of this review, our office's prototype procedure for handling civil rights complaints was sent by emailed to MDYFS. Prior to the completion of the On-Site portion of this AR, Marie Detty Youth and Family Services, Inc. (MDYFS) provided their written procedure for handling civil rights complaints that was compliant with federal regulations.
  • Failure to Provide Records:  MDYFS failed to provide their local wellness policy a t the time of the Off-Site visit [7 CFR Part 210.9 (b) (17)].  Prior to the On-Site visit the MDYFS provided a copy of their local wellness policy.
  • Local Wellness Policy: The local wellness policy provided during the review needed to have the following added: the goals for nutrition promotion [7 CFR Part 210.31 (c) (1)], a description of how and when the policy is to be assessed [7 CFR Part 210.31(c) (5)], designation of personnel with the responsibility for the assessment of the policy [7 CFR Part 210.31 (e)], guidelines and standards for the marketing of food and beverages during the school day [7 CFR Part 210.31 (c) (6)], and the names and titles of the members of the local wellness committee added to the policy [7 CFR Part 210.31 (c) (5) and 7 CFR Part 210.31 (d) (1)].

    At the time of the Off-Site the SFA did not have their local wellness policy posted publicly as required by 7 CFR Part 210.31 (d) (2).  Prior to the On-Site portion of this AR the MDYFS posted their local wellness policy publicly.

Corrective action for the above was made prior to the On-Site portion of this AR.  No further action is required for the above.  

Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted March 3, 2020:

Civil Rights: During the off-site portion of the review it was determined that your agency was not complying with the USDA's Civil Rights requirements. 

The non-discrimination statement posted on MDYFS web site is not the current USDA approved non-discrimination statement.  FNS Instruction 113-1 requires the most current non-discrimination statement be used on School Food Authorities' (SFA) websites.  The current non-discrimination statement was provided by email on 03/11/20. 

The intake forms for both sites (Parker Pointe and the shelter) used to collect data on race and

ethnicity did not have a space for data on ethnicity to be gathered as required by FNS

Instruction 113-1.  FNS Instruction 113-1 requires this data to be collected using a two questions format separating data on ethnicity from the data on race.  The USDA defines ethnicity as Hispanic and non-Hispanic, and race is defined as the following:

  • American Indian or Alaskan Native
  • Asian
  • Black or African American
  • Native Hawaiian or Other Pacific Islander
  • White

Both intake forms will need to be updated to add the separate items where data on ethnicity is gathered as required by FNS Instruction 113-1.

To demonstrate compliance with civil rights requirements:

  • Update MDYFS website to include the current USDA approved non-discrimination statement.
  • Update the intake forms for Parker Pointe and the shelter to gather data on ethnicity and race as described above.
  • Provide copies of the updated intake forms for Parker Pointe and the shelter.
  • Provided the above documents and MDYFS' corrective action plan to demonstrate understanding and compliance.

Failure to Provide Records:  MDYFS failed to provide documentation as required by their agreement with the State Agency (SA) and as required by 7 CFR Part 210.9 (b) (17).  This federal regulation requires SFAs to:

"Upon request make all accounts and records pertaining to its school food service available to the State Agency, and to the USDA Food and Nutrition Service (FNS)."

The SA reviewer made several request to MDYFS to provide the records starting on February 24, 2020 through May 13, 2020.  The SA requested the following records:

  • Documentation of the most recent assessment and update to MDYFS' local wellness policy.
  • Documentation of the training hours for the staff members with duties within MDYFS' school nutrition program.  During the On-Site portion of this review the SA Reviewer was told MDYFS had not been keeping records of the trainings completed by employees with duties within MDYFS' school nutrition programs.
  • The date of the second inspection conducted of the kitchen at the shelter site where meals are cooked for both of the SFA's sites.

To demonstrate compliance with requirements to provide records:

  • Provide MDYFS' corrective action plan to demonstrate compliance and understanding.

Local Wellness Policy:   MDYFS failed to provide the documentation of their most recent assessment and update to their policy.  USDA Memo SP21-2017 requires the assessment and update to the local wellness policy to be documented in a triennial wellness assessment report.  7 CFR Part 210.30 (e) (2) requires the triennial wellness assessment report to be posted publicly.  This public posting can be done on a public bulletin board with the local wellness policy.

To demonstrate compliance with the local wellness policy requirements:

  • Provide a copy of the most recent documentation of the assessment and update to the local wellness policy (triennial wellness assessment report).
  • Post the triennial wellness assessment report publicly.
  • Provide the above requested documentation along with MDYFS' corrective action plan to demonstrate compliance and understanding.

Professional Standards:  MDYFS failed to provide documentation of the training hours for employees with duties within their school nutrition program.  The SA reviewer was told MDYFS had not kept training records for the staff members with duties within MDYFS' school nutrition programs.  SFAs must keep training records for employees with duties within their school nutrition programs.  

7 CFR Part 210.30 (c), 7 CFR Part 210.30 (d), and 7 CFR Part 210.30 (e) require the following training requirements:

Job Category* Annual Requirements
Directors 12 hours
Staff (full time) 6 hours
Part-Time Staff (working less than 20 hours per week in the SFA's school nutrition program) 4 hours
Mid-year hires in all categories (January 1st or later) One-half of training requirement for each job category.

*Your SFA may not have all the job categories listed above.  All SFA's have a director.

The above training requirements are required to be completed every school year (July 1st to June 30).  USDA Memo SP 39-2015 requires SFAs to use a SA approved training tracking tool.  7 CFR Part 210.30 (g) requires the SFA each school year to document the compliance with training requirements.  Training should be documented on the training tracking tool throughout the school year, best practice is to add the training as it is completed.  This will ensure all the training gets entered into the tool.  On 05/11/20, our office's training tracking tool was attached to the On-Site exit conference email.

7 CFR Part 210.15 (b) (8) requires SFAs to retain the SA approved training tracking tool (for the school year) and training  records for employees with duties within a SFA's school nutrition program for the school year be kept for three years plus the current school year.

To demonstrate compliance with Professional Standards:

  • Begin keeping training records for all employees with duties within MDYFS' school nutrition program.
  • Begin tracking the training hours for employees with duties within MDYFS' school nutrition program on a SA approved training tracking tool.
  • Provide MDYFS' plan for corrective action to demonstrate understanding and compliance.

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted May 5, 2020:

Counting and Claiming:  A review of the counting system demonstrates counting errors for the review period (February 2020), which results in a Performance Standard Violation I (PSI), 7 CFR Part 210.18 (g) (1) (ii).  The errors were determined to be non-systemic in nature and were found for breakfast, lunch, and snack at the shelter site.  During the review period there were no counting errors for the Parker Pointe site.

The errors discovered at the shelter site were human counting errors that occurred on different days at the shelter site.  These counting errors caused the meals to be under claimed for breakfast, lunch, and snack. 

Below are the differences identified in MDYFS February lunch counts, when comparing the meal roster to the meals listed on the claim:

  MDYFS OKDHS Diff.
Free 386 387 -1

Lunch meals were under claimed by one meal.

Below are the differences identified in MDYFS's February school breakfast counts, when comparing the meal roster to the meals listed on the claim:

  MDYFS OKDHS Diff.
Free 539 540 -1

Breakfast meals were under claimed by one meal.

Below are the differences identified in MDYFS's February Afterschool Snack Program counts, when comparing the meal roster to the meals listed on the claim:

  MDYFS OKDHS Diff.
Free 341 343 -2

Snacks were under claimed by two.

7 CFR Part 210.8 (a) (2) requires each SFA to review their claims for accuracy prior to submitting them to the 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.
  • Begin using the electronic edit check daily to record meal counts instead of using paper based edit check.
  • Provide copies of the following: meal rosters (breakfast, lunch, and snack) for April 2020, edit check forms (breakfast, lunch, and snack) for April 2020, and the claim for April 2020.
  • Provide the above copies, along with MDYFS' corrective action plan to demonstrate understanding and compliance.

SFA On-Site Reviews:MDYFS did not fill out the count section of the SFA On-Site review checklist: assessment of the meal counting and claiming forms for both of MDYFS' sites.  7 CFR Part 210.8 (a) (1) requires SFAs with multiple sites to conduct On-Site reviews of the counting and claiming system of each site under the SFA's jurisdiction each school year prior to February 1st.   To demonstrate that the counting system of each site was reviewed the form must be filled out completely.  Having the counts documented on the form provides documentation on whether or not there is a finding for the counting system at the site being reviewed.

To demonstrate compliance with On-Site Reviews:

  • Provide MDYFS' corrective action plan to demonstrate understanding and compliance.

Signage explaining what constitutes reimbursable meals:  There was no signage explaining to residents what constituted a reimbursable breakfast and what constituted a reimbursable breakfast and what constituted a reimbursable lunch at Parker Pointe.   7 CFR Part 210.10 (a) (2) and 7 CFR Part 220.20 (a) (2) requires SFAs to have signage explaining what constitutes a reimbursable breakfast and lunch meal.  This signage should list the meal components that make up the reimbursable meal.  The signage can be on a white board, be posted on a bulletin board so long as the signage is near the beginning of the service line.       


To demonstrate compliance with signage explaining what constitutes reimbursable meals:

  • Post signage explaining what constitutes a reimbursable breakfast meal.
  • Post signage explaining what constitutes a reimbursable lunch meal.
  • Provide MDYFS' corrective action plan to demonstrate understanding and compliance.

Technical Assistance Provided During the On-Site Portion of the Administrative Review:

Food Safety Inspections:  7 CFR Part 210.13 (b) requires SFAs to obtain a minimum of two food safety inspections during each school year conducted by the local Health Department office.  SFAs who have only received one food safety inspections by March of each school year must contact their local Health Department office to request a second inspection.  If the local Health Department office refuses to conduct a second inspection when a SFA contacts the office, this refusal must be documented and kept for three years plus the current school year.  If the local Health Department office conducts the second inspection, the documentation of the inspection must be posted publicly as required by 7 CFR Part 210.13 (b).  This public posting can be done on a public bulletin board.  Documentation of food safety inspections conducted by the health department must be kept for three school years plus the current school year as required by 7 CFR Part 210.15.


The food safety inspections are required by the USDA.  7 CFR Part 210.13 (b) specifically calls for these inspections to be conducted by the state or local government agency responsible for food safety inspections.  In the state of Oklahoma this would be the local Health Department office not the Oklahoma Department of Human Services (OKDHS).  Only the local Health Department may determine if they will conduct a second inspection during the school year (July 1st through June 30th).  OKDHS' Child Care Services Licensing office cannot make this determination under this federal regulatio


Reviewer's Comments:  I want to commend Both Rita Colomb and Kerstin Swanson for all of the hard work they do for MDYFS' school nutrition program.  Ms. Swanson's menus for the week that were assessed for this review had no findings, this does not happen very often.  I also want to thank Ms. Colomb for her assistance with taking pictures for the day of review.   


Procurement Review Summary Report


Date:  05-19-20

Name of Agency:  Marie Detty Youth and Family Services, Inc.

                                                                             Date of AR off-site review: 03-03-20

Reviewer:  Matthew Smith                             Date of AR on-site review: 05-05-20

Persons interviewed:  Rita Colomb               Date of exit conference: 05-11-20
     

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 during the Procurement Review (PR):
 

  • Procurement: The procurement plan provided at the beginning of the PR was not compliant with federal regulations [2 CFR Part 200.323 (a)], 7 CFR Part 210.21(c) and 7 CFR Part 220.16 (c)].  During the PR Marie Detty Youth and Family Services, Inc. (MDYFS) adopted a procurement plan compliant with federal regulations.

Corrective action for the above was made during the PR.  No further action is required for the above.
    
There were no additional findings for the Procurement Review.

Reviewer's Comments:  I want to commend your agency on compliance with the regulations regarding procurement in school nutrition programs.

 

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