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Administrative Review Summary Report


Date:  04-28-21
 

Name of Agency:  Crossover Preparatory Academy           Date of off-site review: 02-04-21

Reviewer:  Matthew Smith                                                       Date of on-site review: 03-31-21

Persons interviewed:  Dr. John Lepine Sr. and                      Date of exit conference: 04-21-21
                                      Hayes Lewis

This School Food Authority (SFA) operates the National School Lunch Program, the School Breakfast Program, and the After School Snack Program (the snack program is currently suspended due to the COVID-19 outbreak).

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

  • Civil Rights – Data on Ethnicity and Race:  Crossover Preparatory Academy (CPA) was not gathering data on ethnicity and race using the required two-question format [FNS Instruction 113-1].  The SFA was also not using USDA approved responses for race [FNS 113-1].  Prior to the on-site portion of this AR, CPA took corrective action by starting to use the proper two-question format using USDA approved responses for both questions.

  • Eligibility Determination Letters:  The notification of program eligibility letters used by CPA at the time of the off-site portion of this AR did not contain the current USDA approved non-discrimination statement [FNS Instruction 113-1].  Prior to the on-site portion of this AR, CPA took corrective action and is now using the current USDA nondiscrimination statement on the letters.

  • Meal Patterns:  A review of the 01/25/21 through 01/29/21 indicated some insufficient portion sizes, as well as a missing meal component [7 CFR Part 210.10 (c)]. A salad served during this week, was found during the week assessed was served a few times during the review period (January), as well as one insufficient fruit serving for the lunch for the high school grades on 01/12/21.  Prior to the completion of the on-site visit, CPA took corrective action allowing for the triggered nutrient analysis to be conducted.  The corrective action taken for the insufficient serving sizes due to the salad recipe brought the serving sizes discovered during the review period into compliance with the meal patterns.   The SFA also took corrective action for the insufficient fruit serving for the lunch on 01/21/21 prior to the completion of the on-site portion of this AR.

Your staff took Corrective action for the above prior to the On-Site portion of this AR.  No further action is required

Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted February 4, 2021:

Civil Rights – Annual Training:  Crossover Preparatory Academy (CPA) did not conduct their annual civil rights training.  FNS Instruction 113-1 requires staff members who work with program applications or participants to receive civil rights training annually.  A PowerPoint covering civil rights in school nutrition programs was emailed to CPA on 03/22/21.  This PowerPoint contains all of the required topics can be used in the training of the staff members who take the Point of Service (POS) meal counts.

To demonstrate compliance with civil rights – annual training requirements:

  • Conduct the annual training with the staff members who take the POS meal counts.
  • Provide a copy of the training log for the civil rights training(s) conducted.
  • Provide copy of the above log along with CPA’s plan for corrective action to demonstrate compliance and understanding,

Failure to Provide Requested Records:  CPA failed to provide documentation as required by their State Agency (SA) agreement and federal regulation [7 CFR Part 210.9 (b) (17)].  This federal regulation requires School Food Authorities (SFA) to:

“Upon request make all accounts and records pertaining to its school food service program available to the SA, and to the USDA Food and Nutrition Service (FNS).”

The SA reviewer made requests to provide the following records that were not provided:

  • The end of school year revenue and expense report.  This was provided prior to the on-site portion of this AR.
  • Documentation that the school food services director (Hayes Lewis) completed eight hours of food safety training within 30 days of starting in this positon, or within five years of assuming the position of school food services director.

To demonstrate compliance with the requirement to provide requested records:

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

Professional Standards – Eight-Hour Food Safety Training:  CPA failed to provide documentation that the school food services director (Hayes Lewis) completed eight hours of food safety training within 30 days of assuming the position, or within five years of the director starting in their new position as required by federal regulation [7 CFR Part 210.30 (b) (1) (iv)].

To demonstrate compliance with the eight-hour food safety training requirement:

  • Provide a copy of the documentation of the most recent eight-hour food safety training completed by the school food services director.
  • Provide the above along with CPA’s plan for corrective action to demonstrate compliance and understanding.

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted March 31, 2021:

Counting and Claiming:  During the process of reviewing the claim for the review period (January), the SA reviewer was informed of systemic counting and claiming errors necessitating a review CPA’s claims for September through February.  These errors are Performance Standard I (PSI) violations requiring fiscal action per federal regulation [7 CFR Part 210.18 (g) (1) (ii)].

The following are errors for CPA’s claims for the National School Lunch Program (NSLP) for the months of January through February:

Month CP Free Claimed CPA Paid Claimed SA Free Meal Count SA Paid Meal Count Difference Comments

September

1066

105

1046

103

Free:  20

Paid: 2

There was an over claim of 20 free meals and two paid meals.

October

971

96

967

95

Free:  4

Paid:  1 

There was an over claim of four free meals and one paid meal.

November

404

40

404

40

None

December

166

16

166

16

None

January (Review Period)

597

59

997

98

Free:  -400

Paid:  -39

There was an under claim of 400 free meals and 30 paid meals.

February

584

57

569

56

Free:  -400

Paid:  -39

There was an under claim of 400 free meals and 30 paid meals.

The following are errors for CPA’s claims for the School Breakfast Program (SBP) for the months of January through February:

Month CP Free Claimed CPA Paid Claimed SA Free Meal Count SA Paid Meal Count Difference Comments

September

601

59

594

59

Free:  7

Paid: 0

There was an over claim of seven free meals.

October

654

64

618

61

Free:  36

Paid:  3

There was an over claim of 36 free meals and three paid meals.

November

406

40

363

36

Free:  43

Paid:  4

There was an over claim of 43 free meals and four paid meals.

December

185

18

185

18

None

January (Review Period)

1012

100

574

57

Free:  438

Paid:  43

There was an over claim of 43 free meals and four paid meals.

February

473

47

442

44

Free:  31

Paid:  3

There was an over claim of 43 free meals and four paid meals.

The errors appear to be from double entries into CPA’s electronic Point of Service (POS) system, as well as data entry errors when the SFA entered the claims into the SA’s online claiming system. 

According to CPA’s principal, the staff members who entered the POS meal counts into the electronic system (TeacherEase) neglected to change the meal service from breakfast to lunch before entering the counts.  Apparently, the TeacherEase program automatically defaults to the breakfast meal service when the POS option is selected. 

You must retrain your staff, who enter the meal counts at the POS, on the electronic POS and recognizing a reimbursable meal.     

Prior to entering the monthly reimbursement claim into the SA online claiming system, review the documentation for the monthly claim (the meal rosters, the edit checks, and the CEP claiming worksheet) to ensure the claim is accurate as required by federal regulation [7 CFR Part 210.8 (a) (2)].

To demonstrate compliance with counting and claiming:

  • Review the counting and claiming system and create a plan to ensure accurate recording of daily meal counts.
  • Provide the copies of the following: CPA’s meal rosters for April 2021 and CPA’s edit checks for April 2021.
  • Proved the above copies along with CPA’s corrective action plan to demonstrate compliance and understanding.

HAACP Food Safety Plan:  At the time of the on-site visit, CPA could not locate their HACCP (Hazard Analysis Critical Control Points) food safety plan.  Federal regulation [7 CFR Part 210.13 (c)] requires each SFA to have a HACCP food safety plan.  CPA will need to develop and implement a comprehensive HACCP food safety plan.  The plan should include all the appropriate forms and documentation for monitoring and review.

A HACCP food safety plan template was emailed to CPA on 04/01/21.  This template contains everything needed to develop a HACCP food safety plan.

Keeping food safe is a vital part of healthy eating.  When properly implemented, a HACCP-based food safety program helps to ensure the safety of all meals.  SFAs must routinely monitor and document food safety procedures.

To demonstrate compliance with HACCP food safety plan requirements:

  • Use the sample HACCP plan provided as a guide to develop CPA’s HACCP food safety plan.
  • Provide an electronic copy of your HACCP plan’s cover sheet and table contents.
  • Provide the above along with CPA’s corrective action plan to demonstrate compliance and understanding.

HACCP – Temperature Logs:  At the time of the on-site visit it was discovered, CPA was not keeping temperature logs for the cold food storage units.  Federal regulations [7 CFR Part 210.13 (c) and 7 CFR Part 210.13 (d)] requires SFAs to keep temperature logs for the SFA’s cold food storage units. 

Keeping temperature logs for the cold food storage units ensures the units are operating properly, and can alert the SFA to possible mechanical issues causing the units not being able to maintain temperatures to ensure the food is usable.  Ensuring food is keep at the proper temperatures helps to ensure the safety for all meals.

To demonstrate compliance with temperature logs:

  • Begin keeping temperature logs for all cold food storage units.
  • Provide copies of the most recent temperature logs for the cold food storage units.
  • Provide the above along with CPA’s corrective action plan to demonstrate compliance and understanding.

Nutrient Analysis: The following errors, requiring corrective action, are based on the analysis conducted on the menu week (breakfast and lunch) previously assessed, January 25 through 29, 2021.

Lunch:

For grades 6-8, the nutrient analysis found the weekly calorie average to be 589 calories, which is 11 calories short of the meal pattern average calorie range.  Federal regulation [7 CFR Part 210.10 (f) (1)] establishes an average calorie range of 600-700 calories for the grades 6-8 meal pattern.

For grades 9-10, the nutrient analysis found the weekly sodium average to exceed sodium target 2.  The weekly average for the menus served during the week analyzed was 1407 mg. for the high school grades.  Federal regulation [7 CFR Part 210.10 (f) (3)] establishes sodium target 2 as 1080 mg. or less for the grades 9-12 meal pattern.

To demonstrate compliance with Saturated fat Nutrient target:

  • Submit a plan to correct the calorie short fall for grades 6-8 for the week.
  • Submit a plan to correct the average sodium levels exceeding sodium target 2 for high school menus for the week.
  • Review the rest of your menus for compliance with the meal patterns.
  • Submit the above along with your plan for corrective action to demonstrate understanding and compliance.     

Administrative Review Summary Report

Date:  04-28-21

Name of Agency:  Crossover Preparatory Academy           Date of AR off-site review: 02-04-21

Reviewer:  Matthew Smith                                                       Date of AR on-site review: 03-31-21

 

Persons interviewed:  Dr. John Lepine Sr. and                      Date of exit conference: 04-21-21
                                      Hayes Lewis

This School Food Authority (SFA) operates the National School Lunch Program, the School Breakfast Program, and the After School Snack Program (the snack program is currently suspended due to the COVID-19 outbreak).

Failure to Provide Requested Records:  CPA failed to provide documentation as required by their State Agency (SA) agreement and federal regulation [7 CFR Part 210.9 (b) (17)].  This federal regulation requires School Food Authorities (SFA) to:

“Upon request make all accounts and records pertaining to its school food service program available to the SA, and to the USDA Food and Nutrition Service (FNS).”

The SA reviewer made requests to CPA to provide the following records that were not provided:

  • A list of vendors used during school year 2019-2020.  This was provided prior to the on-site portion of this AR.
  • Invoices/receipts for the school year 2019-2020 for the following vendors:
    • Church’s Chicken.
    • Mazios
    • Oklahoma Style BBQ

To demonstrate compliance with the requirement to provide requested records:

  • Provide the above documentation along with CPA’s plan for corrective action to demonstrate compliance and understanding.

Procurement Plan:  The procurement plan provided during the off-site portion of Crossover Preparatory Academy’s (CPA) Administrative Review (AR) did not include the required price analysis language for procurements above the small purchase threshold (CPA’s small purchase threshold is currently set at $150,000) as required by federal regulation [2 CFR Part 200.323 (a)].  Procurement plans are required to document a cost or price analysis for procurement activities above the small purchase threshold.

To demonstrate compliance with procurement plan requirements:

  • Provide a copy of a procurement plan that contains the required language.
  • Provide the above along with CPA’s plan for corrective action to demonstrate compliance and understanding.
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