School Nutrition Programs Compliance Handbook
CHAPTER 15- REVIEW PROCESS
The State Agency (OKDHS School Nutrition Programs) is required to conduct an Administrative Review (AR) for every School Food Authority (SFA) participating in the National School Lunch Program (NSLP), the School Breakfast Program (SBP), and the Afterschool Snack Program. ARs are conducted to ensure SFAs are compliant with federal requirements for these programs.
The USDA also requires each SFA to have a Procurement Review (PR). The PR for each SFA is conducted at the same time as the SFA’s AR. The purpose of the PR is to ensure the SFA’s compliance 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 is operating under a waiver from the USDA (approved on June 29, 2023) that extended the three-year review cycle (2022 – 2024) to a five-year cycle (2022 – 2027). If a SFA fits the criteria of high-risk for counting and claiming errors may be subject to additional reviews. All SFAs will have a minimum of one AR and PR within this five-year review cycle.
Administrative Review (AR)
The AR is a review of the National School Lunch Program (NSLP) as required by federal regulation [7 CFR 210.18]. OKDHS School Nutrition Programs (SNP) will review each SFA to ensure compliance with the federal requirements for USDA Child Nutrition Programs. The review will consist of a review of both critical areas (see table 1.1) and general areas (see table 1.2) important to program compliance set forth by federal legislation. Noncompliance can result in follow-up reviews and possibly fiscal action.
Table 1.1: Administrative Review (AR) – Critical Areas |
· Performance Standard 1 – Includes certification, counting/claiming procedures, and verification to ensure that only free, reduced-price, and paid meals are claimed for reimbursement for eligible children. · Performance Standard 2 – Reviews the implementation of the required meal patterns and food components to ensure all required food items and serving sizes meet federal requirements. |
Table 1.2: Administrative Review (AR) – General Areas of Review |
· The School Food Authority’s (SFA) program procedures to ensure practices are followed according to the application and policies approved by the state agency (OKDHS). · Overt identification of free and reduced-price students does not occur. · Food quantities to ensure sufficiency to provide food components in the quantities required. · Civil rights procedures and policies to ensure the SFA is compliant with civil rights provisions. · Record retention · Multi-site reviews · Local wellness policy · HACCP/Food safety plan and implementation · Health inspections · Edit checks and counting and claiming · Compliance with competitive food regulations · Compliance with the Buy American Provision · Financial management and price equity · The School Breakfast Program (SBP) – For those SFAs participation in the SBP. · The Afterschool Snack Program – For those SFAs participation in this program. · Other program requirements set forth by the USDA. |
Scheduling the Administrative Review (AR) and Procurement Review (PR)
At least 30 days prior to when OKDHS School Nutrition Programs wants to open an AR and PR for a School Food Authority (SFA), the State Reviewer will contact the SFA to schedule the AR and PR. The State Reviewer will also schedule the pre-AR and PR technical assistance visit.
Pre-Administrative Review (AR) and Procurement Review (PR) Technical Assistance Visit
Due to the complexity of the AR and PR, OKDHS School Nutrition Programs requires a pre-AR and PR technical assistance visit for all School Food Authorities (SFA) due to be reviewed. The purpose of the visit is to review the process for both reviews. During this visit the State Reviewer will go over the documentation requested in the confirmation letter for the reviews to provide clarification on the items requested, as well as to answer all the SFA’s questions. This visit will be scheduled when the AR and PR are scheduled to occur prior to the AR and PR being opened.
Administrative Review (AR) process
OKDHS School Nutrition Programs is required by the USDA to conduct an Administrative Review (AR) for all School Food Authorities (SFA). The AR reviews SFAs compliance with USDA requirements for the programs listed in table 2.
Table 2: Programs Subject to the Administrative Review (AR) |
· National School Lunch Program (NSLP) · School Breakfast Program (SBP) · Afterschool Snack Program · Special Milk Program (SMP) · NSLP Seamless Summer Option (SSO) Program |
The AR covers the critical areas contained in table 1.1, as well as the general areas contained in table 1.2, this section will discuss the process for the AR.
The AR has three phases starting with the off-site portion where the AR is opened. The off-site portion of the AR begins with the off-site visit. During this visit the State Agency (SA) Reviewer will gather documentation requested in the confirmation letter for the AR, fill out USDA AR forms, and work on USDA assessments for the AR during the site visit. The SA Reviewer will then take the documentation and complete the assessments for the off-site portion of the AR prior to the second phase of the AR.
The second phase of the AR, is the on-site portion of the AR. During the on-site portion of the AR, specifically the on-site visit(s), the SA Reviewer observes the SFA’s school food services program in operation by observing meal preparation and meal service for breakfast (if the SFA participates in the SBP) and lunch for compliance with federal requirements.
During the on-site portion of the AR, for those SFAs taking household applications, the application process and verification process for the school year are reviewed for compliance with federal requirements for the critical areas for the AR (see table 1.1) and the general areas of the AR (see table 1.2).
As part of the on-site portion of the AR, the SFA’s counting and claiming system reviewed for compliance with federal requirements by reviewing at least one month’s reimbursement claim.
The on-site exit conference will be conducted when the State Agency (SA) Reviewer has completed the on-site portion of the AR. During this meeting the SA reviewer will go over the findings for the AR as well as the findings for the Procurement Review (PR). The on-site exit conference officially concludes the second phase of the AR.
The third phase of the AR is the AR summary report and corrective action plan phase. Within 30 days of the AR on-site exit conference, OKDHS School Nutrition Programs (SNP) will issue the AR summary report by email.
The email containing the AR summary report will also contain the corrective action plan form (if a formal corrective action plan form is required). OKDHS SNP requires the corrective action plan form to be used to document the formal corrective actions taken requiring a corrective action plan. The AR summary report will contain the date the SFA must submit the completed corrective action plan with supporting documentation (if required by the AR summary report) to OKDHS SNP by email.
OKDHS SNP has 30 days from the receipt of the completed corrective action plan from the SFA to conduct the review process of the plan. If the corrective action plan is approved by OKDHS School Nutrition Program, then a closure letter will be issued by email officially closing the AR.
If a SFA’s AR corrective action plan is not approved, then a follow-up AR summary report will be issued for all areas where the corrective actions taken were not satisfactory to OKDHS SNP. The follow-up AR summary report will be issued with email with a follow-up corrective action plan form. The cover letter for the follow-up AR summary report will contain the date the SFA must submit the completed follow-up corrective action plan with supporting documentation (if required by the follow-up AR summary report). OKDHS SNP will review the completed AR follow-up corrective action plan. If the follow-up AR corrective action plan is approved, then OKDHS SNP will issue a closure letter officially closing the AR. If the follow-up AR corrective action plan is not approved, then the follow-up process will be conducted for those corrective actions that were not satisfactory.
For SFAs operating the NSLP Seamless Summer Option (SSO) program, the AR includes a review is required during the operation of the program. The SSO review is a part of the AR and will be conducted either the summer before the AR or the summer after the review. OKDHS School Nutrition Programs (SNP) will conduct a technical assistance visit prior to the opening of the SSO portion of the AR to go over the process with SFAs being reviewed.
PROCUREMENT REVIEW
OKDHS School Nutrition Programs (SNP) is required by the USDA to conduct a Procurement Review (PR) for all SFAs participating in:
Table 3: Programs Subject to the Procurement Review (PR) |
· National School Lunch Program (NSLP) · School Breakfast Program (SBP) · Afterschool Snack Program · Special Milk Program (SMP) |
The PR is conducted to ensure School Food Authorities (SFA) compliant 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 PR will review SFAs procurement practices and documentation of the procurement activity of the SFA being reviewed.
The PR is conducted at the same time as the Administrative Review (AR) is conducted for each SFA. Throughout the AR, the State Reviewer works on completing the PR. The results of the PR are gone over with each SFA during their AR on-site exit conference.
OKDHS SNP will issue the PR summary report with the AR summary report by email. The PR summary report will contain the findings for the PR. If the findings require a formal corrective action plan, then the email containing the PR summary report will contain the PR corrective action plan form. OKDHS SNP requires the PR corrective action plan form be used to document the corrective actions for findings requiring a formal corrective action plan. The cover letter for the PR will contain the date of the PR corrective action plan and supporting documentation (if required by the PR summary report).
If the PR summary report does not require a formal corrective action plan, then OKDHS School Nutrition Programs will issue a formal closure letter for the PR.
For reviews requiring a formal corrective action plan, OKDHS School Nutrition Programs (SNP) has 30 days to review the plan and supporting documentation (if required by the PR summary report). If the PR corrective action plan is approved by OKDHS SNP, then a closure letter will be issued by email officially closing the PR.
If a SFA’s PR corrective action plan is not approved, then a follow-up PR summary report will be issued for all areas where the corrective actions taken were not satisfactory to OKDHS School Nutrition Programs. The follow-up PR summary report will be issued with email with a follow-up PR corrective action plan form. The cover letter for the follow-up corrective action PR summary report will contain the date the SFA must submit the completed follow-up corrective action plan with supporting documentation (if required by the follow-up PR summary report). OKDHS SNP will review the completed PR follow-up corrective action plan. If the PR follow-up corrective action plan is approved, then OKDHS School Nutrition Programs (SNP) will issue a closure letter officially closing the PR. If the follow-up PR corrective action plan is not approved, then the follow-up process will be conducted for those corrective actions that were not satisfactory.
Writing a Corrective Action Plan
School Food Authorities (SFA) are required to take corrective action and submit a written corrective action plan for findings in the state agency’s (OKDHS School Nutrition Programs) summary reports for both the Administrative Review (AR) and Procurement Review (PR) requiring a formal corrective action plan. The purpose of corrective action plans is to demonstrate the SFA has knowledge and understanding of USDA requirements. Failure to complete corrective action plans by the deadline set by the state agency, OKDHS School Nutrition Programs (SNP), may result in withholding funds from reimbursement claims until a satisfactory complete corrective action plan is submitted.
OKDHS SNP requires the corrective action plan to be documented on a corrective action plan form provided by email with the summary reports for the AR and PR (each review will have a separate form). The corrective action plan forms contain the required areas for corrective action plans for each finding for an AR and PR (see table 4).
Table 4: Required Areas for Corrective Action Plans |
· The issue (finding) – A short summary of the finding · Requirement – A brief description of the program requirement · Action – This section of the plan is where the SFA states the action taken to resolve the issue and to avoid the issue in the future. · Documentation – A list of documentation to verify the action was implemented (if required by the summary report). · Responsible Personnel – The personnel responsible for the corrective action (name and title). · Date of Completion – The date corrective action for the issue was completed. |
Corrective Action Plan Extensions
When extraordinary circumstances occur, School Food Authorities (SFA) may request extensions for findings not corrected in corrective action plans by the required deadline. The SFA must request an extension in writing and demonstrate that actions were initiated. The request must include the reason(s) why the SFA 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. OKDHS School Nutrition Programs 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 documented in the summary reports cover letter.
Fiscal Action and, or withholding:
For critical area findings
If a School Food Authority (SFA) has findings during the review that resulted in the performance standard (PS) violations exceeding the PS threshold of $600 per program per federal fiscal year (October 1st through September 30th) payment of the fiscal action will be required. If the SFA fails to complete corrective action by the corrective action plan deadline, OKDHS School Nutrition Programs will be forced to withhold reimbursement claim payments until corrective action is taken [as required by federal regulation 7 CFR Part 210.18 (k) (1) (i) and (iv)].
For general findings and Procurement Review findings
If a SFA fails to submit a corrective action plan by the deadline, fails to implement corrective action for findings listed in the corrective action plan(s), or fails to demonstrate the SFA is making a good faith effort to correct the findings, OKDHS School Nutrition Programs may withhold payment of reimbursement claims until corrective action is approved and has been verified by OKDHS School Nutrition Programs [as required by federal regulation 7 CFR Part 210.18 (k)]. To prevent the withholding of payments for findings in the general area, be sure to email your corrective action plan to your SA Reviewer by the due date contained in the summary reports cover letter.
Chapter 15 Resource List
The resources listed in table 5.1 are available upon request to Oklahoma Human Services School Nutrition Programs by email at AFS.School.Nutrition.Programs@okdhs.org.
Table 5.1: Chapter 15 Resources |
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OKDHS School Nutrition Programs Training Documents and Forms Handout book for the current school year (electronic version available upon request). |
Common Administrative Review (AR) and Procurement Review (PR) handout. |
The resources listed below in table 5.2 are available online.
Table 5.2: Chapter 15 Online Resources |
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USDA National School Lunch Program (NSLP) Program Operator webpage: |
USDA School Breakfast Program (SBP) Program Operator webpage: |
USDA Afterschool Snack Program webpage: |
OKDHS School Nutrition Programs Resources and Related Information webpage: |
