Administrative Review Summary Report

Date:  10-17-23

Name of Agency:  Genesis Project                                              Date of off-site review: 07-13-23

Reviewer:  Matthew Smith                                                              Date of on-site review: 08-17-23

Fiscal Action: Yes, fiscal action amount will be assessed in the fiscal action and closure letter.                                                                 

Persons interviewed:  Dawn Riff and                                          Date of exit conference: 10-02-23

                                    Angela Nordstrom

Programs Operated by the School Food Authority (SFA): This SFA operates the National School Lunch Program, the School Breakfast Program, and the After School Snack Program.

Fiscal Action:  Is required for this Administrative Review (AR).

Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted July 13, 202

Local Wellness Policy:  The local wellness policy provided during the off-site portion of this AR did not contain the following required areas:

• Guidelines and standards for other food and beverages served (not sold) on campus during the school day [as required by 7 CFR Part 210.31 (c) (2) and (3)].
• Description of how and when the local wellness policy is to be assessed [as required by 7 CFR Part 210.31 (e) (2)].

To demonstrate compliance with local wellness policy requirements:

• Provide a copy of the updated local wellness policy compliant with federal requirements for local wellness policies.
• Post the updated local wellness policy on the bulletin board where Genesis Project (GP) currently posts the policy.
• Provide a copy of the updated local wellness policy along with GP’s plan for corrective action to demonstrate understanding and compliance.

Record Keeping – Production Records:  GP did not keep production records for the week of breakfast and lunch menus assessed as part of this AR.  Federal regulations [7 CFR Part 210.10 (a) (3) and 7 CFR Part 220.8 (a) (3)] requires SFAs to:

“…keep production and menu record for the meals they produce.  These records must show how the meals offered contribute to the required food components and food quantities for each grade group every day.”

During the AR, GP was able to reconstruct the production records based off cycle menus, recipes, and meal rosters for the week.

To demonstrate compliance with production record requirements:

• Provide one completed breakfast production record and one completed lunch production record.
• Provide the above documents along with GP’s plan for corrective action demonstrating understanding and compliance.

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted August 17, 2023:

Counting and Claiming:  A review of the counting and claiming system demonstrates systemic claiming errors for the review period (June 2023), which is a Performance Standard I (PSI) Violation [per federal regulation 7 CFR Part 210.18 (g) (1) (ii)] requiring fiscal action.  These systemic errors were found for both the breakfast and lunch monthly meal counts.

These errors discovered with June’s monthly meal counts were due to adult meals being claimed.  This is in violation of federal regulations prohibiting inclusion of adult meals counts in monthly claims for reimbursement [7 CFR Part 210.7 (a), 7 CFR Part 210.7 (c), 7 CFR Part 210.8 (c), 7 CFR Part 220.9 (a), and 7 CFR Part 220.11 (d) (2)].  GP took immediate corrective action by ceasing to include adult meals for the July 2023 claim.  The Oklahoma Human Services (OKHS) School Nutrition Programs (SNP) reviewer verified no adult meals were included with the July meal counts.

Below are the differences OKHS SNP has identified in GP lunch meal counts claimed for June 2023:

	OKHS SNP Meal Roster Count	GP’s Meal Roster Count	GP’s Edit Check	GP’s Claim	Difference
Free	300	300	426	426	+126

Free lunches meals were over claimed by 126 meals. 

Below are the differences OKHS SNP has identified in GP’s breakfast meal counts claimed for June 2023:

	OKHS SNP Meal Roster Count	GP’s Meal Roster Count	GP’s Edit Check	GP’s Claim	Difference
Free	300	300	426	426	+126

Breakfast meals were over claimed by 126 meals.

Below are the differences OKHS SNP has identified in GP’s snack counts claimed for June 2023:

	OKHS SNP Meal Roster Count	GP’s Meal Roster Count	GP’s Edit Check	GP’s Claim	Difference
Free	300	300	426	352	-52

Snacks were over claimed by 52 meals.

Federal regulation [7 CFR Part 2108 (a) (2)] requires each SFA to review their claims for accuracy prior to submitting them to the State Agency (SA).

These are serious systemic errors in the counting and claiming system.

To demonstrate compliance with counting and claiming requirements:

• Review the counting and claiming system and create a plan to ensure accurate meal counts are claimed.
• Provide copies of the of the following:
  • Meal rosters for October 2023 (breakfast, lunch, and snack)
  • Edit checks for October 2023 (breakfast, lunch, and snack)

• Provide the above requested items along with GP’s plan for corrective action to demonstrate compliance and understanding.
  

Edit Checks:  For the review period (June 2023), GP was not properly conducting the daily edit checks as required by federal regulations [7 CFR Part 210.8 (a) and 7 CFR Part 220.11 (d)].  GP was not comparing the daily attendance to the daily meal counts to the daily attendance to identify potential issues with the daily meal counts.

To demonstrate compliance with edit check requirements:

• Begin conducting and documenting daily edit checks by comparing the daily attendance with the daily meal counts.
• Provide copies of the edit checks for October 2023 (breakfast, lunch, and snack).
•  Provide the above documentation along with GP’s plan for corrective action demonstrating understanding and compliance.

HACCP food safety plan: A required HACCP (Hazard Analysis Critical Control Points) food safety plan could not be found at the time of the On-Site visit [7 CFR Part 210.13 (c) requires each SFA to have a HACCP plan]. GP’s staff will need to develop and implement a comprehensive food safety plan. 

To demonstrate compliance with HACCP food safety requirements:

• Use the sample HACCP plan provided as a guide and develop a HACCP food safety plan for GP.
• Provide a copy of GP’s HACCP plan's cover sheet, along with GP’s corrective action plan to demonstrate understanding and compliance.

Meal Patterns:  During the menu week assessed 06/18/23 – 06/24/23 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 K-5 meal pattern:

Meal Component	Required Serving
Bread/Grain	1 oz. by weight daily and 11 – 12.5 oz. per week

*All items used to meet the daily and weekly bread/grain servings must be Whole Grain-Rich.

Fruit

½ cup daily and 3 ½ cups per week

*Up to half of the weekly serving can be met with the use of 100% fruit juice.

Meat/Meat Alternative	1 oz. by weight daily and 11 – 14 oz. per week
Milk	1 cup daily and 7 cups per week

*Students 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	¾ cup daily and 5 ¼ cups per week
Vegetable Subgroups to be offered throughout the week
-Dark Green ½ cup     -Red/Orange ¾ cup     -Legume ½ cup per week -Starchy ½ cup           -Other ½ cup

Insufficient Quantities for the Menu Week 06/18/23 – 06/24/23

§  The menu served on 06/19/23 had an insufficient daily serving size for the vegetable component.  The menu only credited ½ cup toward this component’s daily serving.

The above insufficient serving size was 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 K-5.
• Bring all insufficient serving sizes and missing components in compliance with the meal patterns for grades K-5.
• Submit GP’s plan for corrective action to demonstrate understanding and compliance.

Milk Variety:  GP served unallowable milk varieties during the menu week assessed (breakfast and lunch menus for the week of 06/18/23 – 06/24/23) and on the day of review (08/17/23).  With these reimbursable meals a reduced-fat (2%) lactose free milk with and without flavored syrup were served in violation of federal regulations [7 CFR Part 210.10 (d) (1) (i and ii) and 7 CFR Part 220.8 (d)].  

This is a first violation, so OKHS SNP is exercising its discretion not to apply fiscal action by disallowing all meals where unallowable milk types were used as allowed for under federal regulation [7 CFR Part 210.18 (g) (2)] and the USDA FNS Administrative Review Manual. 

To demonstrate compliance with milk variety requirements:

• Begin offering at least two varieties of milk from the list above (one of the varieties must be unflavored).
• Provide GP’s corrective action plan to demonstrate understanding and compliance.

Non-creditable flour product used as part of the meal component:  During the menu week assessment it was determined a non-creditable gluten free flour product was used for recipe items used.  This gluten free flour product used in breakfast recipes is non-creditable in the National School Lunch Program (NSLP) and the School Breakfast Program (SBP).  This product was used during the menu week assessed as part of this AR causing the following menu items to be non-creditable:

• The waffles served with the menu on 06/20/23.
•  The biscuits served with the menus on 06/22/23 and 06/23/23.

Federal regulations [7 CFR Part 210.10 (c) (2) (iv) (A) and 7 CFR Part 220.8 (2) (iv) (A)] require all grain items to be made with enriched, and, or whole grain meal, or flour.  The gluten free flour product did not meet these criteria.

To demonstrate compliance with grain requirements:

• In recipe items begin using a flour product that can be credited in the NSLP and the SBP.
• Provide GP’s plan for corrective action to demonstrate understanding and compliance.

Non-creditable food items as part of the meal component:  During the menu assessment it was determined your agency is serving non-creditable items. For the items to be creditable they must contain a CN label or an acceptable production formulation statement, 7 CFR 210 Appendix C.  The following items were identified as non-credible:

• The meatball product used with the lunch menu on 06/22/23.
• The corndog product used with the lunch menu on 06/24/23

If crediting documentation (CN labels or product formulations statements) cannot be obtained, then the non-creditable food items will have to be replaced with creditable food items.

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 GP’s corrective action plan along to demonstrate understanding and compliance.

Whole Grain Rich – Percentage of Weekly Serving Under 80%:  During the assessment of breakfast and lunch menus for the week of 06/18/23 through 06/24/23 it was discovered the percentage of the bread/grain component weekly serving for the lunch menus was under 80%.  The percentage of the weekly bread/grain component serving for lunch menus was 46.15%.  Federal regulations [7 CFR Part 210.10 (c) (2) (iv) (B) and 7 CFR Part 220.8 (c) (2) (iv) (B)] require the percentage of the weekly serving for the bread/grain component (for breakfast and lunch) to be at least 80% WGR. 

To demonstrate compliance with WGR requirements:

• Review the lunch menus for the menu week assessed.  Determine where changes can be made to bring the percentage of the weekly serving into compliance with the meal pattern.
• Provide GP’s plan for corrective action to demonstrate compliance and understanding

Procurement Review Summary Report

Date:  10-17-23

Name of Agency:  Genesis Project                                              Date of AR off-site review: 07-13-23

Reviewer:  Matthew Smith                                                              Date of AR on-site review: 08-17-23

Persons interviewed:  Dawn Riff and                                          Date of exit conference: 10-02-23

                                    Angela Nordstrom

Programs Operated by the School Food Authority (SFA):  This SFA operates the National School Lunch Program, the School Breakfast Program, and the After School Snack Program.

Findings for the Procurement Review (PR)

Procurement Plan:  The procurement plan in place for Genesis Project (GP) at the beginning of this review did not meet federal requirements for procurement plans.  GP’s procurement plan does not address the use of the micro-purchase method of procurement.  Federal regulation [2 CFR Part 200.318 (a)] requires each SFA to have a procurement plan documenting their procurement processes.

To demonstrate compliance with procurement plan requirements:

• Update or amend the procurement plan for GP to cover the use of the micro-purchase method or procurement.
• Provide a copy of the update procurement plan for GP or the amendment to GP’s procurement plan along with GP’s plan for corrective action demonstrating understanding and compliance.