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Administrative Review Summary Report

Date:  05-13-20

Name of Agency:  Integris Bass Baptist Health Center – Meadow Lake

            Date of off-site review: 04-02-20

Reviewer:  Matthew Smith                                                     Date of on-site review: 05-05-20

Persons interviewed:  Rhonda Fullerton                                Date of exit conference: 05-08-20

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

The following areas were corrected prior to the On-Site Portion of this Administrative Review (AR):

  • Buy American Provision: The lunch on 03/14/20, cauliflower that was a product of Ecuador was served [7 CFR Part 210.21 (d), USDA Memo SP02-2017, and USDA Memo SP38-2017].  Prior to the On-Site visit documentation was provided of the Integris Bass Baptist Health Center's (IBBHC) use of a limited exemption to the Buy American Provision (the domestically produced cauliflower was not of satisfactory quality) for the continued use of the non-domestic cauliflower.
  • Civil Rights: The written procedures for handling civil rights complaints had out of date contact information for the USDA on where to send civil rights complaints (FNS Instruction 113-1). Prior to the On-Site portion of the AR the IBBHC took corrective action by updating their procedure for handling civil rights complaints to include the current contact information for the USDA on where to send civil rights complaints.
  • Local Wellness Policy:  The local wellness policy provided by IBBHC needed to have the following added to bring the policy into compliance with federal requirements: goals for nutrition promotion [7 CFR Part 210.31 (c) (1)], name and title of personnel designated with ensuring the policy is implemented [7 CFR Part 210.31 (e) (1)], name and title of the personnel designated with the responsibility for assessing the policy [7 CFR Part 210.31 (e) (1)], and the members of the local wellness committee are not listed within the policy [7 CFR Part 210.31 (c) (5) and 7 CFR Part 210.31 (d) (1)].  Prior to the completion of the On-Site portion of this AR IBBHC revised their local wellness policy to include the required areas.
  • Meal Pattern: During the assessment of breakfast and lunch menus for the week of 03/08/20 through 03/14/20, an insufficient serving weekly serving size was discovered for the required minimum weekly bread/grain serving for breakfast menus served [7 CFR Part 220.8 (c)].  Prior to the On-Site portion of this review the IBBHC took corrective action bringing this required minimum weekly serving size in to compliance.



    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 On-Site Portion of the Review conducted on May 5, 2020:



    Counting and Claiming: A review of the counting and claiming system demonstrates non-systemic counting errors for the review period (March 2020).  The counting errors appeared for two days of Integris Bass Baptist Health Center's (IBBHC) School Breakfast Program (SBP) monthly claim for the review period.  These counting errors caused an over claim of two free meals for the review period.  These errors are Performance Standard Violation I (PSI) and will require fiscal action [7 CFR Part 210.18 (g) (1) (ii) and 7 CFR Part 210.18 (l) (1)].   

     

    Below are the differences, our reviewer identified, in IBBHC's breakfast meal counts for the review period (March 2020): 

     
  IBBHC OKDHS Diff.
Free 947 949 +2


The two over claimed breakfast meals were due to human counting errors that occurred on March 12, 2020 and March 13, 2020.  On both days the breakfast meal counts for the DD housing unit were over by one meal.  These two errors caused the monthly SBP's claimed to be over claimed by two breakfast meals.  The rest of the counts for the review period from the DD housing unit had no errors.  All of the SFA's other housing units' meal counts for the review period had no errors.  It is recommended Staff members taking meal counts be given refresher training on taking meal counts.   Taking this step, as well as reviewing the monthly claim prior to submitting the claim to our office for accuracy [as required by 7 CFR Part 210.8 (a) (2)] and continued use of edit checks will reduce the chance of errors occurring.  The reduction of the chance of errors will increase the accuracy of the monthly reimbursement claim.

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: edit checks for the meals claimed for April 2020 (breakfast and lunch), the meal rosters for April 2020 (for breakfast and lunch for all housing units), and the claim for April 2020.
  • Provide the above copies, along with your corrective action plan to demonstrate understanding and compliance.    

Reviewer's Comments:  I want to commend Rhonda Fullerton and the staff members who work with the school nutrition programs for all of their hard work.    

 

Procurement Review Summary Report


 

Date:  05-13-20

Name of Agency:  Integris Bass Baptist Health Center – Meadow Lake

                                                                                                     Date of AR off-site review: 04-02-20

Reviewer:  Matthew Smith                                                     Date of AR on-site review: 05-05-20

Persons interviewed:  Rhonda Fullerton                              Date of exit conference: 05-08-20

                                   

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


The following areas were corrected during the Procurement Review (PR):

 

  • Buy American Provision: The lunch on 03/14/20, cauliflower that was a product of Ecuador was served [7 CFR Part 210.21 (d), USDA Memo SP02-2017, and USDA Memo SP38-2017].  Prior to the On-Site visit documentation was provided of the SFA's use of a limited exemption to the Buy American Provision (the domestically produced cauliflower was not of satisfactory quality) for the continued use of the non-domestic cauliflower. 

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.

Reviewer's Comments:  I want to commend Ms. Fullerton for the work she has done to maintain compliance with federal procurement requirements.


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