Administrative Review Summary Report

Administrative Review Summary Report

Date:  04-08-24

Name of Agency:  Bishop John Carroll School                  Date of off-site review: 01-18-24

Reviewer:  Matthew Smith                                              Date of on-site review: 02-27-24

Fiscal Action: Yes, fiscal action amount will be assessed in the fiscal action and closure letter.                 

Persons interviewed:  Margret Otto                               Date of exit conference: 04-03-24

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)

·       Buy American Provision:  During the assessment of lunch menus for the week of 12/04/23 – 12/08/23, a nondomestic fruit product was discovered in violation of the Buy American Provision and federal regulation [7 CFR Part 210.21 (d)].  Prior to the completion of the off-site portion of this AR, Bishop John Carroll School (BJCS) replaced the nondomestic product with domestically produced peaches served earlier in the week assessed.

·       Meal Pattern:  During the menu week assessment of lunch menus conducted a non-systemic insufficient serving size was discovered [7 CFR Part 210.10 (c)].  Prior to the completion of this AR, the BJCS took corrective action bringing the serving size into compliance with the meal pattern.

No further action is required for the above. 

Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted January 18, 2024:

Civil Rights – Nondiscrimination Statement:  During the off-site portion of this Administrative Review (AR) it was discovered the full nondiscrimination statement was not posted on BCS’s school nutrition program website.  USDA FNS Instruction 113-1 requires the full non-discrimination statement to be posted on a program operator’s USDA program related websites.

To demonstrate compliance with nondiscrimination statement posting requirements:

·       Post the full nondiscrimination statement on BJCS’ website.

·       Provide BJCS’ plan for corrective action to demonstrate understanding and compliance.

 

Civil Rights – Public Release:  During the off-site portion of this AR, BJCS failed to provide documentation demonstrating the completion of the public release process for school year 2023 – 2024 [as required by USDA FNS Instruction 113-1].  Federal regulation [7 CFR Part 210.15 (b)] requires documentation of the public release process to be retained for at least three school years after the last reimbursement for the school year has been received.

To demonstrate compliance with civil rights public release requirements:

·       Provide BJCS’ plan for corrective action to demonstrate understanding and compliance.

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

• Goals for nutrition promotion [as required by federal regulation 7 CFR Part 210.31 (c) (1)].
• Goals for other school-based activities to promote student wellness [as required by federal regulation 7 CFR Part 210.31 (c) (1)].
• A 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 710.31 (c) (5)].
• Guidelines and standards for the following:
  • Non-program food and beverages [as required by federal regulation 7 CFR Part 210.31 (c) (3)].
  • Other food and beverages served (not sold) on campus during the school day [as required by 7 CFR Part 210.31 (c) (2)].

BJCS’ local wellness policy provided at the time of the off-site portion of the AR had not been assessed in over three years.  Federal regulation [7 CFR Part 210.31 (e) (2)] require local wellness policies to be assessed at least once every three years.

To demonstrate compliance with local wellness policy requirements:

• Conduct the local wellness policy assessment process.
• Provide a copy of the updated local wellness policy (compliant with federal requirements for local wellness policies) and documentation of the assessment of the policy (triennial wellness assessment report).
• Post the updated local wellness policy and documentation of the most recent assessment to the policy on BJCS’ website.
• Provide the above documentation along with BJCS’ plan for corrective action to demonstrate understanding and compliance.

Professional Standards – Annual Training Hours:  Records and documentation of training completed during school year 2022 – 2023, showed employees with duties within the school food services program failed to complete the required annual training hours. 

BJCS school food services director only completed six creditable training hours during school year 2022 - 2023.  Federal regulation [7 CFR Part 210.30 (b) (3)] requires school food services directors to complete at least 12 hours of annual training.

BJCS’ employee with part-time duties in the school food services program did not complete any creditable annual training hours.  Federal regulation [7 CFR Part 210.30 (d)] requires employees with part-time duties in school food services programs to complete at least four hours of annual training.

To demonstrate compliance with professional standard requirements:

• Provide BJCS’ plan for corrective action demonstrating understanding and compliance.

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted February 27, 2024:

Civil Rights – Notification Letters:  During the on-site visit it was discovered the following notification letters did not contain the full nondiscrimination statement as required by USDA FNS Instruction 113-1:

·       Notification of eligibility determination letters

·       Notification of direct certification

·       Notification of verification outcome letter

BJCS was sending just the first page of their template letter that only contained part of the full nondiscrimination statement.

To demonstrate compliance with notification letter requirements:

·       Provide BJCS’ plan for corrective action demonstrating understanding and compliance.

Counting and Claiming:  A review of the counting and claiming system demonstrates non-systemic claiming errors for the review period (December), which are a Performance Standard I (PSI) Violation [per federal regulation 7 CFR Part 210.18 (g) (1) (ii)] requiring fiscal action. 

The errors appeared to be due to data entry errors occurring when the meal counts were entered into BJCS’ electronic system to consolidate the daily meal counts into the monthly meal counts and to conduct the daily edit checks.

Below are the differences Oklahoma Human Services School Nutrition Programs (OKHS SNP) has identified in Bishop John Carroll School (BJCS) lunch meal counts claimed for December:

	OKHS SNP Count	BJCS Edit Check	BJCS Claim	Difference
Free	154	151	151	-3
Reduced	96	96	96	0
Paid	1464	1469	1469	5

Free lunches meals were under claimed by 3 meals.  Paid lunch meals were over claimed by five 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 March 2024 for breakfast and lunch, as well as the edit check for lunch for March 2024.
• Provide the above along with BJCS’ plan for corrective action to demonstrate compliance and understanding.

Direct Certification – Household Notification:  During the review of the direct certification documentation for school year 2023 – 2024, the reviewer discovered BJCS did not retain documentation of approval notification for one household as required by federal regulation [7 CFR Part 245.6 (b) (10)].   Federal regulation [7 CFR Part 245.6 (e)] requires SFAs to retain documentation of the eligibility determination and direct certification processes including copies of the notification to households for three years after the last reimbursement claim has been received for the school year.

To demonstrate compliance with household notification requirements:

·       Provide BJCS’ plan for corrective action to demonstrate compliance and understanding.

Reviewer’s Comments:  The findings contained in this report in no way reflects on the good work being done in BJCS’ school food services program.  I would like to take the opportunity to commend BJCS’ employees with duties within BJCS’ school food services program for all the hard work they do daily.  Keep up the good work.

Procurement Review Summary Report

Date:  04-08-24

Name of Agency:  Bishop John Carroll School                  Date of AR off-site review: 01-18-24

Reviewer:  Matthew Smith                                                Date of AR on-site review: 02-27-24

Persons interviewed:  Margret Otto                               Date of exit conference: 04-03-24

Programs Operated by the School Food Authority (SFA):  This SFA operates the National School Lunch Program.

Findings for the Procurement Review (PR)

Procurement Plan:  Bishop John Carroll School’s (BJCS) procurement plan does not address the use of the micro-purchase method of procurement.  Federal regulation [2 CFR Part 200.318 (a)] requires SFAs to have documented procurement procedures consistent with state laws and federal regulations.  BJCS’ procurement plan will have to be updated or amended to document the procedures for the use of the micro-purchase method of procurement.

To demonstrate compliance with procurement plan requirements:

·       Update or amend BJCS’ procurement plan to document the procedures for the use of the micro-purchase method of procurement.

·       Provide the updated procurement plan or amendment to the procurement plan along with BJCS’ plan for corrective action demonstrating understanding and compliance.

The free meals were over claimed by two meals, the reduced priced meals were over claimed by four meals, and the paid meals were under claimed by one meal.

Below are the differences identified in SPCS’s September school breakfast counts when reviewing the meal roster and edit check for September:

Free meals were over claimed by one meal and reduced priced meals were under claimed by one meal.

7 CFR Part 210.8 (a) (2) requires each SFA to review their claims for accuracy prior to submitting them to the SA.

To demonstrate compliance with counting and claiming:

· Review the counting and claiming system and create a plan to insure accurate daily meal counts are taken and recorded.

· Provide copies of the following: SPCS’ meal rosters for October 2020, SPCS’ edit check forms, and the claim for October 2020.

· Provide the above copies, along with your corrective action plan to demonstrate understanding and compliance.

Reviewer’s Comments: I want to commend your school on a job well done with this review. Your school is doing a good job with its participation in the National School Lunch Program and the School Breakfast Program.

Procurement Review Summary Report

Date: 11-18-20

Name of Agency: Saint Paul’s Community School, Inc.
                                                                      Date of AR off-site review: 02-18-20

Reviewer: Matthew Smith                            Date of AR on-site review: 10-08-20

Persons interviewed: Joanna Beasley and Date of exit conference: 11-13-20
                                    Araceli Davila

This School Food Authority (SFA) operates the National School Lunch Program and the School Breakfast Program.

There were no findings for the procurement review of Saint Paul’s Community School, Inc.