Administrative Review Summary Report

Date: 02-07-17

Name of Agency: Community Children's Shelter Date of off-site review: 12-15-16

Reviewer: Matthew Smith Date of on-site review: 01-17-17

Persons interviewed: Leslie Christian and Date of exit conference: 01-17-17

Falyn Cook

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 December 15, 2016:

Local Wellness Policy: At the time of the Off-Site review the local wellness policy did not meet regulations. Your local wellness policy needs to have the following added to meet regulations:

A plan for measuring the implementation of your agency's local wellness policy, as required by 7 CFR Part 210.30 (c) (6)
The name and title of the person designated to ensure your agency fulfills the local wellness policy, as required by 7 CFR Part 210.30 (e) (1).
The name and title of the person(s) designated to assess your agency's 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).

When changes to the local wellness policy occur review them with the committee and post the 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 agency's local wellness policy along with your plan for corrective action to demonstrate compliance and understanding.

Procurement: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. 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. The procurement plan provided at the time of the Off-Site portion of this administrative review did not include the proceeding steps as required under 2 CFR Part 200.321.

To demonstrate compliance with the procurement requirements:

Provide a copy of your agency's revised procurement plan. Make sure your revised plan includes steps your agency is taking to assure that small, minority and women's businesses enterprises, and labor surplus firms when possible, as required under 2 CFR Part 200.321.
Provide the above along with your corrective action plan demonstrate understanding and compliance.

Meal Patterns:A review of 11/14/16 through 11/20/16 indicated some insufficient portion sizes at lunch.

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.

Insufficient quantities

On 11/16/16, a salad was served that credited at ¼ cup. This caused the daily serving of vegetables to only credit at ¾ of a cup.
On 11/17/16, a slice of bread was served to meet the bread/grain that only credits at 0.75 oz.
On 11/18/16, a hamburger bun was served that only credited at 1.75 oz. was served to meet the bread/grain component.
On 11/19/16, a hamburger bun was served that only credited at 1.75 oz. was served to meet the bread/grain component.
The weekly meat/meat alternative serving was not met. Your agency served 13.75 oz.

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).

It is very important for your staff to carefully review planned menus, product labels and recipes to ensure, the meal pattern requirements are met for every meal claimed for reimbursement. It is critical that your staff document everything that is served as part of a reimbursable meal.

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 your plan for corrective action 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 corndog served on 11/17/16.

Finding CN labeled products can be challenging. Remember; items similar to CN labeled products, but not the same, are not acceptable. 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.

Record Keeping: The benefit issuance document was not provided at the time of the off-site. The benefit issuance document is required to have the following: the students' name, method of certification for each student, and date of certification for each student [7CFR Part 245.2 (1), 7 CFR Part 245.2 (2), and the OKDHS School Nutrition Programs Manual page 5-9]. This allows you to track student eligibility for claiming purposes and for yearly verification reporting.

As changes occur during the school year (July 1^st through June 30 of the following year) your agency needs to update the benefit issuance document. Prior to the completion of the On-Site portion of the AR, a benefits issuance document was created and a copy was provided.

No further action is required regarding the tool for the collection of race and ethnicity.

Reviewer's Comments:The Administrative Review (AR) shows that overall Community Children's Shelter (CCS) is doing a good job with their school food service program. The findings above indicate that some tinkering needs to be done in order to bring the program into compliance. I would like to take this opportunity to commend all the staff members who work with CCS' school nutrition program. The hard work the staff members do showed when the program was reviewed.