Administrative Review Summary Report
Date: 11-19-21
Name of Agency: Youth Services of Tulsa County Date of off-site review: 08-12-20
Reviewer: Matthew Smith Date of on-site review: 09-30-21
Persons interviewed: Kolby Brown and Date of exit conference: 11-10-21
Andre Platt
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):
- Buy American Provision: The Oat Rings honey flavored cereal served with the breakfast on 07/21/21 was a product of Mexico [7 CFR Part 210.21 (d)]. Prior to the on-site portion of this AR, Youth Services of Tulsa County (YST) took corrective action by replacing this product with a domestically produced cereal product.
- HACCP Food Safety Plan: YST could not locate their HACCP food safety plan during the on-site portion of this AR [7 CFR Part 210.13 (b)]. Prior to the completion of the on-site portion of this AR the SFA took corrective action by adopting a new HACCP food safety plan.
- Meal Patterns: During the menu week assessment of the breakfast and lunch menus for the week of 07/18/21 through 07/24/21 significant insufficient serving sizes at breakfast and lunch were discovered as well as a missing meal component at lunch [7 CFR Part 210.10 (c) and 7 CFR Part 220.8 (c)]. Prior to the on-site portion of this AR, YST took corrective action bringing the menu week into compliance with the meal pattern.
OKDHS School Nutrition Programs is exercising its discretion [as permitted by 7 CFR Part 210.18 (g) (2)] to not take fiscal action for all insufficient serving sizes discovered during the menu week assessment. Except for the repeat violation for the insufficient weekly serving for the legume vegetable subgroup for the week of lunch menus assessed (during the previous AR YST had an insufficient serving for the legume subgroup). Fiscal action is required for the performance standard two repeat violation for the insufficient weekly serving for the legume vegetable subgroup, and for a missing meal component for the lunch served on 07/18/21 [as required by 7 CFR Part 210.18 (g) (2)].
- The SFA met the weekly fruit serving requirement with the use of fruit juice over the allowable amount: During the breakfast and lunch menu week assessment (week of 07/18/21 through 07/24/21), it was discovered the percentage of the weekly serving for both breakfast and lunch menus exceeded 50%. [7 CFR Part 210.10 (c) (2) (ii) and 7 CFR Part 220.8 (c) (2) (ii)] Prior to the on-site the SFA took corrective action bringing the weekly serving for fruit for both breakfast and lunch into compliance with the meal patterns for breakfast and lunch.
- Nutrient Analysis: Systemic insufficient serving sizes and a missing meal component discovered during the menu week assessment of the breakfast and lunch menus for the week of 07/18/21 – 07/24/21 triggered a nutrient analysis. The nutrient analysis had the following findings:
- For the Breakfast menus: Average calories for the week were exceeded for grades 9-12 meal pattern [7 CFR Part 220.8 (f) (1)] and the average sodium for the week exceeded the meal patterns for grades 9-12 meal pattern [7 CFR Part 220.8 (f) (3)]. Finally, the saturated fat percentage for the week exceeded 10% [7 CFR Part 2208 (f) (2)].
- For the lunch menus: Average sodium for the week exceeded the meal patterns for grades 9-12 [7 CFR Part 210.10 (f) (2)].
Prior to the completion of the on-site portion of this AR, YST took corrective action brining the breakfast and lunch menus in to compliance with the meal patterns for grades 9-12.
- Whole Grain-Rich (WGR) Bread/Grain: For the reviewed week of 07/18/21 through 07/24/21; YST did not meet the 100% Whole Grain-Rich (WGR) requirement for the bread/grain products served at breakfast and lunch [7 CFR Part 210.10 (c) (2) (iv) and 7 CFR Part 210.10 (c) (2) (iv)]. Prior to the on-site portion of this AR, YST took corrective action for all WGR findings replacing all non-WGR items with WGR items.
You agency took Corrective action for the above 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 August 12, 2021:
Local Wellness Policy: Youth Services of Tulsa County’s (YST) local wellness policy needs to have the following added:
- The name and title of the person(s) designated to assess YST's local wellness policy and to ensure the policy's implementation. It is recommended no more than two people assess the policy. This is required to meet the requirements under 7 CFR Part 210.30 (c) (4) and 7 CFR Part 210.30 (e) (1).
According to the triennial wellness assessment report documenting the most recent assessment and update to the local wellness policy was not compared to the model school local wellness policy. During the assessment of the local wellness policy it is required to compare the local wellness policy to the model school local wellness policy [as required by USDA Memo SP 24-2017 and 7 CFR Part 210.31 (e) (2) (ii)].
To demonstrate compliance with the local wellness policy:
- Add the name of the person designated to assess the local wellness policy and to ensure the policy implementation
- Provide a copy of the updated local wellness policy with the required changes listed above.
- Provide the above requested documentation along with YST’s plan for corrective action to demonstrate compliance and understanding.
Professional Standards – Annual Training Hours: Training records for school year 2020 – 2021 indicated there were employees with duties within YST’s school food services program that failed to complete the required creditable annual training hours. Federal regulations [7 CFR Part 210.30 (b) (3), 7 CFR Part 210.30 (c), 7 CFR Part 210.30 (d), and 7 CFR Part 210.30 (e)] have the following training requirements that must be completed by June 30th of each school year:
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
During school year 2020 – 2021, the director only completed 11 creditable annual training hours.
Four staff members with part-time duties within YST’s school food services program failed to complete the four required creditable annual training hours during school year 2020 – 2021.
The following list contains training topics that can be credited toward the professional standards annual training requirements [7 CFR Part 210.30 (b) (3), 7 CFR Part 210.30 (c), 7 CFR Part 210.30 (d)]:
- Meal counting and reimbursement claim procedures
- Meal patterns
- Nutrition
- Identification of reimbursable meals at the point of service
- Annual civil rights training
- Health and safety standards
- HACCP food safety
- Administrative Review and Procurement Review
- Local Wellness Policy
- Marketing of school food services program
- Procurement
To demonstrate compliance with Professional Standards – Annual Training Hours Requirements:
- Provide YST’s corrective action plan to demonstrate understanding and compliance.
Findings and Recommendations Identified During the On-Site Portion of the Review Conducted September 30, 2021:
Afterschool Snack Program – Meal Pattern: During the review of five consecutive days’ worth of production records for the Afterschool Snack Program, insufficient servings were discovered and a non-creditable item was served. Federal regulation [7 CFR Part 210.10 (o) (2)] has the following meal pattern for the Afterschool Snack Program for children ages 6 – 18:
- Serve two of the following (must be from two different components):
- Milk – Low-fat (1% or less, unflavored only) or fat free (flavored or unflavored) – 1 cup
- Vegetables and Fruits – ¾ cup
- Grains and Breads – 1 oz.
- Meat/Meat Alternative – 1 oz.
The review discovered the following snack insufficient servings:
- 10/05/21, the 100% fruit juice served only credited ½ cup toward the vegetable and fruit component.
- 10/08/21, the 100% fruit juice served only credited ½ cup toward the vegetable and fruit component.
The trail mix served with the snack on 10/08/21 was a non-creditable item. The trail mix was a commercial product containing more than nuts. Replace this product with one that can be credited toward the Afterschool Snack Program meal patterns.
To demonstrate compliance with Afterschool Snack – Meal Pattern requirements:
- Review your snack menus for compliance with the Afterschool Snack Program meal pattern for ages 6 – 18 years old.
- Bring all insufficient serving sizes into compliance with the Afterschool Snack Program for ages 6 -18 years old.
- Replace the trail mix used on 10/08/21 with a creditable item.
Counting and Claiming: A review of the counting system demonstrates systemic counting errors for the review period (July 2021), which results in a Performance Standard
Violation I (PSI). 7 CFR Part 210.18 (g) (1) (ii). The review found systemic errors for both the breakfast and lunch.
The errors discovered with the lunch meal claims appear to be due to Excel formulas in the meal roster spreadsheet used to record the counts not covering added rows for new residents. In addition, YST claimed six lunch meals in error when residents were taken out to lunch on 07/04/21.
Below are the differences identified in YST’s July lunch counts, when comparing the meal roster (including those meals claimed on 07/04/21 in error) to the meals listed on YST’s claim:
|
YST |
OKDHS |
Difference |
Free |
222 |
237 |
-15 |
Lunch meals were under claimed by 15 meals.
Like the lunch meal roster, the errors discovered with the breakfast meal claims appear to be due to Excel formulas in the meal roster spreadsheet used to record the counts not covering added rows for new residents.
Below are the differences identified in YST’s July’s breakfast counts, when comparing the meal roster to the meals listed on YST’s claim:
|
YST |
OKDHS |
Difference |
Free |
220 |
253 |
-33 |
Breakfast meals were under claimed by 33 meals.
Be sure to check the formulas on the Excel spreadsheets used to record counts to ensure the formulas are working correctly, adding all the rows up, especially when adding more rows than contained in the original meal roster spreadsheet supplied by OKDHS School Nutrition Programs.
7 CFR Part 210.8 (a) (2) requires each SFA to review their claims for accuracy prior to submitting them to the State Agency (SA).
These are serious, systemic errors in the counting and claiming system. They result in Performance Standard 1 Violations.
To demonstrate compliance with counting and claiming:
- Provide copies of the following: YST’s meal rosters with edit checks for November 2021.
- Provide the above copies, along with your corrective action plan to demonstrate understanding and compliance.
The SFA met the weekly fruit serving requirement with the use of fruit juice over the allowable amount: During the review period (July 2021) YST met the weekly fruit serving requirement by using 100% fruit juice for the following weeks of lunch menus:
- The week of 07/04/21 through 07/10/21
- The week of 07/11/21 through 07/17/21
- The week of 07/25/21 through 07/31/21
Federal regulations [7 CFR Part 210.10 (c) (2) (ii) and 7 CFR Part 220.8 (c) (2) (ii)] require no more than half of the weekly serving of the fruit component may be met using 100% fruit juice.
It is recommended that only half of the daily serving be met using 100% fruit juice (half cup), and the other half cup be met using canned, fresh, or frozen fruit.
To demonstrate compliance with fruit juice weekly serving requirements:
- Review your menus for compliance with weekly fruit juice serving requirements
- Submit your plan for corrective action to demonstrate understanding and compliance.
Meal Patterns: During the review period and the day of review insufficient serving sizes were discovered.
The breakfast meal pattern 7 CFR Part 220.8 (c) requires the following minimum serving sizes for grades 9-12:
o 1 oz. by weight bread/grain daily and 12.5 – 14 oz. per week
o 1 cup of fruit daily and 7 cups per week
o 1 cup of fluid mil daily, 7 cups per week, offered as a choice between 1% (unflavored) and fat free (flavored or unflavored). Two varieties must be offered daily.
Insufficient Quantities
- Insufficient serving for the required daily fruit serving for the following breakfast menus: 07/06/21, 07/12/21, 07/13/21, 07/14/21, 07/15/21, 07/26/21, 07/27/21, and 07/31/21. On these dates, only ½ cup of fruit could be credited toward the daily serving. These insufficient servings were determined to be systemic in nature.
- Insufficient serving for the required weekly fruit servings for the following weeks:
- The week of 07/11/21 through 07/17/21, only 5 cups of fruit could be credited toward the required weekly fruit serving.
- The week of 07/25/21 through 07/31/21, only 5 ½ cups of fruit could be credited toward the required weekly fruit serving.
The lunch meal pattern 7 CFR 210.10 (c) requires the following minimum serving sizes for the grades 9-12 meal pattern:
- 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, 7 cups per week
Vegetable Subgroup Services:
- Dark green subgroup ½ cup/week
- Red/orange subgroup 1 ¼ cup/week
- Legumes subgroup ½ cup/per week
- Starchy subgroup ½ cup/week
- Other subgroup ¾ cup/week) 7 cups/week.
- 1 cup fluid milk daily, 7 cups weekly, offered as a choice between 1% (unflavored) and fat free (flavored or unflavored). Two varieties must be offered daily.
Insufficient Quantities
§ Insufficient daily serving for the fruit component for the following lunch menus: 07/01/21, 07/02/21, 07/03/21, 07/05/21, 07/06/21, 07/07/21, 07/08/21, 07/09/21, 07/10/21, 07/11/21, 07/13/21, 07/14/21, 07/15/21, 07/16/21, 07/17/21, 07/25/21, 07/27/21, 07/28/21, 07/29/21, and 07/30/21. On these dates, only ½ cup of fruit could be credited toward the fruit component. These insufficient servings were determined to be systemic in nature.
§ Insufficient daily serving size for the vegetable component for the lunch menu served on 07/10/21. The salad served only credited ½ cup of vegetables toward this daily serving.
§ Insufficient daily serving for the bread/grain component for the following lunch menus:
o For the menus served on 07/15/21 and 07/17/21. Only 1 slice of bread was served that credited at 1 oz. towards this daily serving on these dates.
o For the lunch menu served on the day of review (09/20/21), the bun served with the meal only credited 1.75 oz. toward the daily serving. No other creditable bread/grain items were served.
§ Insufficient weekly servings for the fruit component for the following weeks:
o The week of 07/04/21 through 07/10/21, only 3 cups of fruit could be credited toward this weekly serving.
o The week of 07/11/21 through 07/17/21, only 4 cups of fruit could be credited toward this weekly serving.
o The week of 07/25/21 through 07/31/21, only 5 cups of fruit could be credited toward this weekly serving.
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 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.
HACCP food safety Inspection: During school year 2020-2021, YST failed to request second health inspection for their single site. Federal regulation [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, the SFA must call their local health department and request a second inspection. The SFA must document their local health department's response if they decline to conduct the second health inspection.
To demonstrate compliance with health inspection requirements:
- Provide YST's corrective action plan to demonstrate understanding and compliance with health inspection requirements.
Procurement Review Summary Report
Date: 11-19-21
Name of Agency: Youth Services of Tulsa County Date of AR off-site review: 08-12-21
Reviewer: Matthew Smith Date of AR on-site review: 09-30-21
Persons interviewed: Kolby Brown and Date of exit conference: 11-10-21
Andre Platt
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):
· Buy American Provision: The Oat Rings honey flavored cereal served with the breakfast on 07/21/21 was a product of Mexico [7 CFR Part 210.21 (d)]. Prior to the on-site portion of this AR, Youth Services of Tulsa County (YST) took corrective action by replacing this product with a domestically produced cereal product.
Your agency took Corrective action for the above during the PR. No further action is required for the above.
There were no additional findings for the procurement review.
Reviewer’s Comments: I want to commend your agency on compliance with the regulations regarding procurement in school nutrition programs.
