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Administrative Review Summary Report

Date:  04-08-24

Name of Agency:  Bishop John Carroll School

            Date of off-site review: 01-18-24

Reviewer:  Matthew Smith                                                    Date of on-site review: 02-27-24

Fiscal Action: Yes, fiscal action amount will be assessed in the fiscal action and closure letter.                                                                

Persons interviewed:  Margret Otto                                       Date of exit conference: 04-03-24

Programs Operated by the School Food Authority (SFA): This SFA operates the National School Lunch Program.

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

·       Buy American Provision:  During the assessment of lunch menus for the week of 12/04/23 – 12/08/23, a nondomestic fruit product was discovered in violation of the Buy American Provision and federal regulation [7 CFR Part 210.21 (d)].  Prior to the completion of the off-site portion of this AR, Bishop John Carroll School (BJCS) replaced the nondomestic product with domestically produced peaches served earlier in the week assessed.

·       Meal Pattern:  During the menu week assessment of lunch menus conducted a non-systemic insufficient serving size was discovered [7 CFR Part 210.10 (c)].  Prior to the completion of this AR, the BJCS took corrective action bringing the serving size into compliance with the meal pattern.

No further action is required for the above. 

Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted January 18, 2024:

Civil Rights – Nondiscrimination Statement:  During the off-site portion of this Administrative Review (AR) it was discovered the full nondiscrimination statement was not posted on BCS’s school nutrition program website.  USDA FNS Instruction 113-1 requires the full non-discrimination statement to be posted on a program operator’s USDA program related websites.

To demonstrate compliance with nondiscrimination statement posting requirements:

·       Post the full nondiscrimination statement on BJCS’ website.

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

Civil Rights – Public Release:  During the off-site portion of this AR, BJCS failed to provide documentation demonstrating the completion of the public release process for school year 2023 – 2024 [as required by USDA FNS Instruction 113-1].  Federal regulation

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[7 CFR Part 210.15 (b)] requires documentation of the public release process to be retained for at least three school years after the last reimbursement for the school year has been received.

To demonstrate compliance with civil rights public release requirements:

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

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

  • Goals for nutrition promotion [as required by federal regulation 7 CFR Part 210.31 (c) (1)].
  • Goals for other school-based activities to promote student wellness [as required by federal regulation 7 CFR Part 210.31 (c) (1)].
  • A description of the manner in which the public is provided the opportunity to participate in the local wellness policy process [as required by federal regulation 7 CFR Part 710.31 (c) (5)].
  • Guidelines and standards for the following:
    • Non-program food and beverages [as required by federal regulation 7 CFR Part 210.31 (c) (3)].
    • Other food and beverages served (not sold) on campus during the school day [as required by 7 CFR Part 210.31 (c) (2)].

BJCS’ local wellness policy provided at the time of the off-site portion of the AR had not been assessed in over three years.  Federal regulation [7 CFR Part 210.31 (e) (2)] require local wellness policies to be assessed at least once every three years.

To demonstrate compliance with local wellness policy requirements:

  • Conduct the local wellness policy assessment process.
  • Provide a copy of the updated local wellness policy (compliant with federal requirements for local wellness policies) and documentation of the assessment of the policy (triennial wellness assessment report).
  • Post the updated local wellness policy and documentation of the most recent assessment to the policy on BJCS’ website.
  • Provide the above documentation along with BJCS’ plan for corrective action to demonstrate understanding and compliance.

Professional Standards – Annual Training Hours:  Records and documentation of training completed during school year 2022 – 2023, showed employees with duties within the school food services program failed to complete the required annual training hours. 

BJCS school food services director only completed six creditable training hours during school year 2022 - 2023.  Federal regulation [7 CFR Part 210.30 (b) (3)] requires school food services directors to complete at least 12 hours of annual training.

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BJCS’ employee with part-time duties in the school food services program did not complete any creditable annual training hours.  Federal regulation [7 CFR Part 210.30 (d)] requires employees with part-time duties in school food services programs to complete at least four hours of annual training.

To demonstrate compliance with professional standard requirements:

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

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted February 27, 2024:

Civil Rights – Notification Letters:  During the on-site visit it was discovered the following notification letters did not contain the full nondiscrimination statement as required by USDA FNS Instruction 113-1:

·       Notification of eligibility determination letters

·       Notification of direct certification

·       Notification of verification outcome letter

BJCS was sending just the first page of their template letter that only contained part of the full nondiscrimination statement.

To demonstrate compliance with notification letter requirements:

·       Provide BJCS’ plan for corrective action demonstrating understanding and compliance.

Counting and Claiming:  A review of the counting and claiming system demonstrates non-systemic claiming errors for the review period (December), which are a Performance Standard I (PSI) Violation [per federal regulation 7 CFR Part 210.18 (g) (1) (ii)] requiring fiscal action. 

The errors appeared to be due to data entry errors occurring when the meal counts were entered into BJCS’ electronic system to consolidate the daily meal counts into the monthly meal counts and to conduct the daily edit checks.

Below are the differences Oklahoma Human Services School Nutrition Programs (OKHS SNP) has identified in Bishop John Carroll School (BJCS) lunch meal counts claimed for December:

 

OKHS SNP Count

BJCS Edit Check

BJCS Claim

Difference

Free

154

151

151

-3

Reduced

96

96

96

0

Paid

1464

1469

1469

5

Free lunches meals were under claimed by 3 meals.  Paid lunch meals were over claimed by five meals.

Federal regulation [7 CFR Part 210.8 (a) (2)] requires each SFA to review their claims for accuracy prior to submitting them to the State Agency (SA).

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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 March 2024 for breakfast and lunch, as well as the edit check for lunch for March 2024.
  • Provide the above along with BJCS’ plan for corrective action to demonstrate compliance and understanding.

Direct Certification – Household Notification:  During the review of the direct certification documentation for school year 2023 – 2024, the reviewer discovered BJCS did not retain documentation of approval notification for one household as required by federal regulation [7 CFR Part 245.6 (b) (10)].   Federal regulation [7 CFR Part 245.6 (e)] requires SFAs to retain documentation of the eligibility determination and direct certification processes including copies of the notification to households for three years after the last reimbursement claim has been received for the school year.

To demonstrate compliance with household notification requirements:

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

Reviewer’s Comments:  The findings contained in this report in no way reflects on the good work being done in BJCS’ school food services program.  I would like to take the opportunity to commend BJCS’ employees with duties within BJCS’ school food services program for all the hard work they do daily.  Keep up the good work.

Appeal Procedures

Federal regulations, Section 210.18(q), state that the School Food Authority may appeal all or part of a State Agency decision to deny all or part of a Claim for Reimbursement or withhold payments arising from an administrative or follow-up review.  The School Food Authority may file a written request with Natascha Ferguson, Public Guardian, and Administrative Hearing Officer for Oklahoma Department of Human Services, in accordance with the appeal procedures specified below.  Ms. Ferguson’s phone number is (405) 627-5239.  The mailing address is 2400 N. Lincoln Blvd., P.O. Box 25352, Oklahoma City, Oklahoma, 73125.

1.    The written request for a review shall be postmarked within 15 calendar days of the date the appellant received the notice of the denial of all or part of the Claim for Reimbursement or withholding of payment, and the State agency shall acknowledge the receipt of the request for appeal within 10 calendar days;

2.    The appellant may refute the action specified in the notice in person and by written documentation to the review official. In order to be considered, written documentation must be filed with the review official not later than 30 calendar days after the appellant received the notice. The appellant may retain legal counsel, or may be represented by another person. A hearing shall be held by the review official in addition to, or in lieu of, a review of written information submitted by the appellant only if the appellant so specifies in the letter of request for review. Failure of the appellant school food authority’s representative to appear at a scheduled hearing shall constitute the appellant school food authority’s waiver of the right to a personal appearance before the review official unless the review official agrees to reschedule the hearing.  A representative of the State agency shall be allowed to attend the hearing to respond to the appellant’s testimony and to answer questions posed by the review official;

3.    If the appellant has requested a hearing, the appellant and the State agency shall be provided with at least 10 calendar days advance written notice, sent by certified mail, return receipt requested, of the time, date and place of the hearing;

4.    Any information on which the State agency’s action was based shall be available to the appellant for inspection from the date of the receipt of the request for review;

5.    The review official shall be an independent and impartial official other than, and not accountable to, any person authorized to make decisions that are subject to appeal under the provisions of this section;

6.    The review official shall make a determination based on information provided by the State agency and the appellant, and on Program regulations;

7.    Within 60 calendar days of the State agency’s receipt of the request for review, by written notice, sent by certified mail, return receipt requested, the review official shall inform the State agency and the appellant of the determination of the review official.  The final determination shall take effect upon receipt of the written notice of the final decision by the school food authority;

8.    The State agency’s action shall remain in effect during the appeal process;

9.    The determination by the State review official is the final administrative determination to be afforded to the appellant.

Administrative Review Corrective Action Plan

The school Food Authority (SFA) is required to take corrective action and submit a written corrective action plan (CAP) for all findings listed in the State Agency’s Corrective Action memo.  SFAs are required to submit their plans and supporting documentation no later than the deadline provided in the memo.  The CAP purpose is to demonstrate that the school has knowledge and understanding of USDA requirements. 

1.     The SFA is required to use the Corrective Action Plan (CAP) form provided by the State Agency. 
The following is an example of what the CAP form looks like:

The State Agency (SA) will fill out part of the Corrective Action Plan form and leave the following sections for the SFA to fill out:

a)     Action section: state the actions taken to resolve the finding and how these actions will resolve future problems. Responsible personnel section: list the persons responsible for the implementation of the corrective action plan

b)     Responsible personnel.

c)     Date of completion: date the corrective action was completed

2.     Required documentation: submit all documentation requested in the Administrative Review Summary Report (the SA will list the required documents in this section of the CAP).

3.     After each completed issue section, the required documentation for the issue section is to be placed after the section before proceeding to the next issue section. Once all the issue sections are completed, fill out the section with the signature and date of the SFA official.

4.     Submit the CAP along with the required documentation to the SA.

Penalty or withholding:  If an agency fails to complete corrective action by the required deadline or fails to submit a corrective action plan by the submission date, the state agency is required to withhold payments.  Additionally, findings with a PSI or a PSII violation must be completed by the required deadline and no extension will be granted.  OKDHS has the discretion to deny or withhold reimbursement claims on all general areas for repeat violations or if the corrective action is not implemented.   

Extensions: Extensions will not be granted to any SFA unless there is a valid reason for not meeting the required deadlines.  Extensions are based on individual findings that cannot be completed with all other corrective actions.  Extensions must be requested in writing and approved by our office in advance of the deadline for completing corrective action.  The request must include the reason(s) why the agency cannot meet the deadline and must provide an anticipated date for correcting the finding(s).  The extension must be submitted with your complete corrective action plan, listing both the corrected findings and the ones you’re seeking an extension for, by the required deadline.

Email the plan to:   Matthew Smith, Program Field Representative - Matthew.Smith@okdhs.org

For further direction, please contact Matthew Smith at 405-919-9064 or Chet Center at 405-990-9251.