Date: 04-30-25

Name of Agency: Sacred Heart Catholic School                           Date of off-site review: 01-14-25 Reviewer: Matthew Smith                                                              Date of on-site review: 03-06-25 &

 03-07-25

Fiscal Action: Yes, fiscal action amount will be assessed in the fiscal action and closure letter                  

Persons interviewed: Tera Albert and                                         Date of exit conference: 04-24-25

                                    Jill Brown

Programs Operated by the School Food Authority (SFA): This 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):

·       Benefit Issuance Document (BID): The BID provided at the time of the off-site visit did not gather data on how each student’s eligibility was determined [as required by USDA FNS Administrative Review (AR) Manual and federal regulation 7 CFR Part 245.6 (e)].  Prior to the completion of the on-site portion of this AR, Sacred Heart Catholic School (SHCS) took corrective action by beginning to gather this data on students.

·       Eligibility Determination: During the review of household applications that one application was certified in error.  The error resulted in one student receiving reduced priced meals when the student should have been eligible for paid meals.  The error occurred due to SHCS missing some of the reported household income on an application [violation of federal regulation 7 CFR Part 245.6 (c) (4)].  Prior to the completion of the on-site portion of this AR, SHCS provided the household with notification of the benefit change, waited 10 days and then changed the eligibility status of the one student on the application to paid meals.

·       Local Wellness Policy: The policy provided during the off-site did not have the same local wellness committee membership as the triennial wellness assessment report [7CFR 210.31 (c) (5) and 7 CFR Part 210.31 (d) (1)].  Prior to the completion of the on-site portion of this AR, SHCS took corrective action, both documents have the same committee membership.

·       Meal Patterns:  During the menu week assessment of breakfast and lunch menus for the week of 12/09/24 – 12/13/24, non-systemic insufficient serving sizes were discovered [violation of federal regulations 7 CFR Part 210.10 (c) and 7 CFR Part 220.8 (c)].  Prior to the completion of the on-site portion of this AR, SHCS took corrective actions bringing the insufficient serving sizes into compliance with the meal patterns. The State Agency (SA) is exercising its discretion to not apply fiscal action for the above insufficient quantities as permitted under federal regulation [7 CFR Part 210.18 (g) (2)].

·       Whole Grain Rich – Percentage of Weekly Serving Under 80%: During the menu week assessment it was discovered the percentage of the weekly bread/grain component serving for lunch was below 80% [in violation of federal regulation 7 CFR Part 210.10 (c) (2) (iii) (A)].  Prior to the completion of the on-site portion of this AR, SHCS took corrective actions bringing the percentage of the weekly bread/grain serving that is WGR into compliance.

No further action is required for the above. 

Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted January 14, 2025:

Production Records:  During the menu week assessed the production records were not filled out as required to “…show how the meal offered contribute d to the required meal components and food quantities for each age/grade group every day [as required by federal regulations 7 CFR Part 210.10 (a) (3) and 7 CFR Part 220.8 (a) (3)].”

To demonstrate compliance with production record requirements:

• Provide a copy of one complete breakfast production record.
• Provide a copy of one complete lunch production record.
• Provide the above documents along with SHCS’ plan for corrective action to demonstrate understanding and compliance.

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted March 6, 2025, and March 7, 2025:

Resource Management-Account Balance: At the end of school year 2023 – 2024, the revenue and expense report for the Nonprofit School Food Services Account (NSFSA) had a balance in excess of three months’ average operating expenses.  Federal regulation [7 CFR Part 210.14 (d)] requires the NSFSA to have balance limited to an amount not to exceed three months’ average operating expenses for the account to be considered nonprofit.  The balance in the NSFSA exceeded three months’ average operating expenses by $4,404.32.  To bring the NSFA into compliance this excess will have to be spent.

To demonstrate compliance with resource management NSFSA balance requirements:

·       Provide a spenddown plan for the excess balance ($4,404.32).

·       Provide a copy of SHCS’ spenddown plan along with SHCS’ plan for corrective action to demonstrate compliance and understanding.

Resource Management – Non-program Food:  During this AR, it was discovered SHCS was not tracking non-program food revenue and non-program expenses as required by federal regulation [7CFR Part 210.14 (f)]. 

To demonstrate compliance with resource management – non-program food requirements:

·       Begin tracking non-program food revenue and expense to the NSFSA.

·       Provide SHCS’ plan for corrective action to demonstrate compliance and understanding.

Smart Snack: During the on-site portion of this review, three of the non-program foods being sold in the cafeteria were determined to violate the smart snack requirements.

The baked Cheetos chips and the Baked Flaming Hot Cheetos chips did not have a whole grain as the first ingredient as required by federal regulation [7 CFR 210.11 (c) (2) (i)].

The baked Cheddar and Sour Cream chips had 280 mg. of sodium.  Federal regulation [7 CFR Part 210.11 (h)] requires snack foods to have less than 200 mg. of sodium.

These items cannot be sold on campus during the school day [defined as “...the period from midnight before, to 30 minutes after the end of the school day.” Per federal regulation 7 CFR Part 210.11 (a) (5)].

To demonstrate compliance with smart snack requirements:

·       Cease the sale of the non-compliant food items listed above.

·       Begin using the smart snack calculator to determine non-program food’s compliance with smart snack requirements.  The smart snack calculator is available online at https://foodplanner.healthiergeneration.org/calculator/

·       Provide SHCS’ plan for corrective action to demonstrate compliance and understanding.

Reviewer’s Comments: The staff members with duties within SHCS’ school food services program are doing a superb job.  The kitchen operates efficiently starting with meal preparation, continuing with meal service, and ending with cleanup.  Keep up the excellent work. 

Procurement Review Summary Report

Date:  04-30-25

Name of Agency:  Sacred Heart Catholic School                          Date of AR off-site review: 01-14-25

Reviewer:  Matthew Smith                                                              Date of AR on-site review: 03-06-25

 and 03-07-25

Persons interviewed: Tera Albert                                               Date of exit conference: 04-24-25

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

 

Technical Assistance for the Procurement Review (PR)

Solicitation Document: During school year 2023 – 2024, Sacred Heart Catholic School (SHCS) used the small purchase method of procurement to purchase equipment for their kitchen using funds from the Nonprofit School Food Services Account (NSFSA).  SHCS’ procurement plan requires a written solicitation plan to be sent out to potential vendors when the small purchase method of procurement is used.  Federal regulation [2 CFR Part 200.318 (a)] requires School Food Authorities (SFA) to “maintain and use documented procedures for procurement transactions.”  SHCS called around and provided each vendor with a list of the equipment they were wanting to procure; they should have followed the call by sending a written solicitation document documenting the equipment being procured.  For all future procurement activity using the small purchase method of procurement using funds from NSFSA must provide potential vendors with the written solicitation document.  Doing so provides for the conducting of procurement in a free and open manner as required by federal regulation [2 CFR Part 200.319 (a)].

For the equipment procurement activity in school year 2023 – 2024, SHCS obtained OKDHS School Nutrition Programs approval prior to purchasing the equipment which was in excess of $5,000.

 

Findings for the Procurement Review (PR)

There were no findings for the procurement review.

Free meals and reduced priced meals were under claimed by one meal each.

Below are the differenced identified in SCHS’ December lunch meal rosters and the daily edit checks generated by the electronic meal counting system.

Free meals were under claimed by six meals.

Federal regulation [7 CFR Part 210.8 (a) (2)] requires SFAs to review their claims for accuracy prior to submitting the claim to the State Agency (SA).

To demonstrate compliance with counting and claiming requirements:

• Review the counting and claiming system and create a plan to ensure accurate meal counts are taken and recorded.
• Provide copies of SHCS’ meal rosters (breakfast and lunch) for April 2021, and the edit checks (breakfast and lunch) for April 2020.
• Provide copies of the above along with SHCS’ corrective action plan to demonstrate understanding and compliance.

Eligibility Certification:  During a review of the household applications it was determined one household application was certified in error.  The error resulted in one child receiving free meals with eligible for reduced priced meals.  The error was due to not all the sources being used when the household’s income was determined.  This caused the household to be miss categorized in the wrong benefits category [7 CFR Part 245.6].  This error resulted in a Performance Standard I (PSI) which requires fiscal action as required by federal regulation [7 CFR Part 210.18 (g) (1)]. 

During the on-site portion of this AR the household application with the error was brought to SHCS’ attention,  Federal regulation [7 CFR Part 245.6 (c) (3) (iii)] requires SFAs to send notification to households in writing when a reduction of benefits is being made, and allow 10 calendar days for a possible hearing request.

The school-reviewing official must review each incoming application to ensure that the household submitted a completed application.  If the application is complete, the official must determine whether the household is income eligible for benefits or categorically eligible or income eligible for benefits.  It is recommended that someone come behind the determining official and double check the math and benefit category.  A space is provided on the application for a second person to sign off on the determination.

SHCS provided the household with a letter notifying the household of the reduction in benefits on 04/08/21.  The household submitted a new household application prior to the expiration of the 10 day period for a possible hearing request.  The household has had a reduction in household income since the initial application was submitted.  This reduction in household income caused the household to be eligible for free meal benefits.  Prior to the 10 days allowing for a possible hearing request, SHCS was able to make a determination on the new household application determining the household was eligible to receive free meals.

To demonstrate compliance and understanding with eligibility certification requirements:

• Provide a copy of the letter sent along with SHCS’ written corrective action plan to demonstrate understanding and compliance.

 

Reviewer’s Comments:  I want to commend the staff members who work with the SHCS’ school nutrition programs on a job well done during this review.   Keep up the good work

Federal regulation [7 CFR Part 210.8 (a) (2)] requires SFAs to review their claims for accuracy prior to submitting the claim to the State Agency (SA).

To demonstrate compliance with counting and claiming requirements:

• Review the counting and claiming system and create a plan to ensure accurate meal counts are taken and recorded.
• Provide copies of SHCS’ meal rosters (breakfast and lunch) for April 2021, and the edit checks (breakfast and lunch) for April 2020.
• Provide copies of the above along with SHCS’ corrective action plan to demonstrate understanding and compliance.

Eligibility Certification:  During a review of the household applications it was determined one household application was certified in error.  The error resulted in one child receiving free meals with eligible for reduced priced meals.  The error was due to not all the sources being used when the household’s income was determined.  This caused the household to be miss categorized in the wrong benefits category [7 CFR Part 245.6].  This error resulted in a Performance Standard I (PSI) which requires fiscal action as required by federal regulation [7 CFR Part 210.18 (g) (1)]. 

During the on-site portion of this AR the household application with the error was brought to SHCS’ attention,  Federal regulation [7 CFR Part 245.6 (c) (3) (iii)] requires SFAs to send notification to households in writing when a reduction of benefits is being made, and allow 10 calendar days for a possible hearing request.

The school-reviewing official must review each incoming application to ensure that the household submitted a completed application.  If the application is complete, the official must determine whether the household is income eligible for benefits or categorically eligible or income eligible for benefits.  It is recommended that someone come behind the determining official and double check the math and benefit category.  A space is provided on the application for a second person to sign off on the determination.

SHCS provided the household with a letter notifying the household of the reduction in benefits on 04/08/21.  The household submitted a new household application prior to the expiration of the 10 day period for a possible hearing request.  The household has had a reduction in household income since the initial application was submitted.  This reduction in household income caused the household to be eligible for free meal benefits.  Prior to the 10 days allowing for a possible hearing request, SHCS was able to make a determination on the new household application determining the household was eligible to receive free meals.

To demonstrate compliance and understanding with eligibility certification requirements:

• Provide a copy of the letter sent along with SHCS’ written corrective action plan to demonstrate understanding and compliance.

 

Reviewer’s Comments:  I want to commend the staff members who work with the SHCS’ school nutrition programs on a job well done during this review.   Keep up the good work