Skip to main content

Administrative Review Summary Report

​Date:  11-05-18

Name of Agency:  Murrow Indian Children's Home

                                                                                                  Date of off-site review: 09-04-18

Reviewer:  Matthew Smith                                                   Date of on-site review: 10-18-18

Persons interviewed:  Shari Kamp                                       Date of exit conference: 10-18-18

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):

  • Civil Rights: The School Food Authority (SFA) did not provide documentation of employees with duties in the agency's school nutrition programs completion of the annual civil rights training (FNS Instruction 113-1).  Prior to the completion of the On-Site portion of this AR the SFA provided this documentation of the school year 2018-2019 annual civil rights training to the State Agency (SA) reviewer.
  • Resource Management:  The SFA did not provide their end of the school year (2017-2018) report for revenue and expenses for the SFA's nonprofit school food services account [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 the SFA provided this report.
  • Local Wellness Policy:  During the Off-Site visit the SFA had not updated there local wellness policy the last Administrative Review (AR) conducted in school year 2015-2016.  This policy directs the policy to be assessed at the annually [7 CFR Part 210.31 (e) (2)]. Prior to the completion of the On-Site portion of the AR the SFA assessed and updated their local wellness policy and completed a triennial wellness assessment (USDA Memo SP 24-2017).  The SFA also publicly posted both documents on a public bulletin board prior to the completion of the On-Site portion of the AR [7 CFR Part 210.31 (d) and 7 CFR Part 210.31 (e)].

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 4, 2018:

Failure to Provide Requested Records:  The SFA failed to provide documentation as required by their agreement with the State Agency (SA) and as required by 7 CFR Part 210.9 (b) (17).  This federal regulation requires SFAs to:

"Upon request make all accounts and records pertaining to its school food service available to the State Agency, and to the USDA Food and Nutrition Service (FNS)"

The SA reviewer made several requests to the SFA to provide records starting on June 1, 2018 through November 1, 2018.  The SA requested the following records:

  • Labels to include nutrition facts and ingredients for breakfast and lunch menus for the week of 07/15/18—07/21/18
    • For the breakfast meals served on 07/16/18:
      • Labeling for the sausage patties.
    • For the breakfast meals served on 07/17/18:
      • The recipe for the scrambled eggs.  Include the labeling for all products used in the recipe (include the nutrition facts and ingredients).
    • For the breakfast meals served on 07/18/18:
      • Labeling for the breakfast burrito to include CN label (or product formulation statement), nutrition facts, and ingredients.
    • For the breakfast meals served on 07/19/18:
      • Labeling for the sausage patty (if different from the sausage patty served on 07/16/18).
      • Labeling for the whole wheat biscuit. 
    • For the breakfast meals served on 07/20/18:
      • Labeling for all cereal types served.
    • For the breakfast meals served on 07/21/18
      • Labeling for whole wheat pancake sticks to include the CN label product. 
    • For the lunch meals served on 07/15/18:
      • Labeling for the breaded beef patty to include the CN label for the product.
      • Labeling of the whole wheat rolls served with this meal. 
    • For the lunch meals served on 07/16/18:
      • Labeling for the baked beans served with this meal.
      • Labeling for the spinach (if not fresh). 
      • Labeling for the whole wheat rolls (if different than the rolls served on 07/15/18).
    • For the lunch meals served on 07/17/18:
      • Labeling for the hamburger bun used with this meal to include the nutrition facts and ingredients.
    • For the lunch meals served on 07/18/18:
      • Labeling for the macaroni and cheese.  If a recipe item include labeling for all products used to include nutrition facts and ingredients for all products used.
      • Labeling for the rolls served (if different from the ones served on 07/15/18).
    • For the lunch meals served on 07/19/18:
      • Recipe for the beans with ham.  Include labeling for all products used to include the nutrition facts and ingredients for all products.
      • Labeling for the corn bread served. If this is a recipe item please provide labeling for all products used (include the nutrition facts and ingredients for all products).
    • For the lunch meals served on 07/20/18:
      • Recipe for the taco meat to include labeling for all products used (include the nutrition facts and ingredients for each product used).  If ground beef was used indicate the beef to fat ratio (for example 80/20).
      • Labeling for the pineapple tidbits.
      • Labeling for the whole grain tortillas.
    • For the lunch meals served on 07/21/18:
      • Labeling for the hamburger buns used (if different from the hamburger buns used on 07/17/18).
  • Documentation of the training hours for employees with duties within the SFA's school nutrition programs.
  • A copy of the most recent Verification Collection Report form (FNS 742).

Failure to provide the above documentation required to complete the Administrative Review (AR) by the date of this report, and failing to submit a complete corrective action plan will result in the withholding of reimbursement payments (7 CFR Part 210.24).

To demonstrate compliance with providing requested records:

  • Provide the requested records.
  • Provide copies of the requested records along with a copy of your agency's plan for corrective action to demonstrate understanding and compliance.

Professional Standards:  At the time of the Off-Site visit the SFA did not provide documentation on training completed for staff members who have duties within the SFA's school nutrition programs.  The SFA also did not provide a tool to track training for their school nutrition program.  USDA memo SP 39-2015 documents the training records must list the following: employee name, employer/school, training title, topic/objectives, training source, dates, and total training hours.  The required documentation will demonstrate whether or not the SFA is in compliance with the training requirements documented in 7 CFR Part 210.30 (c), 7

CFR Part 210.30 (d), and 7 CFR Part 210.30 (e). The following are the training requirements documented in the preceding regulations:

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 1st or later) One-half of training requirement for each job category.

The SFA does log their staff members training within each employee's training file.

To demonstrate compliance with Professional Standards:

  • Provide documentation of staff members' training hours.
  • Provide a copy of your agency's school nutrition program training tracking tool.
  • Submit the above along with your agency's plan for corrective action to demonstrate understanding and compliance.

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted October 18, 2018:

Buy American Provision: During the On-Site visit, food products were found that were not domestically produced.  7 CFR Part 210.21 (d) requires SFAs when possible to buy domestically produced food products.  Limited exceptions to the requirements to procure domestically produced food products are permitted.  USDA memo SP 24-2016 documents the following exceptions to this requirement:

  • The food product is not produced or manufactured within the United States
  • The food product is not produced or manufactured domestically in sufficient quantities.
  • The food product is not produced or manufactured domestically in satisfactory quality.
  • The costs of domestically produced or manufactured food products are significantly higher in cost than non-domestic products.

If a SFA is going to use one of the above exceptions they must keep documentation justifying the exception.

The following food products were found during the On-Site visit that were not domestically produced or manufactured:

  • Pineapple that was produced in the Philippines.       

The SFA did not have documentation justifying the use of these products under one of the permitted exceptions.  Work with your vendors to ensure the products used in your program are compliant with the buy American provision.  When you determine it is necessary to use one of the permitted exceptions, make sure you keep documentation to justify its use. 
     
To demonstrate compliance with the buy American provision:

  • Review the products that are used in your school nutrition program for compliance with the buy American provision. 
  • Provide your corrective action plan to demonstrate understanding and compliance.

Counting and Claiming: A review of the counting system demonstrated a counting error for the review period (July 2018), which results in a Performance Standard Violation I (PSI), 7 CFR Part 210.18 (g) (1) (ii).  This error was determined by the State Agency (SA) reviewer to be non-systemic in nature.  At the time of the On-Site visit the SFA could not locate the edit checks for the review period (July 2018).  The SA reviewer was told the SFA was not using electronic edit check forms which appears to have contributed to the error occurring.  Technical Assistance was provided, and the SA emailed the SFA an electronic edit check for use in the SFA's future claim process. 

The SFA's July 2018 claim for the National School Lunch Program (NSLP) had an over claim of 2 lunch meals.  The meal rosters were totaled correctly, but when the two points of services meal counts were consolidated is where the error appears to have occurred.  Below is the outcome of the SFA's July claim:

  SFA OKDHS Diff.
Free 282 280 -2

7 CFR Part 201.8 (a) (2) requires each SFA to review their claims for accuracy prior to submitting them to the State Agency (SA).  No other counting and claiming errors were found during the review period. 

This error is a serious, non-systemic error in the counting and claiming system. The error results in Performance Standard 1 Violations and require fiscal action [7 CFR Part 210.18 (g) (1) (ii) and 7 CFR Part 210.18 (I) (1)].

To demonstrate compliance with counting and claiming:

  • Review the counting and claiming system and create a plan to insure accurate consolidation of daily meal counts.
  • Provide copies of October 2018's completed meal rosters, a copy of October 2018's claim, and copies of October 2018's edit check forms, along with your corrective action plan to demonstrate understanding and compliance.   

HACCP food safety plan: A required HACCP (Hazard Analysis Critical Control Points) food safety plan could not be found at the time of the On-Site visit [7 CFR Part 210.13 (c) requires each SFA to have a HACCP plan]. Your staff will need to develop and implement a comprehensive food safety plan. This process approach for preparing food must be used to
insure that foods are stored and prepared properly. The plan should include all the appropriate documentation forms for monitoring and review.

A HACCP plan template was emailed to your agency on 10/22/18. This template contains everything needed to easily develop the missing plan. 

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

To demonstrate compliance with HACCP food safety requirements:

  • Use the sample HACCP plan provided as a guide and develop your plan.
  • Provide a copy of; your HACCP plan's cover sheet, along with your corrective action plan to demonstrate understanding and compliance.

Meal Patterns:A review of 07/15/18 through 07/21/18 is still in progress due to the SFA not providing the required documentation at the time of the completion of the On-Site portion of this AR.  Any findings for this assessment will be addressed in an Administrative Review follow-up summary report.  During the On-Site visit on 10/18/18, there was an insufficient serving size for the lunch meals.

The lunch meal pattern 7 CFR 210.10 (c) requires the following minimum serving sizes; 2 oz. by weight meat/meat alternate daily and 14-17 oz. per week, 2oz. by weight bread/grain daily and 14-17 oz. per week, 1 cup fruit daily and 7 cups per week, 1 cup vegetables daily (dark green subgroup ½ cup/week, red/orange subgroup 1 ¼ cup/week, legumes subgroup ½ cup/per week, starchy subgroup ½ cup/week, and other subgroup ¾ cup/week) 7 cups/week, and 1 cup fluid milk daily, 7 cups weekly, offered as a choice between 1% and fat free.

Insufficient quantities

  • The hamburger bun served with the lunch meals only credited at 1.5 oz. each.

The State Agency (SA) is exercising its discretion to not apply fiscal action for the above insufficient quantities as allowed for under 7 CFR Part 210.18 (g) (2).

It is very important for your staff to carefully review planned menus, product labels and recipes to ensure, the meal pattern requirements are met for every meal claimed for reimbursement. It is critical that your staff document everything that is served as part of a reimbursable meal.
    
To demonstrate compliance with Meal Patterns:

  • Review your menus for compliance with the meal patterns for grades 9-12.
  • Bring all insufficient serving sizes and missing components in compliance with the meal patterns for grades 9-12.
  • Submit your plan for corrective action to demonstrate understanding and compliance.    

Whole Grain-Rich (WGR) Bread/Grain: During the On-Site visit on October 18, 2018, the following items were determined not to be WGR [7 CFR Part 220.8 (c) (2) and 7 CFR Part 210.10 (c) (2) (iv)]:

  • The pancakes served for breakfast on 10/18/18.
  • The hamburger buns served with the lunch meal on 10/18/18. 
  • French toast sticks that were in the freezer in the Joseph Cottage at the time of the On-Site visit.

In order for an item to be WGR it must contain 50% whole grains by weight. The easiest way to tell is to look at the ingredients on the label. If the first ingredient is a Whole Wheat Flour or a Whole Grain, you're good. If a Whole Grain product is not listed first, you need to choose a different product that lists the correct grain first. The key is the word Whole.

There could be additional findings due to the fact that the SFA failed to provide all the documentation for the menu week assessment of the week of 07/15/18 through 07/21/18.  Without documentation of the ingredients of products used to meet the bread/grain component the SA reviewer was unable to determine if the products used were WGR. 

If there are additional findings discovered for the menu week assessment (07/15/18 through 07/21/18), they will be addressed through a follow-up Administrative Review Summary Report. 

To demonstrate compliance with Whole Grain Rich Bread/Grain Requirements:

  • Evaluate your products to determine if they meet the whole grain rich requirement. Replace any products you determine don't meet the WGR requirement.  
  • Provide a copy of your corrective action plan to demonstrate understanding and compliance.

The SFA served non-creditable food item as part of the meal component.  During the menu assessment it was determined your school is serving a non-creditable items. In order for the items to be creditable they must contain a CN label or an acceptable production formulation statement, 7 CFR 210 Appendix C.  Crediting information for USDA commodities can be found on the commodity fact sheets available on the USDA website. The following item was identified as non-credible:

  • The breaded chicken strips served as part of the lunch meal on 07/18/18.
  • The uncooked Chicken breast tenderloin fritters, label provided for the menu week assessment.
  • Fully cooked grilled chicken breast meat strips with rib meat, label provided for the menu week assessment.
  • The Jell-O with fruit served as part of the lunch meal on 07/19/18.

Finding CN labeled products can be challenging. Remember; items similar to CN labeled products, but not the same, are not acceptable. Your ability to purchase food from suppliers with experience serving schools should allow your staff to obtain acceptable products. If all attempts fail and you are unable to obtain CN labels for the items you serve, your only choices are; discontinue serving the item or cook the item from scratch. When scratch cooking; we recommend using the USDA recipes because they will eliminate the panning needed when scratch cooking.

If a food is non-creditable and no other creditable foods are offered, the serving is considered insufficient.  The USDA now considers insufficient serving sizes to be "missing components".

Finding of missing components on subsequent reviews will be considered reoccurring and our office may have to access fiscal action.

To demonstrate compliance with the CN label/product specification requirement:

  • Obtain and provide a copy of the needed product formulation statements. Work with venders and sales representatives to obtain this documentation. 
  • If product formulation statement(s) or CN labeling is not available, provide a copy of the replacement creditable item's labels.
  • Provide a copy of your corrective action plan along with the documentation list to demonstrate understanding and compliance.  

Procurement Review Summary Report

Date:  11-05-18

Name of Agency:  Murrow Indian Children's Home

                                                                                                 Date of AR off-site review: 09-04-18

Reviewer:  Matthew Smith                                                  Date of AR on-site review: 10-18-18

Persons interviewed:  Shari Kamp                                      Date of exit conference: 10-18-18

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

Findings and Recommendations Identified during the Procurement Review (PR):

Failure to Provide Requested Records:  The School Food Authority (SFA) failed to provide documentation as required by their agreement with the State Agency (SA) and as required by 7 CFR Part 210.9 (b) (17).  This federal regulation requires SFAs to:

"Upon request make all accounts and records pertaining to its school food service available to the State Agency, and to the USDA Food and Nutrition Service (FNS)"

The SA reviewer made several requests to the SFA to provide records starting on June 1, 2018 through October 4, 2018.  The SA requested the following records:

  • The SFA's procurement plan
  • The SFA's Code of conduct
  • A complete list of vendors/retailers used during school year 2017-2018, with the amounts spent with each vendor/retailer.

To demonstrate compliance with providing requested records:

  • Provide the requested records.
  • Provide copies of the requested records along with a cop of your corrective action plan to demonstrate understanding and compliance.

Procurement: During this review the SFA did not have a code of conduct, as well as not having a procurement plan.

Each SFA is required to maintain a written code of conduct governing the employees engaged in the award and administration of contracts supported by program funds, 7 CFR Part 210.21(c) and 7 CFR Part 220.16 (c).  The code of conduct must prohibit employees from soliciting or accepting gratuities, favors, or anything of monetary value from contractors or parties of subcontracts [as required by 2 CFR 200.318 (c) (1) and 7 CFR Part 3016.36 (3) (1-1v)].

Each SFA must have a written procurement plan on file, 7 CFR Part 210.21(c) and 7 CFR Part 220.16 (c). The plan must specify procurements procedures used by the SFA.  All procedures must adhere to the federal requirements for procurement. The procurement plan identifies the school's purchasing periods for the goods, equipment, and services related to the School Nutrition Programs and the various methods procurement being practiced.

The procurement plan provides an explanation for using certain procurement methods to obtain items used in the school food service program. The school district can determine the extent of the plan.  An SFA may implement a plan that applies to all schools under its jurisdiction, or allow each school to implement an individual plan.  A new procurement plan does not need to be developed every year. The procurement plan must include steps the SFA takes to assure that small, minority and women's businesses enterprises, and labor surplus firms when possible as required under 2 CFR Part 200.321.

To demonstrate compliance with the procurement requirements:

  • Provide a copy of your agency's procurement plan.
  • Provide a copy of your agency's code of conduct that addressees employees not accepting or soliciting gratuities, favors, or anything of monetary value from contractors or parties of subcontractors, as required by 2 CFR 200.318 (c) (1) and 7 CFR Part 3016.36 (3) (1-1v).
  • Provide a complete list of vendors used in school year 2017-2018 with the amount spent with each vendor.
  • Provide the above along with the agency's corrective action plan demonstrating understanding and compliance.
Back to Top