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Administrative Review Summary Report

Date:  09-30-16

Name of Agency:  MCCYS                                                    Date of off-site review: 08-10-16

Reviewer:  Matthew Smith                                                     Date of on-site review: 09-13-16

Persons interviewed:  Jaushlyn Hoover                                 Date of exit conference: 09-13-16

This School Food Authority (SFA) operates the National School Lunch Program and the School Breakfast Program

Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted August 10, 2016:

Civil Rights: MCCYS did not have a policy for handling civil rights complaints, FNS Instruction 113-1.  Prior to the On-Site portion of this Administrative Review MCCYS provided SA with a copy of their policy for handling civil rights complaints. 

No further action is required regarding MCCYS' policy for handling civil rights complaints.

At the time of the Off-Site portion of this Administrative Review MCCYS did not have a tool to document the collection of race and ethnicity data for each student, FNS Instruction 113-1. Prior to the On-Site portion of the AR, MCCYS added questions to their intake and enrollment paperwork collecting each student's race and ethnicity. 

No Further action is required regarding the tool for the collection of race and ethnicity.

Also at the time of the Off-Site portion of this review your agency had not completed the required annual civil rights training. The USDA requires that all staff who work with program applicants or participants receive annual Civil Rights training, FNS Instruction 113-1.  Prior to the On-Site portion of this Administrative Review MCCYS held its annual civil rights training. 

No further action is required regarding the annual civil rights training.

Local Wellness Policy: At the time of the Off-Site review the assessment and update to the local wellness policy had not been completed. Also, your agency did not provide documentation of the last update to the local wellness policy. Your agency's local wellness policy needs to have the following added, 7CFR Part 210.30:

  • The name and title of the person(s) assessing the policy.  It is recommended no more than two people assess the policy.
  • Names and titles of the wellness committee's members.

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.  
This documentation should include; mention the policy was assessed, state briefly what changes were made, who was present at the committee meeting, and the date of the meeting.

Prior to the On-Site your agency updated the local wellness policy.  The documentation provided reflects the requested changes listed above. 

No further action is required regarding local wellness policy or policy update.

Meal Patterns:A review of 07/17/16 through 07/23/16 indicated some insufficient portion sizes at lunch.

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 chicken and noodles served on 07/22/16, only yields 1 oz. toward the meat/meat alternative.  No other meat or meat alternatives were served with this meal.  The daily requirement for the meat/meat alternative is 2 oz.
  • The bun served on 07/23/16, credited at 1.25 oz. toward the daily bread/grain component requirement.  No other breads or grains were served with this meal.  The daily requirement for the bread/grain is 2 oz.
  • The weekly meat/meat alternative minimum serving size was not met.  MCCYS served 13 oz. during the assessment period this is 1 oz. short of the weekly requirement.

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).

Missing Meal Components

  • The bread/grain component was missing from the meal served on 07/19/16. 

Missing meal components are a Performance Standard 2 (PS2) violation which will require fiscal action.

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.    

The school served non-creditable food items as part of the meal component.  During the menu assessment it was determined your school is serving 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 items were identified as non-credible:

  • Fish served on 07/19/16.  This fish will have to be replaced with a product that has either CN label or product formulation statement.

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 as a 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.  

Whole Grain-Rich (WGR) Bread/Grain: For the reviewed menu week of July 17 through 23, 2016; your agency did not meet the 100% Whole Grain-Rich (WGR) requirement for bread/grain products served at breakfast and lunch, 7 CFR Part 220.8 (c) (2) (iv) and 7 CFR Part 210.10 (c) (2) (iv).   For breakfast the percentage for meeting the whole grain rich requirement was 90%.  For the lunch the percentage for meeting the whole grain rich requirement was at 78%.

  • 07/23/16, at breakfast had biscuits that were served to meet the bread/grain component that were not WGR. 
  • 07/21/16, the cornbread served at lunch to meet the bread/grain component was not WGR.
  • 07/23/16 the bun served during the lunch meal was not WGR. 

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.

Note:  Findings for the whole grain-rich requirement may result in fiscal action for repeat violations on future reviews. 

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.

Procurement:At the time of the off-site portion of the AR both the code of conduct and the School Food Authority's (SFA) procurement policy were not provided.  The 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).  This written code will eliminate any conflict of interests that might arise during the procurement process.

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 an 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.

Prior to the On-Site portion of this Administrative Review, MCCYS provided their procurement plan and code of conduct. 

No further action is required.

Reviewer's Comments:  This AR shows that overall MCCYS is doing a good job with their food service program.   As with every program some tinkering may be necessary in order to bring certain areas into compliance.  I would like to commend all of the staff members who work with MCCYS' school nutrition programs for all the hard work they do.  

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