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Administrative Review Summary Report

​Date:  02-12-19

Name of Agency:  Saint James Catholic School                  Date of off-site review: 12-17-18

Reviewer:  Matthew Smith                                                    Date of on-site review: 01-21-19 and  01/28/19

Persons interviewed:  Alicia Vasquez                                   Date of exit conference: 01-28-19

This School Food Authority (SFA) operates the National School Lunch Program and the School Breakfast Program.

The following areas were corrected prior to the On-Site Portion of this Administrative Review (AR):

  • Local Wellness Policy: The SFA's local wellness policy did not have personnel designated to assess the policy and ensure the policy is implemented [7 CFR Part 210.31(c) (4) and 7 CFR Part 210.31 (e) (1)].The policy also did not provide a description of the measuring of the implementation of the policy and for the reporting of the policy and the assessment of the policy [7 CFR Part 210.31 (c) (6)].  
    The triennial wellness assessment report was not posted publicly as required by 7 CFR Part 210.31 (d).

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 December 17, 2018:

Verification: Verification was not conducted according to federal requirements.The SFA directly verified one approved application.  SFAs are required to verify 3% of the approved applications on file on October 1st, rounding up to the next whole number [7 CFR Part 245.6a (c) (3) (i)].  Based on the number of applications on file, the school should have verified two approved applications.

To demonstrate compliance with the Verification requirements:

  • Review your school's verification practices and ensure they meet the requirements.
  • Implement a plan to demonstrate the proper procedures for conducting the verification process.  The plan must include confirmation reviews and the selection of households for verification.  Use the process provided annually by OKDHS. 
  • Provide a copy your plan for corrective action to demonstrate understanding and compliance.  

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted January 22, 2019 and January 28, 2019:

Counting and Claiming: A review of the counting and claiming system demonstrates a non-systemic claiming error for the review period (November 2018).  The error occurred when the SFA transferred their lunch meal counts to the State Agency (SA) claiming system.  This error caused in an under claim for free meals for the lunch meal claim for the review period.  The error also caused over claims for reduced price meals and paid meals for the review period.  This error is a Performance Standard Violation I (PSI), 7 CFR Part 210.18 (g) (1) (ii).   

Below are the differences, our reviewer identified, in your lunch meal count.  The data comes from comparing the meal counts from the SFA electronically point of service counts to the lunch meals listed on in the SFA's reimbursement claim for the review period (November 2018).

  SFA OKDHS Diff.
Free 1306 1352 -46
Reduced 281 266 +15
Paid 563 532 -31

7 CFR Part 201.8 (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.
  • Provide copies of the following: edit checks for the meals claimed for January 2019 and the claim for January 2019.
  • Provide the above copies, along with your corrective action plan to demonstrate understanding and compliance.   

Eligibility Certification:  During the review of household applications, it was determined that two applications were certified in error. The errors resulted in three children receiving free meals when eligible for reduced price meals. The errors were due to miss-categorizing the households' income in the wrong benefits category (7 CFR Part 245.6). These errors resulted in a Performance Standard I (PSI) Violations. 

At the time of the On-Site portion of the AR the applications with the errors were brought to the SFA's attention.   7CFR Part 245.6 (c) (3) (iii) requires the SFA to send notification to the households in writing, and allow 10 calendar days for a possible hearing request.

The school-reviewing official must review each incoming application to ensure that the household submitted a complete application. If the application is complete, the official must then determine whether the household is categorically eligible or income eligible for benefits. It is recommended that someone come behind the determining official and double check the math and benefit category.  A space is provided on the application for a second person to sign off on the determination.

This is a Performance Standard 1 (PS 1) violation which requires fiscal action, 7 CFR Part 210.18 (g) (1).

To demonstrate compliance with eligibility certification requirements:

  • Inform the households in writing of their change in benefits status, allow 10 days for a possible hearing request
  • Once the 10 calendar day timeframe has past, change the benefits status from free to reduced meal eligibility.
  • Provide copies of the letters sent, date changes were made and your written corrective action plan to demonstrate understanding and compliance. 

HACCP food safety plan: At the time of the on-site review the SFA had not conducted the monthly self-inspections as required by their HACCP plan.  The monthly self-inspections keep your agency in compliance with 7 CFR 210.13 (C) (2) (iv) which requires SFA's HACCP plan to have monitoring procedures in place to ensure compliance with their plans.

It is important the person in charge of the inspections takes them seriously, so your staff can swiftly rectify any problems before they become more serious issues.

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.  SFAs 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 completing the logs and self-inspection forms.
  • Conduct the monthly review of the kitchen.
  • Provide a copy of the completed monthly review, along with your corrective action plan to demonstrate understanding and compliance.

Reviewer's Comments:  Overall the SFA is doing a good job with their school nutrition programs.  The meal preparations and meal services that I observed were organized and orderly.  This is due to the hard working kitchen staff members.  I would like to commend them on a job well done. 

Procurement Review Summary Report

Date:  02-12-19

Name of Agency:  Saint James Catholic School             Date of AR off-site review: 12-17-18

Reviewer:  Matthew Smith                                                Date of AR on-site review: 01-22-19

 and 01-28-19

Persons interviewed:  Alicia Vasquez and                       Date of exit conference: 01-28-19

This School Food Authority (SFA) operates the National School Lunch Program and the School Breakfast Program.

The following areas were corrected during the Procurement Review (PR):

  • Procurement: At the time of the PR was commenced, the provided procurement plan did not meet federal requirements [7 CFR Part 210.21(c) and 7 CFR Part 220.16 (c)].  During the PR the SFA provided a copy of their procurement plan that was in compliance with federal regulations.

Corrective action for the above was made during the PR.  No further action is required for the above.

No further findings for the procurement review.
 

Reviewer's Comments:  Keep up the good work with compliance with procurement rules and regulations.

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