Administrative Review Summary Report

Date:  02-16-21

Name of Agency:  Saint Anthony South Campus                         Date of off-site review: 08-06-20

Reviewer:  Matthew Smith                                                              Date of on-site review: 12-08-20

Persons interviewed:  Melissa Goodman                                      Date of exit conference: 02-08-21

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):

• The SFA served juice that was not 100% fruit juice:  During the menu week assessment of the breakfast menus served during the week of 06/12/20 – 06/18/20, it was discovered a cran-grape juice product was used that did not contain 100% fruit juice [7 CFR Part 210.10 (c) (2) (ii)].  Prior to the completion of the on-site portion of this AR the SFA took corrective action replacing this product with fruit juices that contain 100% fruit juice.

Corrective action for the above were 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 August 6, 2020:

Afterschool Snack Program:  Saint Anthony South Campus (SASC) failed to conduct a self-inspection as part of the Afterschool Snack Program within the first four weeks of school as required by federal regulation [7 CFR Part 210.9 (c) (7)].  This regulation further requires a second self-inspection be conducted prior to the end of the school year.  Our office provides a checklist that must be used to document these self-inspections.

During the AR, SASC failed to provide five consecutive days of snack production records upon the request of the State Agency (SA).  Without these records the SA reviewer could not determine compliance with the snack meal pattern [7 CFR Part 210.10 (c) (o) (2)].

To demonstrate compliance with Afterschool Snack Program self-inspection requirements:

• Conduct the first self-inspection and provide a copy of the completed self-inspection checklist.
• Provide five consecutive days of snack production records.
• Provide the above along with SASC’s corrective action plan to demonstrate compliance and understanding.

Failure to Provide Requested Records:  SASC failed to provide the following requested records:

• List of employees with duties within the SASC’s school food services program.  Provided prior to the completion of the on-site portion of this AR.
• Records for the training hours within the school food services program that can be credited toward the annual training hours. During this AR the SFA stated these records could not be provided.
• The most recent triennial wellness assessment report documenting the most recent assessment and update to the local wellness policy.
• Additional documentation on the cran-apple juice served with the breakfast menus served during the menu week of June 12, 2020 through June 18, 2020. Provided prior to the completion of the on-site portion of this AR.
• Information on the pancake serving size for the breakfast menu served on 06/13/20.  Provided prior to the completion of the on-site portion of this AR.
• The Child Nutrition (CN) label for the chicken product used with the lunch menu served on 06/14/20.  Provided prior to the completion of the on-site portion of this AR.
• Five consecutive days of snack production records.
• Temperature logs for the review period (June 2020).

Federal regulation [7 CFR Part 210.9 (b) (17) requires “Upon request make all accounts and records available to the state agency (OKDHS School Nutrition Programs) and to the USDA Food and Nutrition Service (FNS).”  Saint Anthony South also has an agreement with OKDHS School Nutrition Programs requires SASC to provide OKDHS School Nutrition Programs with documents and information upon the request of OKDHS School Nutrition Programs.

To demonstrate compliance with the requirements to provide requested records:

• Provide the following requested documentation and information:
  • The most recent triennial wellness assessment report.
  • Five consecutive days of snack production records.
  • Temperature logs for June 2020.
• Provide SASC’s plan for corrective action to demonstrate compliance and understanding.

Local Wellness Policy: SASC’s local wellness policy needs to have the following added:

• The goals for other school based activities that promote student wellness.  Federal regulation [7 CFR Part 210.31 (c) (1)] require local wellness policies to have four goal areas: goals for nutrition education, goals for nutrition promotion, goals for physical activity, and goals for other school based activities that promote student wellness.  Each goal area should have their own section of the policy.
• Guidelines and standards for the marketing of food and beverages during the school day as required by federal regulation 7 CFR Part 210.31 (c) (3) (iii).  Federal regulation 7 CFR Part 210.11 (a) (5) defines the school day as “…the period from the midnight before, to 30 minutes after the end of the school day.”  For a Residential Childcare Institution (RCCI) such as Saint Anthony South Campus, the guidelines can be as simple as a prohibition of the marketing of food and beverages during the school day on campus.  These guidelines and standards should have their own section within the policy.

SASC failed to provide documentation of the most recent assessment and update in the form of a triennial wellness assessment report during both the off-site and on-site portion of this AR.   Federal regulations [7 CFR Part 210.31 (e) (2), 7 CFR Part 210.31 (f) (3), and USDA Memo SP24-2017] require the assessment and update to local wellness policies to be documented on a triennial wellness assessment report.  Federal regulation [7 CFR Part 210.31 (d)] requires the triennial wellness assessment report be publicly posted.  This public posting should be with the local wellness policy.  Two ways in which the triennial wellness assessment report can be posted publicly, are on your agency’s website, or on a public bulletin board at your agency’s site.

To demonstrate compliance with the local wellness policy:

• Add the goals for other school-based activities that promote student wellness to the local wellness policy.
• Add guidelines and standards for the marketing of food and beverages on campus during the school day to the local wellness policy.
• Provide an updated copy of the local wellness policy.
• Provide the above requested documentation along with SASC’s plan for corrective action to demonstrate compliance and understanding.   

Professional Standards:  SASC failed to provide documentation of the trainings completed by staff members with duties within their school food services program that could be credited toward the annual training requirements contained within federal regulations [7 CFR Part 210.30 (b) (3), 7 CFR Part 210.30 (c), 7 CFR Part 210.30 (d), and 7 CFR Part 210.30 (e)].  Upon the last request made the reviewer was told SASC was unable to provide the records at this time.

Federal regulations [7 CFR Part 210.30 (b) (3), 7 CFR Part 210.30 (c) (3), 7 CFR Part 210.30 (d), and 7 CFR Part 210.30 (e)] require the following training requirements:

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

The above training requirements must be completed every school year (July 1^st through June 30^th).  USDA Memo SP39-2015 requires SFAs to use a state agency (OKDHS School Nutrition Programs) approved training tracking tool.  7 CFR Part 210.30 (g) requires SFAs to document compliance each school year.  The best practice is to document trainings as staff members (who have duties within the school food services programs) complete them.   This will ensure the trainings are entered into the training tracking tool.  On November 3, 2020, SASC was emailed a training tracking tool (an Excel spreadsheet) that has been approved for use by OKDHS School Nutrition Programs.

Trainings that can be credited toward the professional standards annual training requirements [7 CFR Part 210.30 (b) (3), 7 CFR Part 210.30 (c), 7 CFR Part 210.30 (d)]:

• Meal counting and reimbursement claim procedures
• Meal patterns
• Nutrition
• Identification of reimbursable meals at the point of service
• Annual civil rights training
• Health and safety standards
• HACCP food safety
• Administrative Review

To demonstrate compliance with the professional standards requirements:

• Begin tracking training completed by staff members with duties within the school food services program.
• Provide SASC’s plan for corrective action to demonstrate compliance and understanding.

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted December 8, 2020:

Meal Patterns: A review of 06/12/20 through 06/18/20 indicated some insufficient portion sizes at breakfast and lunch.

The breakfast meal pattern 7 CFR Part 220.8 (c) requires the following minimum serving sizes; 1oz. by weight bread/grain daily and 12.5-14 oz. per week, 1 cup Fruit, and 1 cup fluid milk, offered as a choice between 1% and fat free.   No more than 50% of the fruit components for a menu week can be met with 100% fruit juice.

Insufficient quantities

§  The menus served during the week only credited 11.50 oz. toward the minimum required weekly bread/grain serving.  This insufficient serving 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).

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 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 SASC’s plan for corrective action to demonstrate understanding and compliance.    

Procurement Review Summary Report

Date:  02-16-21

Name of Agency:  Saint Anthony South Campus

Date of AR off-site review: 08-06-20

Reviewer:  Matthew Smith                                                                      Date of AR on-site review: 12-08-20

Persons interviewed:  Melissa Goodman                                               Date of exit conference: 02-08-21

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

There were no findings for the procurement review.