Administrative Review Summary Report

Date: 01-30-23

Name of Agency: Peace Academy Date of off-site review: 10-06-22

Reviewer: Matthew Smith Date of on-site review: 11-10-22

and 11-17-22

Persons interviewed: Shazia Malik and Date of exit conference: 01-18-23

Kim Muhammad

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):

Certification and Benefit Access – Benefit Issuance Document (BID): At the time of the off-site visit, Peace Academy provided a BID that was not compliant with federal requirements [7 CFR Part 245.6 and the USDA Administrative Review Manual] for gathering data on students. Prior to the completion of the on-site portion of this AR, Peace Academy took corrective action and provided a BID that was compliant with federal requirements
Certification and Benefit Access – Incomplete Household Application: During the review of the household applications, one application was discovered that did not have the last four digits of the Social Security Number (SSN) listed, or an indication that the adult does not have a SSN [as required by federal regulation 7 CFR Part 245.6 (a) (6)]. Prior to the completion of the on-site portion of this AR, Peace Academy took corrective action by contacting the household and getting the application completed.
Failure to Provide Requested Records: During this AR, Peace Academy failed to provide requested documentation despite several requests as required by federal regulation [7 CFR Part 210.9 (b) (17)] and Peace Academy’s permanent agreement with OHS SNP. Prior to the completion of the on-site portion of this AR, Peace Academy provided all the requested documentation.
Meal Pattern – Menu Week Assessment: During a review of the breakfast and lunch menus for the week of 09/19/22 – 09/23/22, systemic insufficient serving sizes were discovered at breakfast and lunch [meal patterns required by federal regulation 7 CFR Part 210.10 (c) and 7 CFR Part 220.8 (c)]. Prior to the completion of the on-site portion of this AR, Peace Academy took corrective action for all of the insufficient serving sizes. Oklahoma Human Services School Nutrition Programs (OHS SNP) is exercising its discretion to not apply fiscal action for the insufficient serving sizes as permitted by federal regulation [7 CFR Part 210.18 (g) (2)].
Meal Pattern – Review Period: During a review of the production records from the review period (September 2022) insufficient serving sizes were discovered [meal patterns required by federal regulation 7 CFR Part 210.10 (c)]. Prior to the completion of the on-site portion of this AR, Peace Academy took corrective action for each insufficient serving size.
Non-Creditable Item was Served as Part of a Reimbursable Meal: During the menu week being assessed (breakfast and lunch menus for the week of 09/19/22 – 09/23/22), Peace Academy served pizza products that were non-creditable in the National School Lunch Program [federal regulation Appendix C of 7 CFR Part 210]. Prior to the completion of the on-site portion of this AR, Peace Academy took corrective action by replacing the non-creditable pizza products with pizza products that can be credited toward the meal patterns for the NSLP.
Nutrient Analysis: The systemic insufficient serving sizes discovered during the menu week assessment of breakfast and lunch menus for the week of 09/19/22 – 09/23/22. The nutrient analysis for the lunch menus for this week had the following findings
- For grades K-5: The weekly calorie average exceeded the meal pattern average range [as required by federal regulation 7 CFR Part 210.10 (f) (1)] by 110 calories.
- For grades K-5: The percentage of saturated fat of the weekly calorie average exceeded 10% [federal regulation 7 CFR Part 210.10 (f) (2)].
- For grades 6-8: The weekly calorie average exceeded the meal pattern average range by 131 calories.
- For grades 9-12: The weekly calorie average exceeded the meal pattern average range by 76 calories.

Prior the completion of the on-site, Peace Academy took corrective action bringing the above into compliance with the meal patterns for the National School Lunch Program (NSLP).

Resource Management – Adult Meal Charge: At the time of the off-site portion of this AR, CPA adult meal charge was insufficient to be compliant with USDA FNS Instruction 785-5 Rev. 1. Prior to the completion of the on-site portion of this AR, Peace Academy increase their adult lunch meal charge to $5.00 for each adult lunch, which is compliant with FNS Instruction 785-5 Rev. 1.

No further action is required for the above.

Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted October 6, 2022:

Local Wellness Policy: The local wellness policy provided at the time of the off-site portion of the AR, did not contain the following required areas:

Guidelines and standards for the marketing of food and beverages on campus during the school day [as required by federal regulations 7 CFR Part 210.31 (c) (3) (iii)].
Description of the manner in which the public is provided the opportunity to participate in the local wellness policy process [as required by federal regulation 7 CFR Part 210.31 (c) (5)].

Peace Academy’s local wellness policy must be updated to include the above required areas.

To demonstrate compliance with local wellness policy requirements:

Update Peace Academy’s local wellness policy to include the above required areas.
Publicly post the updated local wellness policy.
Provide a copy of Peace Academy’s updated local wellness policy along with Peace Academy’s plan for corrective action to demonstrate understanding and compliance.

Production Records: The production records for the menu week being assessed were not properly documenting how the meals produced contributed toward the meal patterns as required by federal regulations [7 CFR Part 210.10 (a) (3) an 7 CFR Part 220.8 (a) (3)].

To demonstrate compliance with production record requirements:

Provide copies of one breakfast production record and one lunch production record that properly documents how the meals produced contribute to the meal patterns.
Provide the above documents as well as Peace Academy’s plan for corrective action to demonstrate understanding and compliance.

Findings and Recommendations Identified during the On-Site Portion of the Review conducted on November 10, 2022 and November 17, 2022:

Certification and Benefit Access – Eligibility Certification: During the review of the household applications, one application was discovered have an error in the eligibility determination [7 CFR Part 245.6 (c)]. The application was determined to be eligible for reduced priced meals. It appears the wrong eligibility table was used when determining the household’s eligibility. The application should have been denied eligibility for free and reduced priced meals.

This is a performance standard 1 (PS 1) violation, which requires fiscal action, as required by federal regulation [7 CFR Part 210.18 (g) (1)].

To demonstrate compliance with eligibility certification requirements:

Inform the household in writing of their change in status, allow 10 days for a possible hearing request.
Once the 10 calendar day timeframe has past, change the benefit status from reduced priced meals to paid meals.
Provide a copy of the letter send, date the change was made, as well as Peace Academy’s corrective action plan to demonstrate understanding and compliance.

Procurement Review Summary Report

Date: 01-30-23

Name of Agency: Peace Academy Date of AR off-site review: 10-05-22

Reviewer: Matthew Smith Date of AR on-site review: 11-10-22

and 11-17-22

Persons interviewed: Shazia Malik and Date of exit conference: 01-18-23

Kim Muhammad

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):

Failure to Provide Requested Records: During this PR, Peace Academy failed to provide requested documentation despite several requests as required by federal regulation [7 CFR Part 210.9 (b) (17)] and Peace Academy’s permanent agreement with Oklahoma Human Services. Prior to the completion of the on-site portion of this AR, Peace Academy provided all the requested documentation.

No further action is required for the above.

Procurement Plan: The procurement plan provided during this PR, did not address a cost or price analysis being performed in connection with every procurement in excess of the small purchase threshold [as required by federal regulation 2 CFR Part 200.323 (a)].

To demonstrate compliance with procurement plan requirements:

Update the procurement plan to address performing a cost or price analysis in connection with every procurement in excess of the small purchase threshold.
Provide a copy of Peace Academy’s updated procurement plan along with Peace Academy’s plan for corrective action to demonstrate understanding and compliance.