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Administrative Review Summary Report

Date: 11-18-20

Name of Agency: Saint Paul’s Community School, Inc.
                                                                             Date of off-site review: 02-18-20

Reviewer: Matthew Smith                                Date of on-site review: 10-08-20

Persons interviewed: Joanna Beasley and     Date of exit conference: 11-13-20
                                     Araceli Davila

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

Due to the outbreak of COVID-19 and the resulting closure of the SFA for school year 2019-2020 during this AR OKDHS School Nutrition Programs suspended this AR as permitted by USDA Memo COVID-19: Child Nutrition Response #9. This AR was resumed during school year 2020-2021.

Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted February 18, 2020:

Civil Rights: Saint Paul’s Community School, Inc. (SPCS) did not conduct the public release process for school year 2019-2020. Federal regulations [FNS Instruction 113-1 and 7 CFR Part 245.5] require School Food Authorities (SFA) to conduct a public release information the public of the SFA;s participation in the National School Lunch Program (NSLP) and the School Breakfast Program (SBP) prior to the beginning of the school year. The public release must cover the following areas [as required by FNS Instruction 113-1]:

· The income guidelines for free and reduced price meals for the school year that the public release is for the upcoming school year.

· The full current USDA approved non-discrimination statement

· The release must explain households will be notified of their children’s eligibility for free meals if the members of the household are receiving assistance [Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), or the Federal Distribution Program on Indian Reservations (FDPIR)].

· The release must explain that a child or another household member’s receipt of benefits for assistance programs (SNAP, TANF, and FDPIR) extends the eligibility to all children who are members of the household.

· The release must further explain no further application is required for free meals if the household is notified that the children are directly certified.

7 CFR Part 245.5 requires SFAs to publicly announce their release at the beginning of the school year. The public release should be sent to local media. 7 CFR Part 245.5 also requires SFAs to provide a copy of the public release to any interested person upon their request.

To demonstrate compliance with civil rights public release requirements:

· Please provide SPCS’ corrective action plan demonstrating compliance and understanding.

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

· The policy provided at the time of the Off-Site visit did not have a description of how and when the policy is to be assessed [7 CFR Part 210.31 (c) (4) and 7 CFR Part 210.31 (e) (1)]. Federal regulation 7 CFR Part 210.31 (e) (2) requires local wellness policies to be assessed at least once per every three school years. USDA Memo SP24-2017 requires the assessment to be documented using a triennial wellness assessment report. Best practice is to conduct the assessment every school year.

· The local wellness policy provided does not designate personnel with the responsibility for assessing the policy [7 CFR Part 210.31 (c) (4) and 7 CFR Part 210.31 (e) (1)]. It is recommended no more than two people be designated with this responsibility.

The local wellness policy and documentation of the assessment and update to the local wellness policy (the triennial wellness assessment report) are required to be posted publicly [as required by 7 CFR Part 210.31 (d) (2) and 7 CFR Part 210.31 (e) (2)]. The public posting can be done on the school’s website, or on a public bulletin board at your school. If the policy is posted on the school’s website federal regulation [FNS Instruction 113-1] requires the current full USDA approved non-discrimination statement must be posted on the website.

To demonstrate compliance with local wellness policy requirements:

· Add a description of how and when the local wellness policy is to be assessed.

· Add the name(s) of the personnel designated with the responsibility for the assessment of the local wellness policy.

· Provide a copy of the updated local wellness policy with the above added along with SPCS’ corrective action plan to demonstrate understanding and compliance.

Professional Standards: SPCS school food services director for school year 2019-2020 did not complete eight hours of food safety within 30 days of starting the position, or within five years of the date of hire as required by federal regulation 7 CFR Part 210.31(b) (1) (v). Prior to the completion of the off-site portion of this AR the director at that time completed an eight hour food safety training through the Institute of Child Nutrition (ICN).

Due to the outbreak of COVID-19 this AR and SPCS closing for the school year OKDHS School Nutrition Programs suspended the review as allowed for by USDA COVID-19: Child Nutrition Response #9.

Prior to the beginning of school year 2020-2021, the director (that was in pace during the off-site portion of this AR) left the SPCS. The new school food services director for school year 2020-2021, did not complete eight hours food safety within 30 days of starting the position, or within five years of the day of hire as required by federal regulation 7 CFR Part 210.31 (b) (v). The new director was provided with information regarding ICN’s free online food safety trainings by email on 09/18/20.

To demonstrate compliance with professional standard food safety training requirements:

· Complete eight hours of food safety training.

· Provide documentation of completion of eight hours of food safety training.

· Provide the above along with SPCS’ corrective action plan demonstrating compliance and understanding.

Verification:

More than three percent of the approved household applications were put through the verification process: During school year 2019-2020, the SPCS verified two approved household applications which was over 3% of the approved household applications on file on October 1, 2019. Federal regulation 7 CFR Part 245.6a requires School Food Authorities (SFA) to only verify 3% of the approved household applications on file on October 1st of the school year. SPCS had 20 approved household applications on

file on October 1, 2020. Three percent of 20 is 0.60. The USDA’s Eligibility Manual for School Meals (page 99) requires all numbers to be rounded up to the next whole number. SPCS should have verified only one approved household application.

Records for the verification process were not accessible during this AR: SPCS could not locate their records for the verification process completed for school year 2019-2020. Federal regulation [7 CFR Part 245.6a (h)] requires SFAs to keep the records of the verification for at a minimum three years. These records include:

· The letter notifying households that they have been selected for the verification process.

· The household applications being verified.

· Correspondence with the selected households.

· Documentation of household income.

· Notification letter of the results of the verification process that were sent to each household that were selected to go through the verification process.

To demonstrate compliance with verification requirements:

· Review the verification process used for this school year to find out where breakdown in the verification process occurred.

· Begin keeping verification records for a minimum of three school years.

· Provide your corrective action plan to demonstrate your understanding and compliance with the verification requirements.

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

Benefit Issuance Document: Errors were discovered on the Benefit Issuance Document (BID) during the review of household applications and direct certification documentation as part of the on-site portion of this AR.

An error was found on one household application, with one student listed on it, was approved for reduced priced meals. The student was not added to the BID. SPCS sent a letter to the household providing notification the household was approved for reduced priced meals. As households are approved for free meal and reduced priced meal benefits the students in the household need to be listed on the BID [as required by the USDA Administrative Review manual and 7 CFR Part 245.6]. SFAs should add each student’s name to the BID as eligibility determinations are made.

Additional errors with the BID were discovered during the review of direct certification documentation. There were four students directly certified that were previously determined to be eligible by household application for reduced priced meals. All four students were listed on SPCS’ BID as being eligible for reduced priced meals at the time the direct certification documentation was reviewed (on 10/23/2020). All four should have been listed as receiving free meals through direct certification. SFAs are required to make adjustments in eligibility determinations when direct certification lists are received throughout the school year on the SFA’s BID [as required by 7 CFR Part 245.6 (b)]. When receiving each direct certification list SFAs should compare the list to their DIB and make updates to the BID to reflect any changes each list indicates are needed.

To demonstrate compliance with Benefit Issuance Document requirements:

· Provide the dates the above errors were corrected on SPCS’ BID.

· Provide SPCS’ corrective action plan to demonstrate understanding and compliance.

Counting and Claiming: A review of the counting system demonstrates non-systemic counting errors for the review period (September 2020), which results in a Performance Standard Violation I (PSI), 7 CFR Part 210.18 (g) (1) (ii). The non-systemic errors were found for breakfast and lunch.

The errors appear to have been data entry errors on the edit check spreadsheets.

Below are the differences identified in St. Paul’s Community School, Inc. (SPCS) September lunch counts when reviewing the meal roster and edit check for September:

Lunch Counts SPCS OKDHS Diff.

Free

438

436

+2

Reduced

319

315

+4

Paid

162

163

-1

The free meals were over claimed by two meals, the reduced priced meals were over claimed by four meals, and the paid meals were under claimed by one meal.

Below are the differences identified in SPCS’s September school breakfast counts when reviewing the meal roster and edit check for September:

Lunch Counts SPCS OKDHS Diff.

Free

293

292

+1

Reduced

213

214

-1

Paid

143

143

0

Free meals were over claimed by one meal and reduced priced meals were under claimed by one meal.

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.

· Provide copies of the following: SPCS’ meal rosters for October 2020, SPCS’ edit check forms, and the claim for October 2020.

· Provide the above copies, along with your corrective action plan to demonstrate understanding and compliance.

Reviewer’s Comments: I want to commend your school on a job well done with this review. Your school is doing a good job with its participation in the National School Lunch Program and the School Breakfast Program.

Procurement Review Summary Report

Date: 11-18-20

Name of Agency: Saint Paul’s Community School, Inc.
                                                                      Date of AR off-site review: 02-18-20

Reviewer: Matthew Smith                            Date of AR on-site review: 10-08-20

Persons interviewed: Joanna Beasley and Date of exit conference: 11-13-20
                                    Araceli Davila

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

There were no findings for the procurement review of Saint Paul’s Community School, Inc.

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