Administrative Review Summary Report
Name of Agency: Holy Trinity Catholic School
Date of off-site review: 10-09-18
Reviewer: Matthew Smith Date of on-site review: 11-15-18
Persons interviewed: Lenda Shaefer Date of exit conference: 11-15-18
This School Food Authority (SFA) operates the National School Lunch Program.
The following areas were corrected prior to the On-Site Portion of this Administrative Review (AR):
- Trans-Fat Requirement: During the menu week assessment of the week of 09/18/18—09/20/18 it was discovered the School Food Authority (SFA) served a gravy product containing 1.5 g. of trans-fats. Prior to the completion of the On-Site portion of this AR the SFA replaced this product with a gravy product that does not contain any trans-fats.
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 Off-Site Portion of the Review Conducted October 9, 2018:
Civil Rights: At the time of the Off-Site the School Food Authority (SFA) told the State Agency (SA) reviewer they had not conducted the annual civil rights training and could not provide documentation for the last civil rights training conducted by the SFA. The USDA requires all staff members who work with program applicants or participants receive an annual civil rights training (FNS Instruction 113-1). Documentation must be kept recording the topics covered and the staff members who completed the training (FNS Instruction 113-1).
During the On-Site portion of this AR it was discovered the nondiscrimination statement was not included on appropriate program material as required by FNS Instruction 113-1. Materials found not to contain the non-discrimination statement at the time of the On-Site visit were: letters to households, verification letters, and the lunch menus provided to households. FNS Instruction 113-1 directs SFA's to include on appropriate program materials to include the following nondiscrimination statement:
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
(1) mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
(2) fax: (202) 690-7442; or
(3) email: email@example.com.
FNS Instruction 113-1 allows for the following abbreviated nondiscrimination statement to be used if space is limited: "this institution is an equal opportunity provider."
To demonstrate compliance with the civil rights requirements:
- Conduct the annual civil rights training for school year 2018-2019 with staff members who have duties within the school food service program.
- Provide documentation of civil rights training for school year 2018-2019. This documentation must include the topics covered, as well as documentation of the staff members who completed the training.
- Add the nondiscrimination statement or the abbreviated nondiscrimination statement to the appropriate program materials. Provide a copy of an appropriate program material with the nondiscrimination statement on it.
- Submit the above requested documentation along with your plan for corrective action to demonstrate understanding and compliance.
Eligibility Determination: The SFA disclosed at the begging of this school year the household applications had eligibility determinations made prior to the first 30 days of the school year ending, but eligibility determinations were not made within 10 days of receiving the household applications as required by 7 CFR Part 245.6 (c) (6). Eligibility determinations are required to be made as soon as possible (within 10 days) after receiving applications from households. After the determination is made, the independent review of the household application has confirmed the eligibility determination then the SFA can issue the notification letter to the household. At this point the student(s) name(s) should be added to the benefit issuance document, as well as to the SFA's point of service system (the paper meal roster).
To demonstrate compliance with eligibility determination requirements:
- Ensure when household applications are received eligibility determinations are made within 10 days [as required by 7 CFR Part 245.6 (c) (6).
- Provide your school's plan for corrective action to demonstrate understanding and compliance.
Local Wellness Policy: The local wellness policy provided during the Off-Site portion of the AR was last assessed and reviewed in May of 2015, prior to the last AR conducted for the SFA. This policy directs the policy to be assessed at the end of each school year. No documentation was provided that any assessment and update of the policy was conducted since May of 2015. 7 CFR Part 210.31 (e) (2) requires local wellness policies to be assessed once every three years (best practice is to assess the policy annually). The last assessment of the SFA's policy was over three years ago. The policy needs to be assessed and updated. USDA Memo SP 24-2017 requires a triennial wellness assessment report to be completed to document the assessment and the update. The local wellness policy will need to be assessed and updated to bring the policy into compliance with its requirement to be assessed at the end of each school year, as well as to be brought into compliance with federal regulations [7 CFR Part 210.31 (e) (2)].
Prior to the completion of the On-Site portion of this AR the SFA provided a copy of their updated local wellness policy, but failed to provide the triennial assessment report documenting the assessment of the policy.
The newly assessed and updated policy, as well as the triennial wellness assessment report will need to be posted publicly as required by 7 CFR Part 210.31 (d) and 7 CFR Part 210.31 (e). As stated above this can be accomplished by posting both documents on a bulletin board that is accessible to the public visiting the school.
To demonstrate compliance with the local wellness policy requirements:
- Provide a copy of the triennial wellness assessment report.
- Post the updated local wellness policy and the triennial wellness assessment report publicly.
- Provide a copy of the above document, as well as your plan for corrective action demonstrating understanding and compliance.
Meal Patterns:A review of 09/18/18 through 09/20/18 indicated insufficient portion sizes at lunch.
The lunch meal pattern 7 CFR 210.10 (c) requires the following minimum serving sizes; 1 oz. by weight meat/meat alternate daily and 9-10 oz. per week, 1 oz. by weight bread/grain daily and 8-9 oz. per week, ½ cup fruit daily and 2 ½ cups per week, ¾ cup vegetables daily (dark green subgroup ½ cup/week, red/orange subgroup ¾ cup/week, legumes subgroup ½ cup/per week, starchy subgroup ½ cup/week, and other subgroup ½ cup/week) 3 ¾ cups/week, and 1 cup fluid milk daily, 5 cups weekly, offered as a choice between 1% and fat free.
- The lunch served on 09/20/18, only had ½ cup of carrots served with it.
- The menus for the week failed to credit any vegetables to the legume vegetable subgroup.
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 that is served as part of a reimbursable meal.
To demonstrate compliance with Meal Patterns:
- Review your menus for compliance with the meal patterns for grades K-8.
- Bring all insufficient serving sizes and missing components in compliance with the meal patterns for grades K-8.
- Submit your plan for corrective action to demonstrate understanding and compliance.
Professional Standards: At the time of the Off-Site visit documentation of the training completed by the employees with duties in the SFA's school nutrition program were not provided. 7 CFR Part 210.30 (c), 7 CFR Part 210.30 (d), and 7 CFR Part 210.30 (e) require the following training requirements:
|Job Category*||Annual Requirements|
|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.
The above training requirements are required to be completed every school year (July 1st to June 30). USDA Memo SP 39-2015 requires SFAs to use an approved training tracking tool. During the AR the SA Reviewer emailed the SA approved training tracking tool. 7 CFR Part 210.30 (g) requires the SFA each year to document the compliance with training requirements. Training should be documented on the training tracking tool throughout the school year, best practice is to add the training as it is completed. This will ensure all the training gets entered into the tool.
Prior to the completion of the On-Site Portion of this AR the SFA provided their training tracking tool. The school food services director (Kim Annuschat) and the part time kitchen staff members had not met their annual training hours. The above training requirements must be met by 06/30/19. No further action is required regarding the training tracking tool.
At the time of the Off-Site visit the SFA's school food services director had not completed the required eight hours of food safety training within 30 days of being hired or within five years of the date of hire as required by 7 CFR Part 210.30 (b) (v) and 7 CFR Part 210.30 (b) (2). Food service directors are further required to complete eight hours of food safety every five years.
To demonstrate compliance with professional standard requirements:
- Have the food services director complete eight hours of food safety training.
- Submit a copy of the documentation the food services director completed the eight hours of food safety training.
- Submit the above documentation along with your school's plan for corrective action to demonstrate understanding and compliance.
Verification: Each year, SFAs must confirm the eligibility of students receiving free and reduced price meals (7 CFR Part 245.6a). Depending on the verification method used, SFAs will select a percentage of applications, notify the selected families, and verify the income reported on their applications.
Verified over the 3% required: It was determined that your staff verified too many applications. Only 3% of all the approved, non- direct certified applications should be verified as required by 7 CFR Part 245.6a (c) (3) (i). Based on the number of your approved applications, only one application was required to be verified. Three applications were verified by the SFA, which would be 50% of the approved applications the SFA had on file on October 1, 2018.
To demonstrate compliance with verification requirements:
- Review the verification process used for this school year to find out where breakdown in the verification process occurred.
- Provide your corrective action plan to demonstrate your understanding and compliance with the verification requirements.
Findings and Recommendations Identified During the On-Site Portion of the Review Conducted November 15, 2018:
Counting and Claiming: A review of the counting system demonstrated counting and claiming errors for the review period (September 2018), which results in a Performance Standard Violation I (PSI), 7 CFR Part 210.18 (g) (1) (ii). The errors were determined by the State Agency (SA) reviewer to be systemic in nature. At the time of the On-Site visit the SFA did not provide the edit check for the review period (September 2018). The SFA told the SA reviewer during the review process that she (Ms. Schaefer) thought Renweb did an edit check, but no one at the SFA knew how to ensure this was getting done and printing a copy of the edit check. Edit checks are required to be used as a tool to help ensure the meal counts are accurate.
The SFA's September 2018 claim for the National School Lunch Program (NSLP) had an over claim. The meal rosters were not totaled correctly in a few places. Below is the outcome of the SFA's September 2018 claim:
7 CFR Part 201.8 (a) (2) requires each SFA to review their claims for accuracy prior to submitting them to the State Agency (SA). No other counting and claiming errors were found during the review period.
The SFA is consistently late in submitting their reimbursement claim to the SA. From the SA reviewer's review of the September 2018 claim this could be due to the SFA's counting and claiming system. The SFA at the point of service has meal tickets that are signed off on when a student receives a reimbursable meal and the tickets are then submitted to the office. The office then adds the meal count on a paper roster before entering the meal counts into the SFA's computer program (Renweb). The SFA's counting and claiming system appears to be causing the SFA's delay in submitting their claims on time.
This error is a serious, systemic error in the counting and claiming system. The error results in Performance Standard 1 Violations and require fiscal action [7 CFR Part 210.18 (g) (1) (ii) and 7 CFR Part 210.18 (I) (1)].
To demonstrate compliance with counting and claiming:
- Review the counting and claiming system and create a plan to insure accurate consolidation of daily meal counts.
- Provide copies of December's 2018's completed meal rosters, a copy of December 2018's claim, and copies of December 2018's edit check, along with your corrective action plan to demonstrate understanding and compliance.
Reviewer's Comments: Our office highly recommends attending our annual training in the summer. During the training we go over changes to school nutrition programs, focus on some of the areas our office has found there is a need for more training on, and we go over the application and verification process in detail. This training would be beneficial to both Ms. Schaefer and Ms. Annuaschat.
I cannot stress this last point enough call us when you need assistance, we want to help your school have a successful school nutrition program.
Procurement Review Summary Report
Name of Agency: Holy Trinity Catholic School
Date of AR off-site review: 10-09-18
Reviewer: Matthew Smith Date of AR on-site review: 11-15-18
Persons interviewed: Lenda Shaefer Date of exit conference: 11-15-18
This School Food Authority (SFA) operates the National School Lunch Program.
The following areas were corrected during the Procurement Review (PR):
- Procurement: At the time of the PR was commenced, your agency did not provide a code of conduct [7 CFR Part 210.21(c) and 7 CFR Part 220.16 (c)]. During the PR your agency provide a copy of the code of conduct that was compliant with federal regulations.
Corrective action for the above was made during the PR. No further action is required for the above.
Failure to Properly Procure a Food Service Management Company (FSMC): The SFA failed to properly procure the FSMC that the SFA allowed a Food Service Management Company (FSMC) to operate on their single site without a contract during school year 2017-2018 [2 CFR Part 200.320 (c) (2) (iii), 7 CFR Part 3016.36 (d), 7 CFR Part 3016.36 (d) (2) (ii) (c), 2 CFR Part 200.320 (c), 2 CFR Part 200.320 (d) (4), and 7 CFR Part 210.19 (e)]. SFA are required to conduct procurement in accordance with federal regulations allowing for free and open competition.
During school year 2017-2018 the SA discovered the SFA had not properly procured the FSMC operating on their single site without a contract. The State Agency (SA) worked with the SFA immediately after this discovery to properly procure a FSMC. Through the process of properly procuring a FSMC, the SFA determined it was more cost effective to hire a kitchen manager as an employee of the SFA to operate their own kitchen SFA.
The SFA was given Technical Assistance (TA) on the SA's requiring the SFA to seek the SA's assistance prior to starting the process of procuring a FSMC. This will ensure the SFA is provided with the TA necessary to procure a FSMC using a process that allows for free and open competition of prospective FSMCs and a process compliant with federal regulations.
To demonstrate compliance with properly procuring a FSMC:
- Provide a corrective action plan demonstrating understanding and compliance with properly procuring a FSMC under federal regulations and the SA's requirement of seeking the SA assistance prior to starting the process of procuring a FSMC.
Procurement: At the time of the off-site portion of the AR the SFA failed to provide their procurement plan.
Each SFA must have a written procurement plan on file, 7 CFR Part 210.21(c) and 7 CFR Part 220.16 (c). The plan must specify procurements procedures used by the SFA. All procedures must adhere to federal requirements for procurement. The procurement plan identifies the school's purchasing periods for the goods, equipment, and services related to the School Nutrition Programs and the various methods procurement being practiced.
The procurement plan provides an explanation for using certain procurement methods to obtain an items used in the school food service program. The SFA can determine the extent of the plan. A SFA may implement a plan that applies to all schools under its jurisdiction, or allow each school to implement an individual plan. A new procurement plan does not need to be developed every year.
To demonstrate compliance with procurement requirements:
- Provide a copy of agency's/school's procurement plan
- Provide the above along with your corrective action plan to demonstrate understanding and compliance.
Reviewer's Comments: Federal procurement rules and regulations can be complex; our office highly recommends contact us if you have questions or need assistance.