Administrative Review Summary Report

Date: 11-30-20

Name of Agency: Integris Mental Health Date of off-site review: 09-14-20

Reviewer: Matthew Smith Date of on-site review: 11-05-20

Persons interviewed: Tracey Williams Date of exit conference: 11-23-20

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):

Failure to Provide Records: Integris Mental Health (IMH) failed to provide documentation requested by OKDHS School Nutrition Programs [7 CFR Part 210.9 (b) (17)]. Prior to the completion of the on-site portion of this AR, IMH provided all of the requested documentation.
Meal Patterns: During the menu week (08/16/20 through 08/22/20) assessment of breakfast and lunch menus, IMH used a dinner roll that only credited at 1.5 oz. (the roll was used with lunch meals on 08/17/20, 08/18/20, and 08/22/20). The menus on the days this product was used no other bread/grain items were served, which caused insufficient daily and weekly serving sizes for the bread/grain component [7 CFR Part 210.10 (c)]. Prior to the on-site portion of this AR, IMH took corrective action bringing the serving sizes into compliance with the grades 9 through 12 meal pattern
Resource Management: IMH did not have a Nonprofit School Food Services Account (NSFSA) that was separate from the food services account (that also was paying for adult patient meals) as required by 7 CFR Part 210.14 (a).

IMH did not conduct an end of school year revenue and expense report [7 CFR Part 210.14 (a), 7 CFR Part 210.14 (b) and 7 CFR Part 210.19 (a) (1)].

Prior to the completion of the on-site portion of this AR, IMH took corrective action by providing a revenue and expense report. IMH school food services program has a separate accounting code that the expenses for the IMH’s school food services program are charged.

IMH did not have internal controls to ensure only allowable expenses are charged to the NSFSA [2 CFR Part 200.303].

Prior to the completion of the on-site portion of this AR, IMH took corrective action by adding an internal control for the NSFSA (only school food services employee wages and benefits will be charged to the account).

Corrective action for the above was 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 September 14, 2020:

Benefit Issuance Document: The benefit issuance document (or master list) provided during the off-sit portion of this Administrative Review (AR) did not contain all of the required areas. 7

CFR Part 245.6 (e) and the USDA FNS Administrative Review Manual require benefit issuance document to contain the following information on program participants (residents):

Name of the resident
Benefit status of the resident
Income of the resident
Date or period that the income is for
Date of eligibility determination
Date entered and date exited
Initials of the determining

Integris Mental Health (IMH) was provided OKDHS School Nutrition Programs’ prototype benefit issuance document that is compliant with federal requirements. Emailed 10/15/2020

To demonstrate compliance with benefit issuance document requirements:

Update you benefit issuance document to gather the above required information for residents, or begin using OKDHS School Nutrition Programs prototype benefit issuance document.
Provide a copy of the above along with IMH’s corrective action plan to demonstrate understanding and compliance.

Civil Rights: The written procedure for provided during the off-site portion of this AR has religion listed as a protected class. FNS Instruction 113-1 has the following protected classes listed for nutritional assistance programs:

Race
Color
National origin
Age
Sex, and
Disability

These are the only protected classes.

The written procedure for handling civil rights complaints also had out of date contact information for where to send civil rights complaints. The following is the current contact information for where to send a civil rights complaint:

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

(1) mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;

(2) fax: (202) 690-7442; or

(3) email: program.intake@usda.gov.

IMH was emailed (on 10/15/2020) OKDHS’ School Nutrition Programs’ prototype procedure for handling civil rights complaints which is compliant with federal requirements and includes the current contact information for where to send civil rights complaints.

To demonstrate compliance with civil rights requirements:

Provide an updated copy of IMH’s procedure for handling civil rights complaints.
Provide a copy of the above along with IMH’s corrective action plan to demonstrate understanding and compliance.

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

The name and title of the person(s) designated to assess IMH's local wellness policy and to ensure the policy's implementation. It is recommended no more than two people assess the policy. This is required to meet the requirements under 7 CFR Part 210.30 (c) (4) and 7 CFR Part 210.30 (e) (1).
The local wellness policy does not contain a description for how IMH promotes public involvement with the development, implementation, assessment of the policy, and the update of the local wellness policy [as required by 7 CFR Part 210.31 (c) (5)]. The policy should contain what IMH is doing, or is going to do to promote public involvement with IMH’s local wellness policy.
The local wellness policy does not contain guidelines and standards for the marketing of food and beverages on campus during the school day as required by 7 CFR Part 7 CFR Part 210.31 (c) (iii). Being IMH does not sell food and beverages to the residents, a statement could be added to the policy that simply states “the marketing of food and beverages on campus during the school day is prohibited.

When changes to the local wellness policy occur, review them with the committee and post the policy changes where you publicly post the policy. Once you review and update your policy, consider the policy updated for this program year. An evaluation of program requirements must occur once during a 3-year cycle and any other time the agency or committee identifies the need for updating. All policy updates need to be documented in a wellness assessment report, USDA Memo SP24-2017. The wellness report needs to be posted publicly as required by

7 CFR Part 210.30 (E) (2).

To demonstrate compliance with the local wellness policy:

Add the name of the person designated to assess the local wellness policy and to ensure the policy is implemented.
Provide a copy of the wellness assessment report for the SFA's local wellness policy.
Provide a copy of the updated local wellness policy with the required changes listed above.
Provide the above requested documentation along your plan for corrective action to demonstrate compliance and understanding.

Professional Standards: IMH’ director failed to complete 12 hours of training that could be credited toward the annual training requirements during school year 2019-2020. The director completed seven hours that could be credited in school year 2019-2020. All of IMH’s school food services full time employees failed to complete six hours of training that could be credited toward the annual training requirements during school year 2019-2020. All of the full time staff members only had 1.5 hours that could be credited in school year 2013-2020. Federal regulations [7 CFR Part 210.31 (b) (3), 7 CFR Part 210.31 (c), 7 CFR Part 210.30 (d), and 7 CFR Part 210.30 (e)] require the following annual training requirement:

Job Category*	Annual Requirements
Directors	12 hours
Staff (full time)	6 hours
Part-Time Staff (working less than 20 hours per week in the SFA’s school nutrition program)	4 hours
Mid-year hires in all categories (January 1^st or later)	One-half of training requirement for each job category.

Training must be completed annually by June 30^th of each school year
(The school year begins on July 1^st of each year).

Trainings that can be credited toward the annual training requirements include (but are not limited to):

Meal counting and the reimbursement claim procedures
Identification of reimbursable meals at the point of service
Annual civil rights training
Nutrition health and safety standards
HACCP food safety topics

Only trainings covering the above topics may credit toward the annual training requirements.

To demonstrate compliance with professional standards requirements:

Provide IMH’s corrective action plan to demonstrate understanding and compliance.

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted November 5, 2020:

Counting and Claiming: A review of the counting system demonstrates a counting error for the review period (September 2020) for IMH’s Afterschool Snack Program. The error resulted in an under claim for the Afterschool Snack Program for the month of September 2020, which caused a Performance Standard Violation I (PSI), 7 CFR Part 210.18 (g) (1) (ii).

The error in the September Afterschool Snack Program claim appears to be due to snack rosters showing a different count than what was entered into Nutrikids.

Below are the differences, our reviewer identified, in your September 2020 Afterschool Snack Program count:

	IMH	OKDHS	Difference
Free	908	916	8

Free snacks were under claimed by 8 snacks.

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).

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: your IMH’s edit check for the snacks claimed for November 2020, and the snack rosters for November 2020.
Provide the above copies, along with IMH’s corrective action plan to demonstrate understanding and compliance.

Food Safety Inspections: IMH received its most recent health inspection on 11/07/2019 during school year 2019-2020. Prior to that the next most recent health inspection was conducted on 06/11/2019 during school year 2018-2019. IMH did not provide documentation that a second inspection was requested during school year 2019-2020 [as required by the USDA FNS Administrative Review Manual]. 7 CFR Part 210.13 (b) requires SFA to obtain a minimum of two inspections during each school year (7 CFR Part 210.2 defines the school year as the period of 12 calendar months beginning July 1^st of any year and ending June 30^th of the following year) conducted by the state or local agency responsible for food safety inspections.

If a second inspection has not been received SFAs are required to contact the state or local agency responsible for food safety inspections (the Oklahoma City County Health Department) to request a second inspection (as required by the USDA FNS Administrative Review Manual). Best practice is to contact the health department in March if your agency has not received a second health inspection for the school year.

To demonstrate compliance with food safety inspections:

Provide IMH’s corrective action plan to demonstrate understanding and compliance.

Procurement Review Summary Report

Date: 11-30-20

Name of Agency: Integris Mental Health Date of AR off-site review: 09-14-20

Reviewer: Matthew Smith Date of AR on-site review: 11-05-20

Persons interviewed: Tracey Williams Date of exit conference: 11-23-20

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 during the Procurement Review (PR):

Procurement Plan: The procurement plan provided during the AR Off-Site did not include the required price analysis language for procurements above the small purchase threshold [Integris Mental Health’s (IMH) small purchase threshold is currently set at $150,000) as required by 2 CFR Part 200.323 (a)]. Procurement plans are required to document the requirement of a cost or price analysis for procurement above the small purchase threshold.

To demonstrate compliance with procurement plan requirements:

Provide a procurement plan that contains how SJCHA would conduct formal procurements to include requirements for SJCHA to conduct a price analysis for procurements above the small purchase threshold.
Provide the above along with SJCHA corrective action plan to demonstrate compliance and understanding.