Administrative Review Summary Report

Date:  04-07-23

Name of Agency:  St. Paul’s Community School, Inc.

            Date of off-site review: 01-19-23

Reviewer:  Matthew Smith                                                              Date of on-site review: 02-21-23

 and 02-23-23

Persons interviewed:  Morgan Shillow and                                 Date of exit conference: 04-05-23

                                    Zoi White

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):

Civil Rights: At the time of the off-site portion of this AR only the school food services director had completed the annual civil rights training for school year 2022 – 2023 [as required by USDA FNS Instruction 113-1].  Prior to the completion of the off-site portion of this AR, St. Paul’s Community School, Inc. (SPCS) conducted civil rights training for the remaining employees with duties within SPCS’ school food services program.

No further action is required for the above. 

Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted January 19, 2023:

Civil Rights – Public Release:  During the off-site portion of this AR, St. Paul’s Community School (SPCS) failed to provide documentation demonstrating the public release process for school year 2022 – 2023 had been completed.  USDA FNS Instruction 113-1 requires SFAs to notify the public of the SFA’s participation in USDA programs.  To be compliant with this requirement, the public release must be sent to local media outlets.

To demonstrate compliance with civil rights requirements or the public release:

• Provide SPCS’ plan for corrective action demonstrating understanding and compliance.

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

• Guidelines and standards for the food served (not sold) outside of the school foods services program on campus during the school day [as required by federal regulation 7 CFR Part 210.64 (c) (2)].

SPCS’ local wellness policy will have to be updated to include the above required area.

SPCS has not assessed their local wellness policy since it was adopted over three years ago.  Federal regulation [7 CFR Part 210.31 (e) (2)] requires SFAs to assess their local wellness policies at least one every three years.  SPCS will have to assess and update their local wellness policy.

The updated policy and the documentation of the most recent update to the policy are required to be publicly posted [as required by federal regulation 7 CFR Part 210.31 (d) (2) and (3)].

To demonstrate compliance with local wellness policy requirements:

• Update the local wellness policy to include the guidelines and standards for food served (not sold) outside of the school food services program during the school day.
• Conduct the assessment and update process for SPCS’ local wellness policy.
• Document the assessment process and provide this documentation to Oklahoma Human Services School Nutrition Programs (OHS SNP) along with the assessed and updated local wellness policy.
• Provide copies of the above documents along with SPCS’ plan for corrective action 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 12/05/23 through 12/09/23 it was discovered the percentage of the bread/grain component weekly serving for the breakfast was not compliant with meal pattern requirements.  The percentage of the weekly serving of the bread/grain component serving for the breakfast menus was 73.33%.  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.  The percentage of the weekly bread/grain component servings for breakfast will have to be brought up to at least 80%.

To demonstrate compliance with WGR requirements:

·       Provide SFA’s plan for corrective action to demonstrate compliance and understanding

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted February 21, 2023, and February 23, 2023:

Benefit Issuance Document – Record Keeping:  The Benefit Issuance Document (BID) provided during this AR was determined to have not been kept up to date.  SPCS was keeping the eligibility determinations up to date in a spreadsheet used to generate the meal rosters for the point of service.  This spreadsheet could not be used as a BID due it not being compliant with requirements for BIDs [as required by federal regulation 7 CFR Part 245.6 (e) and the USDA FNS Administrative Review manual].

Prior to the completion of the on-site portion of this AR, SPCS provided a BID that was compliant with federal requirements for BIDs.  As changes occur, SPCS is required to update the BID [as required by federal regulation 7 CFR Part 245.6 (e) and the USDA FNS Administrative Review Manual].

To demonstrate compliance with BID requirements:

• Provide SPCS’ plan for corrective action to demonstrate understanding and compliance with keeping the BID up to date.

Buy American Provision:  During the on-site visit to SPCS’ caterer’s kitchen on 02/23/23, several non-domestically produced food items were discovered.  The following non-domestic food items were found:

• Canned olives, which were a product of Egypt.
• Canned jalapenos, which were a product of Peru.
• Fresh cucumber, which were a product of Mexico.

The documentation of the use of a limited exemptions to the Buy American Provision by SPCS’ caterer was insufficient to justify the use of the limited exemptions.

Federal regulations [2 CFR Part 200.322, 7 CFR Part 210.21 (d), and 7 CFR Part 220.16 (d)] require SFAs “to purchase to the maximum extent practicable, domestic commodities or products.” 

To demonstrate compliance with Buy American Provision requirements:

• Request Keystone review their menus for SPCS school food services program to ensure compliance with the requirements for the Buy American Provision.
• Require Keystone to remove and replace all non-domestic products with insufficient limited exemption to the Buy American Provision with domestically food products.
• Provide SPCS’ plan for corrective action to demonstrate understanding and compliance.

Counting and Claiming:  A review of the counting and claiming system demonstrates systemic claiming errors for the review period (December 2022), 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.

The errors appear to have occurred during the edit check process.  SPCS’ meal rosters provide the correct meal counts, but the edit check does not have the correct meal counts.

Below are the differences Oklahoma Human Services School Nutrition Programs (OHS SNP) has identified in SPCS’ lunch meal counts claimed for December 2022:

	OHS SNP Count	SPCS’ Meal Roster Count	SPCS’ Edit Check	SPCS’ Claim	Difference
Free	472	472	482	482	+10
Reduced	207	207	205	205	-2
Paid	192	192	184	184	-8

Free lunches meals were over claimed by 10 meals.  Reduced priced lunch meals were under claimed by two meals, and paid lunch meals were under claimed by eight meals.

Below are the differences OHS SNP has identified in SPCS’ breakfast meal counts claimed for December 2022:

	OKHS Count	SPCS’ Meal Roster Count	SPCS’ Edit Check	SPCS’ Claim	Difference
Free	273	273	317	317	+44
Reduced	96	96	116	116	+20
Paid	104	104	126	126	+22

Breakfast meals for all eligibility determination categories were over claimed:

• Free breakfast meals were over claimed by 44 meals.
• Reduced priced breakfast meals were over claimed by 20 meals.
• Paid breakfast meal were over claimed by 22 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.
• Complete the edit check process for breakfast and lunch meals daily.
• Provide copies of the of the following: meal rosters for April 2023 for breakfast and lunch, as well as the edit checks for breakfast and lunch for April 2023.
• Provide the above along with SPCS’ plan for corrective action to demonstrate compliance and understanding.

Eligibility Certification:  During the review of household applications, it was determined two the applications had eligibility determination errors [7 CFR 245.6 (c)].  The errors resulted in the following:

• One of application was originally determined to be eligible for free meals when it should have been determined to be approved for reduced priced meals.  The error occurred due to the to not all the household income on the application being included when the original eligibility determination was made.
• The other household application was determined to be approved for reduced priced meals when it should have been denied.  The household application only had three names listed on it but had the number of household members listed as six. SPCS did not contact the household for clarification, so the application so had been figured with three household members and should been denied for reduced priced meals.

These errors resulted in a performance standard I (PSI) violation requiring fiscal action [as required by federal regulation 7 CFR Part 210.18 (g) (1)]. 

To demonstrate compliance with eligibility certification requirements:

• The household should have been notified of the change in eligibility status, allowing for 10 days for a possible appeal of the new determination prior to change the eligibility determination.
• Provide copies of the letters notifying the household of the change in status.
• Provide the dates the eligibility determinations were changed for the children in the household.
• Provide the above along with SPCS’ plan for corrective action to demonstrate understanding and compliance.

Eligibility Certification – Incomplete Household Applications:  During the review of all household applications, incomplete household applications with eligibility determinations were discovered.  The applications that were discovered did not gather the following data:

• Applications were discovered without the last four digits of the Social Security Number (SSN) for the adult who signed the application or the dox checked indicating the adult signing the application does not have a SSN [as required by federal regulation 7 CFR Part 245.6 (a) (6)].
• Applications were discovered that did not have all of the names of the household listed [as required by federal regulation 7 CFR Part 245.6 (a) (6)].

Federal regulation [7 CFR Part 245.6 (a) (6)] requires household applications to gather information as part of the eligibility process.  If an application does not gather all of the required information, then the determining official cannot make an eligibility determination.

To demonstrate compliance with eligibility certification requirements for household applications:

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

HACCP Food Safety Inspections:  SPCS has not received a food safety inspection from the local Health Department (HD) for their meal service area for this school year and had not contacted their local HD to request an inspection.  Federal regulation [7 CFR Part 210.13 (b)] requires SFAs to obtain a minimum of two food safety inspections during each school year, as well as to require the most recent food safety inspection report to be posted publicly in a location visible to the public.

To demonstrate compliance with HACCP food safety inspections:

• Contact the local HD to request a food safety inspection of the meal service area.
• Provide SPCS plan for corrective action to demonstrate understanding and compliance.

HACCP Food Safety Plan:  SPCS did not have a HACCP food safety plan at the time of the on-site visit.  Federal regulation [7 CFR Part 210.13 (c)] requires SFAs to have a written food safety plan “…that covers any facility or part of a facility where food is stored, prepared, or served.” 

The HACCP food safety plan must cover taking receiving vended meals from SPCS’ caterer.  This protocol for receiving vended meals must include taking temperature of the foods received to ensure the foods are not in the temperature danger zone, as well as to setup protocol for the documentation of where these temperatures will be recorded.  SPCS must work with their caterer to ensure the vended meals are not subjected to the temperature danger zone.

To demonstrate compliance with HACCP food safety plan requirements:

• Adopt a HACCP food safety plan for SPCS.
• Provide SPCS’ plan for corrective action to demonstrate understanding and compliance.

Production Records:  SPCS was not documenting the left-over vended meals for breakfast and lunch on the production records.  Federal regulations [7 CFR Part 210.10 (a) (3) and 7 CFR Part 210.8 (a) (3)] require SFA to be kept on how the meals produced are compliant with the meal patterns, as well as to be filled out in a manner providing data for proper meal planning.

To demonstrate compliance with production record requirements:

• Record the left-over breakfast meals and lunch meals on the production records.
• Provide SPCS’ plan for corrective action demonstrating understanding and compliance.

Potable Water:  During the on-site visit conducted on 02/21/23, it was discovered the potable water was not in the food service area or in an immediately adjacent area to the food services area accessible to the students during all meal services [as required by federal regulations 7 CFR Part 210.10 (a) (1) and 7 CFR Part 220.8 (a) (1), as well as USDA Memo SP28-2011].

To demonstrate compliance with potable water requirements:

• Provide SPCS’ plan for corrective action demonstrating understanding and compliance.

Procurement Review Summary Report

Date:  04-7-23

Name of Agency:  St. Paul’s Community School, Inc.                   Date of AR off-site review: 01-19-23

Reviewer:  Matthew Smith                                                             Date of AR on-site review: 02-21-23

 and 02-23-23

Persons interviewed:  Morgan Shillow and                                 Date of exit conference: 04-05-23

                                    Zoi White

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

Buy American Provision:  During the on-site visit to St. Paul’s Community School’s (SPCS) caterer’s kitchen on 02/23/23, several non-domestically produced food items were discovered.  The following non-domestic food items were found:

• Canned olives, which were a product of Egypt.
• Canned jalapenos, which were a product of Peru.
• Fresh cucumber, which were a product of Mexico.

The documentation of the use of a limited exemptions to the Buy American Provision by SPCS’ caterer was insufficient to justify the use of the limited exemptions.

Federal regulations [2 CFR Part 200.322, 7 CFR Part 210.21 (d), and 7 CFR Part 220.16 (d)] require SFAs “to purchase to the maximum extent practicable, domestic commodities or products.” 

To demonstrate compliance with Buy American Provision requirements:

• Request Keystone review their menus for SPCS school food services program to ensure compliance with the requirements for the Buy American Provision.
• Require Keystone to remove and replace all non-domestic products with insufficient limited exemption to the Buy American Provision with domestically food products.
• Provide SPCS’ plan for corrective action to demonstrate understanding and compliance.

Failure to Maintain Contract Oversight:  SPCS failed to maintain proper oversight to ensure their caterer (Keystone) performed in accordance with terms, conditions, and specifications of the catering vended meals contract and amendments [as required by federal regulation 2 CFR Part 200.318 (b)].  SPCS permitted Keystone to charge delivery fees which were not covered in the vended meals contract or the contract amendments.

To demonstrate compliance with oversite of contract requirements:

• Provide SPCS plan for corrective action to demonstrate understanding and compliance.

Failure to Maintain Procurement Records:  During this review, SPCS could not locate records of the procurement process for their vended meals contract and amendments to the

contract.  Federal regulation [2 CFR Part 200.318 (i)] requires SFAs to “maintain records sufficient to detail the history of procurement.”

To demonstrate compliance with maintaining records of procurement requirements:

• Begin maintaining records for all procurement activities.
• Provide SPCS’ plan for corrective action to demonstrate understanding and compliance.

Procurement Plan:  SPCS procurement plan does not address the use of the micro-purchase method of procurement.  Federal regulation [2 CFR Part 200.318 (a)] requires SFAs to have documented procurement procedures consistent with federal requirements.

To demonstrate compliance with procurement plan requirements:

• Update SPCS’ procurement plan to include procedures for the use of the micro-purchase method of procurement.
• Provide documentation of the above along with SPCS’ plan for corrective action to demonstrate understanding and compliance.

Vended Meals Contract:  SPCS singed the most recent contract amendment without obtaining approval from Oklahoma Human Services School Nutrition Programs (OHS SNP).  Federal regulation [2 CFR Part 200.318 (b)] requires SFAs to obtain state agency approval prior to signing contract and contract amendments with vendors.

The most recent contract amendment was for a Food Service Management Company (FSMC) and covered services not being provided to SPCS.  The contract amendment must amend parts of the contract, in this case a vended meal contract and not add additional services.  Adding additional services could be a material change to the contract which could have caused another qualified vendor to bid differently, therefore material changes require the contract to be re-procured.

To demonstrate compliance with contract requirements:

• For school year 2023 – 2024, SPCS’ vended meal contract cannot be amended to continue for another school year.  The vended meal service will have to be procured for school year 2023 – 2024.
• Provide SPCS’ plan for corrective action to demonstrate compliance and understanding.

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:

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.