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Administrative Review Summary Report

Date:  05-14-19

Name of Agency:  Tulsa Boys' Home

                                                                                                  Date of off-site review: 03-19-19

Reviewer:  Matthew Smith                                                   Date of on-site review: 04-23-19

Persons interviewed:  Donna Wickett                                 Date of exit conference: 04-23-19

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 conduct the annual civil rights training during school year 2016-2017.  FNS Instruction 113-1 requires staff members who work with program applicants or participants to receive annual civil rights training.  Prior to the completion of the On-Site portion of this AR this training was conducted (on 04/17/19) and documentation was provided to the State Agency (SA) reviewer.
  • Local Wellness Policy: The triennial wellness assessment report was not posted publicly on the SFA's website [7 CFR Part 210.31 (d) and 7 CFR Part 210.31 (e) (2)].  Prior to the On-Site visit the SFA posted the triennial wellness assessment report on their website.
  • Meal Patterns:  During the menu week assessment for the breakfast and lunch menus for the week of 02/17/19—02/23/19, systemic insufficient serving sizes were discovered.  The USDA considers SFAs with these types of systemic errors high-risk, triggering a nutrient analysis for the menu week [7 CFR Part 210.18 (g) (2) (ii)].  Prior to the nutrient analysis the SFA took corrective action on 04/18/19 for all issues of non-compliance found during the week [7 CFR Part 210.10 (c)].  Due to the violations above; our office has no choice but to remove the 6 cent performance-based reimbursement, beginning with April's claim [as required by 7 CFR Part 210.18 (g) and the Administrative Review Manual].
  • Trans-Fat: The gravy served with the breakfast meal on 02/17/19 contained trans-fats [7 CFR Part 210.10 (f) (4) and 7 CFR Part 220.8 (f) (4)].  Prior to the nutrient analysis the gravy product in question was replaced with a gravy product containing no trans-fats.
  • Nutrient Analysis:  A nutrient analysis was triggered for the breakfast and lunch menus for the week of 02/17/19—02/23/19.

    The nutrient analysis for the breakfast menus conducted found that the average sodium level for the week exceeded the average weekly sodium level for the grades 9-12 meal pattern. The average for the week was 745 mg. [7 CFR Part 220.8 (f) (3)].  The analysis also found the saturated fat percentage exceeded the requirement that be < 10%.  The menus for the week had a saturated fat percentage of 10.69% [7 CFR Part 220.8 (f) (1)].

    The nutrient analysis for the lunch menus conducted found the average calories for week exceed the limit for the grades 9-12 meal pattern.  The menus for the week had an average of 964 calories [7 CFR Part 210.10 (f) (1)].

    Prior to the completion of the On-Site portion to this AR the SFA took corrective action for the above findings bringing the breakfast and lunch menus for the week of 02/17/19—02/23/19 into compliance with the meal patterns for grades 9-12.

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 March 19, 2019:

After School Snack Program Monitoring Checklist: The SFA failed to complete the self- monitoring review first with in the first four weeks of school. An ASP monitoring review must be conducted twice a year, 7 CFR Part 210.9 (c) (7) and 7 CFR Part 210.10 (o). The first review is required to be conducted during the first four weeks of school starting and snack service starting.  The SFA conducted their first review on 10/01/18, which was after the first four weeks of school starting.  The second should be scheduled prior to the end of the school year. 

The designated personnel must review the After School Snack Program a minimum of two times a year using the DHS supplied monitoring checklist. Marking the review on a calendar may help your staff maintain a reoccurring ASP Administrative Review Summary Report review schedule. 

For each no answer on the form, you must take corrective action to ensure compliance.  Keep the checklist and all supporting documentation for the snack program on file according to federal recordkeeping requirements.   

To demonstrate compliance with After School Snack Monitoring requirements:

  • Provide your corrective action plan to demonstrate understanding and compliance with the After School Snack Program monitoring checklist.

Buy American Provision: During the Off-Site portion of the AR, a food product was 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 Off-Site portion of this AR that were not domestically produced or manufactured:

  • The fruit salad served with the lunch on 02/22/19 was a product of Thailand.  

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.

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

  • The policy does not designate personnel with the responsibility of ensuring the implementation of the policy.  Federal regulations [7 CFR Part 210.31 (c) (4) and 7 CFR Part 210.31 (e) (1)] require each SFA to designate personnel with this responsibility. No more than two people should be designated.
  • The policy does not contain a description for measuring the implementation of the policy.  Local wellness policies are required to have a description of how the SFA is going to measure the implementation of the policy [7 CFR Part 210.31 (e)].
  • The policy does not designate personnel with the responsibility of assessing the policy. Federal regulations [7 CFR Part 210.31 (c) (4) and 7 CFR Part 210.31 (e) (1)] require each SFA to designate personnel with this responsibility.  No more than two people should be designated.
  • The policy does not have a description of when the policy is to be assessed.  Wellness policies are required to document the frequency of the assessment of the policy, at a minimum wellness policies are required to be assessed once every three years [7 CFR Part 210.31 (e) (2)].  The best practice is to assess the policy annually.

The goals for nutrition education only address grades k-8.  According to the SFA's application for participation for this school year the SFA only have grades 9-12.  The policy should be updated to reflect this.

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 following to the local wellness policy:
    • Add personnel designated with the responsibility for ensuring the implementation of the policy.
    • Add a description for measuring the implementation of the policy.
    • Add personnel designated with the responsibility for assessing the policy.
    • Add a description for when the policy is to be assessed.
  • 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.   

Record Keeping: A review of the production records conducted during this AR indicated some issues with documentation on the production records.  Several production records were incomplete.  The following issues were noted:

 

  • Fresh fruit being served was not always being documented.
  • The production record for the lunch served on 02/17/19 did not have the vegetable served listed with the serving size for the vegetable served.
  • None of the lunch production records documented the condiments being provided with the meals.

To insure proper integrity, documentation of food production should accurately note the amount of servings planned (including adults and second servings), the actual serving sizes for each item and the total amount of food product used to prepare the meal.

For serving sizes, document the serving sizes planned and served.  For meats and meat entrees list the number of pieces, one slice, one burger, one sandwich, or serving in ounces

(ex. 5 nuggets or 2 ounces slice). Ounces should reflect only the actual serving size and will be rarely used. Unless fresh fruit is being served, fruits and vegetable are primarily list by cup size (ex. 1 whole banana, ½ Cup diced pears or ¾ Cup green beans). Using standardized recipes will help the agency in planning for the correct serving size.

For the total amount prepared, use actual weights.  For meats or fresh vegetables, list the weight (ex.  10 lbs., 5 ounces) or total number of pieces prepared.  For canned vegetables and fruits, document the weight of the can or specify the can size (ex. 2, 108 oz. cans or 1, # 10 can).  For breads, pastas and grains, document the total weight or number of slices.   For milk, document the number of gallons or pints used. 

For the planned number of servings, documentation of food production should accurately note the amount of servings planned (including adults and second servings).

SFAs are required to keep production records for all the meals that are produced and claimed for reimbursement [7 CFR Part 210.10 (a) (3)].  Federal regulation 7 CFR Part 210.10 (a) (3) requires the production record show:

"…how the meal offered contributes to the required food components and food quantities for each grade served every day."

The production records are a part of the documents supporting a SFA's reimbursement claim and are required to be kept for at least three school years [7 CFR Part 210.20 (b) (14)].

To demonstrate compliance with Production Documentation:

  • Staff should begin immediately completing the daily production records by; listing all items served, listing components in the proper categories and documenting actual serving sizes.
  • Ensure production records are complete.
  • Provide a copy of one breakfast and one lunch production record along with your corrective action plan to demonstrate understanding and compliance.  

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted April 23, 2019:

Counting and Claiming: A review of the counting and claiming system demonstrates counting and claiming errors for the review period (February 2019).  The errors are systemic in nature, and occurred with the SFA's breakfast, lunch, and snack claims.  These errors appear to be due to the consolidation of the point of service locations (breakfast and snack are served in the lodges and lunch is served in the cafeteria) and consolidation of the meal rosters which are done by lodge.  Also, there was one resident that was listed in two lodges and had double meal counts for one breakfast meal service, two lunch meal services, and two snack services.  These errors are performance standard I violations [7 CFR Part 210.18 (g) (1) (ii).


Below are the differences, the State Agency (SA) reviewer identified in the SFAs breakfast meal count for the review period (February 2019): 

 

  SFA OKDHS Diff.
Free 1436 1432 -4

Below are the differences, the SA reviewer identified in the SFAs lunch meal count for the review period (February 2019): 

  SFA OKDHS Diff.
Free 1439 1432 -7

Below are the differences, the SA reviewer identified in then SFAs snack count for the review period (February 2019): 

  SFA OKDHS Diff.
Free 1039 1021 -18

7 CFR Part 201.8 (a) (2) requires each SFA to review their claims for accuracy prior to submitting them to the SA.

These are serious, systemic errors in the counting and claiming system. They result in Performance Standard 1 Violations and require fiscal action [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 daily meal counts are taken and recorded.
  • Provide copies of the following: meal rosters for May 2019, edit checks for the meals claimed for May 2019, and the claim for May 2019.
  • Provide the above copies, along with your corrective action plan to demonstrate understanding and compliance.          

Signage explaining what constitutes reimbursable meals:  There was no signage explaining to residents what constituted a reimbursable breakfast in the lodges where the residents live.  The breakfast meals at the SFA's single site are served daily in the lodges.  7 CFR Part 210.10 (a) (2) and 7 CFR Part 220.20 (a) (2) require SFAs to have signage explaining what constitutes a reimbursable meal.        


The signage can be on a white board, be posted on a bulletin board so long as the signage is near the beginning of the service line.        


To demonstrate compliance with signage explaining what constitutes reimbursable meals:

  • Post signage in the lodges explaining what constitutes a reimbursable breakfast meal.
  • Provide your corrective action plan to demonstrate understanding and compliance.

Reviewer's Comments:  Overall Tulsa Boys' Home is doing a good job running its school nutrition programs.  The staff members who work within Tulsa Boy's Home's school nutrition program are doing a good job.  Keep in mind having findings for an Administrative Review does not necessarily reflect on the job that is be done by the staff members working in the program. There are a lot of federal regulations governing the school nutrition programs (National School Lunch Program, the School Breakfast Program, and the Afterschool Snack Program) operated by Tulsa Boys' Home.  Donna Wickett is doing a good job for being in her first year operating these programs for Tulsa Boys' Home. 

Procurement Review Summary Report

Date:  05-14-19

Name of Agency:  Tulsa Boys' Home

                                                                                                   Date of AR off-site review: 03-19-19

Reviewer:  Matthew Smith                                                    Date of AR on-site review: 04-23-19

Persons interviewed:  Donna Wickett                                  Date of exit conference: 04-23-19

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

There were no findings for the procurement review.

Reviewer's Comments:  I want to commend Tulsa Boys' Home on compliance with the regulations regarding procurement in school nutrition programs.

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