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School Nutrition Programs Compliance Handbook

School Nutrition Programs Compliance Handbook

Chapter 15 - Review Process

The State Agency (SA) is required to conduct administrative reviews of SFAs a minimum of every three years.  Schools fit the criteria of high-risk for counting and claiming errors may be subject to additional reviews.  All schools will have a minimum of one administrative review within this three year review cycle. Additionally, the time period between reviews cannot exceed four years. 

The USDA requires each SFA have a Procurement Review conducted every three years to ensure the SFAs are compliant with federal procurement regulations [7 CFR Parts 210.21, 215.14(a), 220.16, 225.17, and 226.22 and 2 CFR 200.318-.326].  OKDHS School Nutrition Programs will conduct each SFA's Procurement Review at the same time as the Administrative Review for the SFA is conducted.  As with the Administrative Reviews the time periods between Procurement Reviews cannot exceed four years.

Administrative Review

The administrative review is a review of the National School Lunch Program as required by Regulation 7 CFR 210.18 in the Federal Register.  The School Nutrition Programs Unit will review each SFA to ensure compliance with the Child Nutrition Programs.  The review will consist of an administrative review of both critical and general areas important to program compliance set forth by federal legislation.  Noncompliance can result in follow-up reviews and fiscal action. 

Critical Areas of Review

The critical areas for review include two performance standards:

  • Performance Standard 1- Includes certification, counting/claiming, and verification to ensure that only free, reduced-price and paid lunches claimed for reimbursement are served only to children eligible for free, reduced price and paid lunches, counted, recorded, consolidated and reported through a system which consistently yields correct claims.
     
  • Performance Standard 2- reviews the implementation of the required meal patterns and food components to ensure that all required food items and serving sizes meet federal requirements.  

General Areas of Review
The general areas for review include, but are not limited to:

  • The school's program procedures to ensure practices are followed according to the application and policies approved by the state agency. 
  • Overt identification of free and reduced-price students do not occur.
  • Food quantities to ensure sufficiency to provide food components in the quantities required.
  • Civil rights procedures and policies to ensure the Local Education Authority is in compliance with civil rights provisions.
  • Record retention
  • Multiple site reviews
  • Edit checks to ensure accurate counting and claiming
  • Compliance with competitive food regulations.
  • Procurement procedures
  • Local Wellness Policy
  • HACCP/ Food Safety Plan and implementation
  • Health Inspections   
  • Financial Management and price equity
  • Other program requirements set forth by USDA. 

Administrative Review process

The process listed below applies to all Administrative Reviews. 

  1. State Reviewer will contact the SFA to ask pre-onsite review questions and requesting supporting documentation.  This process may be completed by telephone, fax, email or onsite.  A review of answers and documentation will guide the on-site review.  At this stage, corrective action may be cited by the reviewer and corrective action will be required.  
     
  2. Reviewer will conduct the off-site and on-site portions of the review and record all findings during the review.  Technical assistance is provided at this time.  Additional documentation and observation may be required.  An entrance and exit conference is scheduled to inform key personnel of the review process and findings.  Timelines for corrective action may be set. 
  3. State office will send a letter to the SFA with notice of findings and recommendations.  In the letter is: a deadline for completing corrective action; and recommendations for correcting all findings.  The SFA must immediately begin correcting the problems listed in the notice.
  4. SFA will submit a corrective action plan by the given deadline, using the provided format for writing a corrective action plan.  Technical assistance is available. 
  5. State Office will review the corrective action plan and approve or deny the plan. When a plan is denied, it is in pending status.  SFA will review correct all areas that were not sufficiently addressed in the first corrective action plan.  Failure to complete corrective action by the deadline may result in fiscal action and withholding of payment. 
  6. With an approved plan, the review is completed and closed until the next review. 

Procurement Review

The procurement review is conducted to ensure SFAs are in compliance with federal procurement requirements [7 CFR Parts 210.21, 215.14(a), 220.16, 225.17, and 226.22 and 2 CFR 200.318-.326].     The Procurement Review will review SFAs procurement practices and documentation of the procurement activity of the SFA being reviewed. 

PROCUREMENT REVIEW PROCESS

The process below applies to all Procurement Reviews

  1.    The State Reviewer will request copies of the SFA's written code of conduct (for procurement), the SFA's written procurement plan, a list of vendors for the previous school year, the amount the SFA spent with each vendor in the previous school year.
  1.   State Reviewer will ask the SFA questions regarding their procurement practices throughout the review.
  1.    During the On-site visit for the Administrative Review the State Reviewer will conduct a review of invoices for vendors selected for further review. 
  1.   State Reviewer will review all procurement findings as they are made during the Procurement Review.  At the time of the exit conference for both the Administrative Review and the Procurement Review the State Reviewer will review all the findings discovered during the Procurement Review, provide technical assistance and request necessary corrective actions.
  1.   State Office will send a letter to the SFA with a summary report containing findings for the review and recommendations.  Sent with the summary report is: a deadline for completing corrective action; and recommendations for correcting all findings.  The SFA must immediately begin correcting the problems listed in the notice.
  1.   SFA will submit a corrective action plan by the given deadline, using the provided format for writing a corrective action plan.  Technical assistance is available. 

     
  2.   State Office will review the corrective action plan and approve or deny the plan. When a plan is denied, it is in pending status.  SFA will review correct all areas that were not sufficiently addressed in the first corrective action plan.  Failure to complete corrective action by the deadline may result in fiscal action and withholding of payment. 

     
  1.   With an approved plan, the review is completed and closed until the next review.

Corrective Action Plan

When SFAs are found noncompliant, SFAs must conduct corrective action within the timeframe required by the State Agency.  Corrective action consists of implementing steps and requirements required by the USDA Child Nutrition Programs to participate in the program. 

Writing a Corrective Action Plan

The school/RCCI is required to take corrective action and submit a written corrective action plan (CAP) for all findings listed in the State Agency's Corrective Action memo.  Agencies are required to submit their plans and supporting documentation no later than the deadline provided in the memo.  The CAP purpose is to demonstrate that the school has knowledge and understanding of USDA requirements.  Failure to complete the CAP by the State Agency deadline may result in withholding of funds until actions are complete. 

SFAs are required to use the SA provided corrective action form.  The form will be sent with the summary reports.  The form provides the following areas required for a corrective action plan:

  1.   Issue—a short summary of the finding
  2.   Requirement—a brief description of the requirement
  3.   Action—in this section of the plan the SFA states the action taken to resolve the issue and avoid future problems.
  4.  Documentation—a list of documentation to verify the action was implemented.
  5.  Responsible personnel—the personnel responsible for implementation of the corrective action (name and title).
  6.  Date of completion—the date corrective action was completed.

Plans should be written in the following format:

  1. Issue-  restate or summarize the finding from the Coordinated Review
  1. Requirement- write a brief summary demonstrating understanding of program requirements. 
  1. Action- state the actions taken to resolve the finding and how these actions will resolve future problems (examples:  Weekend or backup staff will be trained on procedures to ensure consistency; a meal roster will be used at the point of service to capture actual counts; or production records will be completed daily to demonstrate actual meal preparation )
  1. Documentation- submit documentation to verify the action was implemented.  Submit revised or corrected forms, production records, product labels, policies that demonstrate implementation, meal rosters, or any other forms demonstrating corrections.
  1. Responsible personnel- list the person(s) responsible for the implementation of corrected action (name and title).
  1. Date of Completion- list the date the agency corrected the problem.  If the school cannot correct the finding by the deadline given in the Corrective Action Memo, the agency must complete the written portion of the corrective action plan, indicate what actions have been taken to initiate corrective action and the date of anticipated completion.  The agency must seek technical assistance with the State Agency prior to the deadline and provide documentation that actions have been initiated.   
  1. Signature and date of School Food Official (this is the director, principal, or person who oversees the Agency, also known as school food official) 

Extensions: When extraordinary circumstances occur, schools may request extensions for findings not corrected in the CAP by the required deadline. The school must request an extension in writing and demonstrate that actions were initiated.  The request must include the reason(s) why the agency cannot meet the deadline, and must provide an anticipated date for correcting the finding(s).  Only findings that are not completed due to extraordinary circumstances are reviewed for extensions.  The State Agency will determine if circumstances are extraordinary.  Findings that can be reasonably corrected prior to the deadline must be completed.  The extension must be submitted with the corrected action plan for all other findings by the required deadline. 

Penalty or withholding: 

For critical area findings:  if an agency has findings during the review that resulted in the performance standard (PS) violations exceeding the  PS threshold and the agency fails to complete corrective action by the CAP deadline, the State Agency will withhold payment until corrective action is taken. 

For general findings:  if an agency fails to submit a corrective action plan by the deadline, fails to implement corrective action for findings listed in the CAP, or fails to demonstrate the agency is making a good faith effort to correct the findings, OKDHS may withhold reimbursement claims until corrective action is approved and verified by OKDHS.  To prevent withholding of payments for findings in the general area,

Mail the plan to:   School Nutrition Programs

                                  P.O. Box 25352

                                  OKC, OK 73125-0352

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Oklahoma Department of Human Services 

2400 N Lincoln Boulevard

Oklahoma City, Ok  73105