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Administrative Review Summary Report

Date:  10-28-19

Name of Agency:  Youth Services of Bryan County

                                                                                               Date of off-site review: 08-07-19

Reviewer:  Matthew Smith                                               Date of on-site review: 09-17-19

                                                                                               and 10-16-19

Persons interviewed:  Stormy Patterson                        Date of exit conference: 10-16-19

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):

  • Meal Patterns: During the menu week assessment for the week of July 21, 2019 through July 27, 2019, systemic insufficient serving sizes for the fruit component were discovered for both breakfast and lunch meals, which cause the weekly required fruit serving for both breakfast and lunch menus to be insufficient [7 CFR Part 210.10 (c) and 7 CFR Part 220.8 (c)].  The SFA took corrective action for the systemic daily fruit serving sizes for the breakfast and lunch meal prior to the nutrient analysis being conducted, theses corrective actions also brought the weekly fruit servings into compliance with the breakfast and lunch  meal patterns.

During the menu week assessment the following insufficient serving sizes were also discovered for the breakfast meals (in addition to the systemic insufficient fruit serving sizes):
   -For the meal on 07/25/19, insufficient serving for the bread/grain required daily serving size [7 CFR Part 220.8 (c)]
   -The weekly serving of fruit for the breakfast meals was insufficient [7 CFR Part 220.8 (c)].
   -The weekly serving for the bread/grain requirement for the week was only 45% Whole Grain-Rich (WGR) [7 CFR Part 220.8 (c)].
The SFA took corrective action for all the above findings prior to the nutrient analysis being conducted.

For the lunch meals served during the menu week assessed (07/21/19—07/27/19), the following insufficient serving size were discovered (in addition to the systemic insufficient fruit serving sizes):
   -For the meal on 07/21/19, insufficient serving size for the vegetable component [7 CFR Part 210.10 (c)]
   -For the meal on 07/22/19, insufficient serving for the bread/grain component [7 CFR Part 210.10 (c)].
   -For the meal on 07/24/19, insufficient serving size for the bread/grain component [7 CFR Part 210.10 (c)].
   -For the meal served on 07/27/19, insufficient serving size for the meat/meat alternative component [7 CFR Part 210.10 (c)].
   - The weekly serving for the bread/grain requirement for the week was only 44.6% Whole Grain-Rich (WGR) [7 CFR Part 210.10 (c)].
   -The weekly required vegetable component serving size was insufficient [7 CFR Part 210.10 (c)].
The SFA took corrective action for all of the above findings prior to the nutrient analysis being conducted. 

The above insufficient serving sizes are Performance Standard 2 Violations (PS2).  The State Agency (SA) is exercising it discretion not to take fiscal action on the above insufficient serving sizes [7 CFR Part 210.18 (g) (2)].

The following insufficient serving size was discovered for the lunch menus served during the menu week assessed (07/21/19—07/27/19):
   -The weekly required serving size for the red/orange vegetable subgroup was insufficient [7 CFR Part 210.10 (c)].  

The SFA took corrective action for the above insufficient vegetable subgroup serving.  This was a repeat violation involving the red/orange vegetable subgroup for the SFA (during the last AR the SFA was cited for an insufficient serving size for this subgroup) and is a PS2 violation. 7 CFR Part 210.18 (g) (2) requires SA fiscal action be taken for repeated violations involving vegetable subgroups during the week assessed as part of this AR (07/21/19—07/27/19).   

Due to the violations described above; our office has no choice but to remove the 6 cents, per lunch, performance-based reimbursement, beginning with November's claim [as required by 7 CFR Part 210.18 (g) and the Administrative Review Manual].

  • Non-creditable item was served as part of a reimbursable meal:During the menu week assessment it was determined the SFA was serving a non-creditable item, the frozen pizza served with the lunch meal on 07/28/19 (7 CFR Part 210 Appendix C). The SFA replaced this item with a creditable entrée produced form a recipe.
  • The SFA met the weekly fruit serving requirement with the use of fruit juice over the allowable amount: The breakfast menu week assessed (07/21/19—07/27/19) the SFA met the weekly fruit serving requirement by using fruit juice for 71.43% of the weekly serving [7 CFR Part 210.10 (c) (ii) and 7 CFR Part 220.8(c) (ii)]. The SFA took corrective action prior to the nutrient analysis being conducted.
  • Nutrient Analysis and Dietary Specifications not met: A nutrient analysis was triggered for the grade 9-12 meal pattern.

    Breakfast:  The average weekly sodium was exceeded [797 mg, 7CFR Part 220.8 (f) (3)]

    Lunch:  The weekly saturated fat percentage exceeded the requirement for <10% [10.38%, 7 CFR Part 210.10 (f) (2)].
  • Local Wellness Policy: The SFA's local wellness policy provided during the Off-Site portion of this AR needs to have the following added
    • The policy does not provide a description of how and when the policy will be assessed.  [7 CFR Part 210.31 (c) (4) and 7 CFR Part 210.31 (e) (1)]
    • The SFA's policy does not designate personnel designated with the responsibility for assessing the policy [7 CFR Part 210.31 (c) (4) and 7 CFR Part 210.31 (e) (1)].
    • The policy also does not designate personnel with the responsibility for implementing the policy [7 CFR Part 210.31 (c) (4) and 7 CFR Part 210.31 (e) (1)].  
    • The policy does not include a description for the measuring the implementation of the policy [as required by 7 CFR Part 210.31 (c) (6)]. 

The SFA failed to document their most recent assessment and update to the local wellness policy on a triennial wellness assessment report as required by USDA Memo SP24-2017. 

The policy has not been assessed since the fall of 2016 [7 CFR Part 210.31 (e) (2)]

Corrective actions for the above findings were made prior to the completion of 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 August 7, 2019:

Professional Standards:  Youth Services of Bryan County's (YSBC) acting school nutrition programs director did not complete 12 hours of training during school year 2018-2019 as required by 7 CFR Part 210.30 (b) (3).  YSBC's director only completed 4.75 hours of training during school year 2018-2019. 

The following are the training requirements contained in 7 CFR Part 210.30 (b) (3), 7 CFR Part 210.30 (c), and 7 CFR Part 210.30 (d):

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.

 *Your SFA may not have all the job categories listed above.  All SFA's have a director.

To demonstrate compliance with Professional Standards:

  • Provide YSBC's plan for corrective action to demonstrate understanding and compliance.

Resource Management:  Youth Services of Bryan County's (YSBC) Nonprofit School Food Services Account (NSFSA) had a balance over the allowed three months of average expenditures for your agency's school nutrition programs [7 CFR Part 210.14 (b)].  At the time the end of the school year revenue and expense report for school year 2018-2019 was conducted the account had a balance of $3,885.26, which is $1,624.61 over the allowed three month of average expenditures ($2,260.65).  This $1,624.61 must be spent down in order for the NSFSA to be compliant with 7 CFR Part 210.14 (b).

The end of the school year revenue and expense report for school year 2018-2019 documented wages and benefits being charged to the NSFSA for a fulltime employee with part time duties in YSBC's school nutrition program.  The employee having duties outside of the agency's school nutrition programs make these charges indirect costs.   These indirect costs were charged the NSFSA without an approved (by our office) Indirect Cost Rate Agreement (ICRA) as required by 2 CFR Part 200.57.  Since the indirect charges to the NSFSA in question do not have an approved ICRA, this makes the charges unallowable.  The USDA's Administrative Review Manual directs in cases such as this:

"…the SFA inappropriately spent nonprofit school food services funds on unallowable expense during the resource management review period (in this case school year 2018-2019), corrective action will require a transfer from the SFA's general fund into the nonprofit school food services account."

The total unallowable expenses are $1,549.75 ($1,300 for the wages and $249.75 for the benefits).  This amount will have to be deposited to the NSFSA.  This will bring the amount required to be spent down to $3,174.36 ($1,624.61 originally discovered overage plus $1,549.75 amount to reimburse the NSFSA for the unallowable expenditures) on allowable expenditures.

Prior to charging indirect costs, and to compiling an ICRA, your agency should review the USDA's Indirect Cost Guidance for State Agencies and School Food Authorities (this guidance was emailed to YSBC on 08/13/19). 

Prior to the On-Site portion of the AR, YSBC spent $627.87 on a dishwasher (included delivery, hoses, and installation) for their single site's kitchen.  YSBC still needs to spend $2,546.49 in order to bring their NSFSA into compliance with having a balance under the allowed three months average operating expenses.   

To demonstrate compliance with resource management:

  • Cease charging indirect costs to YSBC's Nonprofit School Food Services Account (NSFSA) without an approved Indirect Cost Rate Agreement (ICRA)
  • Provide a plan to spend down the remaining $2,546.49 bringing your NSFSA into compliance with being nonprofit (having a balance less than three months of operating expenses) as required by 7 CFR Part 210.14 (b).
  • Provide the above along with YSBC's plan for corrective action to demonstrate understanding and compliance.

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted September 17, 2019 and October 16, 2019:

Counting and Claiming: A review of the counting system demonstrates systemic counting errors for the review period (July 2018) as well as for the Afterschool Snack review period (August 2019), which results in a Performance Standard Violation I (PSI), 7 CFR Part 210.18 (g) (1) (ii).  The errors were systemic in nature and were found for breakfast, lunch, and snack. 

The errors resulted from using a paper based edit check.  The daily meal counts and snack counts were not calculated correctly.  This caused the meals to be under claimed for breakfast, lunch, and snack. 

Below are the differences identified in Youth Services of Bryan County (YSBC) July lunch counts, when comparing the meal roster to the meals listed on the claim:

  YSBC OKDHS Diff.
Free 71 72 +1

Free meals were under claimed by one meal.

Below are the differences identified in YSBC's July school breakfast counts, when comparing the meal roster to the meals listed on the claim:

  YSBC OKDHS Diff.
Free 72 73 +1

Free meals were under claimed by one meal.

Below are the differences identified in YSBC's August Afterschool Snack Program counts, when comparing the meal roster to the meals listed on the claim:

  YSBC OKDHS Diff.
Free 23 25 +2

Free snacks were under claimed by two snacks.

At the time of the On-Site portion of this AR the State Agency (SA) Reviewer strongly recommended YSBC use the electronic edit check.   Technical assistance was given on how to use the electronic edit check to reduce human errors during the consolidation of YSBC's meal counts for inclusion in the monthly claim.  

7 CFR Part 210.8 (a) (2) requires each SFA to review their claims for accuracy prior to submitting them to the 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.
  • Begin using the electronic edit check daily to record meal counts instead of using paper based edit check.
  • Provide copies of the following: your agency's meal rosters for November 2019, your agency's edit check forms, and the claim for November 2019.
  • Provide the above copies, along with your corrective action plan to demonstrate understanding and compliance.

Health Inspections:  During school year 2018-2019, YSBC failed to request second health inspections for both of the sites that were in operation at that time.   7 CFR Part 210.13 (b) requires School Food Authorities (SFA) to receive at least two health inspections during the school year. If two are not received during a school year the SFA must call their local health department and request a second inspection.  The SFA should document their local health department's response if they decline to conduct the second health inspection.

To demonstrate compliance with health inspection requirements:

  • Provide YSBC's corrective action plan to demonstrate understanding and compliance with health inspection requirements.

Reviewer's Comments:  I want to commend Stormy Patterson for taking the technical assistance provided and applying it toward the needed corrective actions.  I want to encourage Ms. Patterson to continue to ask questions and request assistance as needed from our office.  

Procurement Review Summary Report

Date:  10-28-19

Name of Agency:  Youth Services of Bryan County

                                                                                                 Date of AR off-site review: 08-07-19

Reviewer:  Matthew Smith                                                  Date of AR on-site review: 09-17-19

                                                                                                                                          and 10-16-19

Persons interviewed:  Stormy Patterson                           Date of exit conference: 10-16-19

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 during the Procurement Review (PR):

  • Procurement: At the time of the PR was commenced, the procurement plan provided did not document the steps taken to assure that small, minority and women's business enterprise and small labor surplus firms are used when possible [2 CFR Part 200.321].  During the PR Youth Services of Bryan County (YSBC) provided a copy of a procurement that is compliant with 2 CFR Part 200.321.

Corrective action for the above was made during the PR.  No further action is required for the above.
      
There were no additional findings for the procurement review for YSBC.

Reviewer's Comments:  Overall YSBC is conducting their procurements in compliance with procurement regulations.

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