Administrative Review Summary Report
Date: 03-30-26
Name of Agency: Holy Trinity Catholic School Date of off-site review: 11-06-25
Reviewer: Matthew Smith Date of on-site review: 12-11-25 and 02-19-26
Fiscal Action: Yes, fiscal action amount will be assessed in the fiscal action and closure letter
Selected for Independent Review: No
Persons interviewed: Jamie Jenkins, Anne Wells, Date of exit conference: 03-25-26
and Kim Annuaschat
Programs Operated by the School Food Authority (SFA): This SFA operates the National School Lunch Program.
The following areas were corrected prior to the On-Site Portion of this Administrative Review (AR):
· Civil Rights: Holy Trinity Catholic School (HTCS) did not provide documentation demonstrating the most recent annual civil right training had been conducted [conducted as required by pertinent civil rights and nondiscrimination laws[1] and regulations[2]]. Prior to the completion of the on-site portion of this AR, HTCS took corrective action by conducting the annual civil rights training.
· Civil Rights – Eligibility Determination Letters: During the on-site visit it was discovered HTCS sent out eligibility determination letters that did not contain the complete nondiscrimination statement [as required by pertinent civil rights nondiscrimination laws and regulations]. HTCS took corrective action prior to this AR being open by adding the complete current nondiscrimination statement to their template eligibility determination letter.
· Failure to Provide Requested Records: During the off-site portion of this AR, HTCS failed to provide requested program records as required by federal regulation [7 CFR Part 210.9 (b) (17] and the permanent agreement HTCS has with Oklahoma Human Services (OKDHS). Prior to the completion of the on-site portion of this AR, HTCS took corrective action by providing the requested records.
· Local Wellness Policy: The local wellness policy provided at the time of the off-site visit did not have separate goal areas for three out of the four required goal areas; they were in a section titled “goals.” The policy also did not contain the following required areas:
o Guidelines and standards for the marketing of food and beverages on campus during the school day [as required by federal regulation 7 CFR Part 210.31 (c) (3) (iii)].
o Guidelines and standards for program food and beverages [as required by federal regulation 7 CFR Part 210.31 (c) (3) (i)].
o Guidelines and standards for fundraisers involving food and beverage on campus during the school day [as required by federal regulation 7 CFR Part 210.31 (c) (3) (ii) and (iii)].
o Guidelines and standards for food served but not sold on campus during the school day [as required by federal regulation 7 CFR Part 210.31 (c) (2)].
o A list of the local wellness committee membership [as required by federal regulations 7 CFR Part 210.31 (c) (5) and 7 CFR Part 210.31 (d) (1)].
o A description of how those interested in participating in the local wellness policy can get involved [as required by federal regulation 7 CFR Part 210.31 (c) (5)].
Prior to the completion of the on-site visit, HTCS took corrective action by providing an updated local wellness policy compliant with federal requirements.
· Resource Management: HTCS failed to provide documentation demonstrating the end of school year revenue and expense report was conducted for school year 2024 – 2025 to verify the nonprofit status of the Nonprofit School Food Services Account (NSFSA) as required by federal regulations [7 CFR Part 210.14 (a), 7 CFR Part 210.14 (b) and 7 CFR Part 210.19 (a) (1)]. Prior to the completion of the on-site portion of this AR, an end of school year revenue and expense report was provided.
· Resource Management – Accurate Tracking Revenue and Expenses: During the off-site portion of this AR, HTCS provided documentation indicating revenue from the reimbursement claims for October 2024 and December 2024 were not credited to the NSFSA. Federal regulation [7 CFR Part 210.14 (a)] requires accurate tracking of revenue and expenses. Prior to the on-site visit, HTCS provided documentation demonstrating revenue from both reimbursement claims were credited into the NSFSA.
No further action is required for the above.
Findings and Recommendations Identified During the On-Site Portion of the Review Conducted December 11, 2025 and February 19, 2026:
Counting and Claiming: A review Holy Trinity Catholic School’s (HTCS) counting and claiming system demonstrates non-systemic claiming errors for the review period (October 2025), which is a Performance Standard I (PSI) Violation [per federal regulation 7 CFR Part 210.18 (g) (1) (ii)] requiring fiscal action. These non-systemic errors were found for both the breakfast and lunch monthly meal counts.
The errors appear to be accidental data entry errors and not due to HTCS’ counting and claiming system.
Below are the differences Oklahoma Human Services School Nutrition Programs (OKDHS SNP) has identified in HTCS’ lunch meal counts claimed for October 2025:
|
OKDHS SNP Count |
HTCS’ Edit Check |
HTCS’ Claim |
Difference |
Free |
305 |
304 |
300 |
-5 |
Reduced |
30 |
30 |
30 |
0 |
Paid |
755 |
764 |
762 |
7 |
Free lunches meals were under claimed by five meals. Paid lunch meals were over claimed by seven meals.
Federal regulation [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).
To demonstrate compliance with counting and claiming requirements:
- Review the counting and claiming system and create a plan to ensure accurate meal counts are claimed.
- Complete the edit check process for breakfast and lunch meals daily.
- Provide copies of the of the following: meal rosters for lunch meal services for March 2026, as well as the edit checks for lunch for March 2026.
- Provide the above along with HTCS’ plan for corrective action to demonstrate compliance and understanding.
Meal Patterns: During the menu week assessed 10/20/25 – 10/24/25 there were some insufficient serving sizes for the lunch menus served. For the day of review, 12/07/25, insufficient daily serving sizes were also discovered.
The lunch meal pattern [as required by federal regulation 7 CFR 210.10 (c)] requires the following minimum serving sizes for the grades K-8 meal pattern:
Meal Component |
Required Serving |
Bread/Grain |
1 oz. by weight daily and 8 – 9 oz. per week |
*At least 80% of the weekly bread/grain component serving must be Whole Grain-Rich (WGR). |
Fruit |
½ cup daily and 2 ½ cups per week |
*Up to half of the weekly serving can be met with the use of 100% fruit juice. |
Meat/Meat Alternative |
1 oz. by weight daily and 9 – 10 oz. per week |
Milk |
1 cup daily and 5 cups per week |
*Students must be given a choice of milk from fat free unflavored, fat free flavored, and 1% unflavored. **One of the choices must be unflavored. |
Vegetable |
¾ cup daily and 3 ¾ cups per week |
Vegetable Subgroups to be offered throughout the week |
|
-Dark Green ½ cup -Red/Orange ¾ cup -Legume ½ cup per week -Starchy ½ cup -Other ½ cup |
|
Insufficient Quantities for the Menu Week 10/20/25 – 10/24/25
§ The menu served on 10/21/25 had an insufficient daily serving size for the vegetable component. The vegetables served with this date’s menu only credited at ½ cup of vegetables toward the vegetable component’s daily serving.
§ The menu served on 10/23/25 had insufficient daily servings for the bread/grain component. For grades pre-k through 2nd only 0.25 oz. could be credited toward the daily bread/brain component serving. For grades 3rd through 8th only 0.75 oz. could be credited toward the daily bread/grain serving.
§ Insufficient daily serving size for the vegetable component. Only ½ cup could be credited toward the daily serving for the vegetable component.
§ The minimum required weekly vegetable component serving was not met. Only 3 ½ cups could be credited toward the weekly vegetable component serving.
§ The minimum required weekly red/orange vegetable subgroup was not met. Only ½ cup of vegetables could be credited toward the weekly red/orange vegetable subgroup.
§ The minimum required weekly serving for the bread/grain component was not met. Only 6.75 oz. could be credited toward the weekly bread/grain component serving.
Insufficient Quantities for the Day of Review – 12/11/25
§ The menu had insufficient serving sizes for the bread/grain component. For grades pre-k through 2nd only 0.25 oz. could be credited toward the daily serving for the bread/grain
component. For grades 3rd through 8th grade only 0.25 oz. could be credited toward the daily serving for the bread/grain component.
The above insufficient serving sizes were determined to be non-systemic in nature.
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 (l) (2) (iii)].
To demonstrate compliance with the requirements for meal patterns:
- Review your menus for compliance with the meal patterns.
- Bring all insufficient serving sizes and missing components in compliance with the meal patterns.
- Submit HTCS’ plan for corrective action to demonstrate understanding and compliane.
Production Records: The production records provided as part of the menu week assessment of the lunch menus for 10/20/25 – 10/24/25, had the following issues:
· Did not document the leftovers for the menu produced.
· The production records did not have the grade levels for each item listed separately in the body of the record.
· Items being used to credit toward required meal components had a serving size range. When there is a different serving size for an item two rows in the body must be used and the grade levels the serving size is for must be documented in the row.
· The production record for 10/23/25, did not have shredded cheddar cheese documented on record when it was served as part of the reimbursable meal for that day.
Federal regulation [7 CFR Part 210.10 (a) (3)] requires SFAs to maintain production records for the meal being claimed for reimbursement. The production records are required to document how the meals produced contribute toward the meal patterns.
To demonstrate compliance with production record requirements:
· Provide a copy of one lunch production record.
· Provide the above along with HTCS’ plan for corrective action to demonstrate understanding and compliance.
Recordkeeping: As part of the maintenance of the Nonprofit School Food Services Account (NSFSA) area of the comprehensive resource management review, HTCS could not find one receipt for the month of expenses selected to be reviewed (April 2025). The receipt in question was for a transaction at Walmart on 04/18/25 for $86.22. The State of Oklahoma requires financial documentation to be retained for seven years after the last payment has been received for the school year.
To demonstrate compliance with recordkeeping requirements:
· Provide HTCS’ plan for corrective action to demonstrate understanding and compliance
Verification – Confirmation Review: HTCS did not have documentation demonstrating the required confirmation review was conducted as part of the verification process [as required by federal regulation 7 CFR Part 245.6a (e) (1)]. The confirmation review is when the original eligibility determination is reviewed by someone other than the person making the initial eligibility determination.
To demonstrate compliance with confirmation review requirements for the verification process:
· Provide HTCS’ plan for corrective action to demonstrate understanding and compliance.
Verification – Notification Letters: HTCS failed to send a verification notification letter the household that was selected for the verification process for school year 2025 – 2026 [as required by federal regulation 7 CFR Part 245.6a (f) (1)]. At the end of the verification process for school year 2025 – 2026, HTCS also failed to send the household selected for verification a notification of the outcome of the verification process (confirming the original determination) as required by federal regulation [7 CFR 245.6a (f)].
To demonstrate compliance with verification notification requirements:
· Provide HTCS’ plan for corrective action to demonstrate understanding and compliance.
Procurement Review Summary Report
Date: 03-30-26
Name of Agency: Holy Trinity Catholic School Date of AR off-site review: 11-06-25
Reviewer: Matthew Smith Date of AR on-site review: 12-11-25
and 02-19-26
Persons interviewed: Jamie Jenkins, Anne Wells, Date of exit conference: 03-25-26
and Kim Annuaschat
Programs Operated by the School Food Authority (SFA): This SFA operates the National School Lunch Program.
Findings for the Procurement Review (PR)
There were no findings for the Procurement Review for Holy Trinity Catholic Schoo
Laws may include but are not limited to: Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, Americans with Disabilities (ADA) Act of 1990, ADA Amendments Act of 2008, Age Discrimination Act of 1975, Civil Right Restoration Act of 1987.
Regulations include, but are not limited to: 7 CFR 15, 7 CFR 16, 28 CFR 35, 28 CFR 36, 28 CFR 42, USDA Departmental Regulations, FNS Program Regulations.
