Administrative Review Summary Report

Date: 01-15-26

Name of Agency: Murrow Indian Children’s Home                      Date of off-site review: 08-07-25

Reviewer: Matthew Smith                                                               Date of on-site review: 09-18-2

                                                                                                and 10-17-25

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

Persons interviewed: Dawn Hibbard and                                    Date of exit conference: 01-09-26

                                   Margret Anderson

Programs Operated by the School Food Authority (SFA): This SFA operates the National School Lunch Program, the School Breakfast Program, and the After School Snack Program.

The following areas were corrected prior to the On-Site Portion of this Administrative Review (AR):

·       Afterschool Snack Program – First Self-Monitoring Inspection: Murrow Indian Children’s Home (MICH) failed to conduct the first self-monitoring inspection within the first four weeks of school starting for the school year as required by federal regulation [7 CFR Part 210.9 (c) (9)].  Prior to the completion of the on-site portion of this AR, MICH took corrective action by completing the first self-Monitoring inspection.

·       Failure to Provide Request Records: During the off-site portion of this AR, Murrow Inian Children’s Home failed to provide records to Oklahoma Human Services (OKDHS) School Nutrition Programs (SNP) as required by federal regulation [7 CFR Part 210.9 (b) (17)] and their permanent agreement with OKDHS.  Prior to the completion of the on-site portion of this AR, MICH provided OKDHS SNP with the records requested.

·       HACCP Food Safety Plan: During the on-site visit conducted on 10/17/25, the SFA was unable to locate their HACCP food safety plan.  Federal regulation [7 CFR Part 210.13 (c)] requires School Food Authorities (SFA) to have a HACCP food safety plan.  Prior to the completion of the on-site portion of this AR, MICH adopted a HACCP food safety plan compliant with federal regulation [7 CFR Part 210.13 (c)].

·       Meal Patterns: For the menu week of breakfast and lunch menus assessed non-systemic insufficient serving sizes were discovered [in violation of federal regulations 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, MICH took corrective actions bringing the non-systemic insufficient serving sizes into compliance.

·       Non-Creditable Items Served as Part of Reimbursable Meals: During the menu week assessment of lunch menus non-creditable food items were served as part of reimbursable lunch meals in violation of federal regulation [Appendix C of 7 Part 210].  Prior to the completion of the on-site portion of this AR, MICH took corrective actions replacing the non-creditable food items with creditable food items.

·       Professional Standards – Eight Hour Food Safety Training: At the time of the off-site visit, the school food services director had not completed eight hours of food safety training five years prior to starting in the position, or within 30 days from the date the director started in the position.  Prior to the completion of the on-site portion of this AR, the director completed eight hours of food safety training.

·       Whole Grain-Rich (WGR) – Percentage of Weekly Serving Under 80%: For the menu week of breakfast menus assessed the percentage of the weekly serving of the weekly grain serving at breakfast was below 80% in violation of federal regulation [7 CFR Part 220.8 (c) (2) (ii)].  The percentage of the weekly bread/gran serving for the lunch menus was below 80% in violation of federal regulation [7 CFR Part 210.10 (c) (2) (iii) (A) and (D)].  Prior to the completion of the on-site portion of the AR, MICH took corrective actions bringing the percentages of the weekly servings that were WGR for breakfast and lunch over 80%.

No further action is required for the above. 

 

Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted August 7, 2025:

Local Wellness Policy: The local wellness policy for Murrow Indian Children’s Home (MICH) provided during the off-site portion of this AR did not contain the following required areas:

• Did not have a specific goal area for the goals for nutrition education [as required by federal regulation 7 CFR Part 210.31 (c) (3)].
• Guidelines and standards for the following:
  • Fundraisers involving food and beverages sold for consumption on campus during the school day [as required by federal regulation 7 CFR Part 210.31 (c) (3)].

MICH’s local wellness policy must be updated to include the above required mentioned areas.

To demonstrate compliance with local wellness policy requirements:

• Provide a copy of the updated local wellness policy compliant with federal requirements.
• Replace the local wellness policy posted on the bulletin board at MICH’s site with the updated local wellness policy.
• Provide a copy of the updated local wellness policy along with MICH’s plan for corrective action to demonstrate understanding and compliance.

Production Records: The production records submitted as part of the menu week assessment were not being filled out correctly.  Federal regulations [7 CFR Part 210.10 (a) (3) and 7 CFR {art 220.8 (a) ) (3)] required as part of a reimbursable meal.  The issues discovered with the production records include:

·       Leftovers not being documented on the production records

·       Two serving sizes were listed on one line.

·       Condiments served were not listed on the records

·       The choices of milk types being offered were not documented on the production records.

To demonstrate compliance with production record requirements:

·       Provide a copy of one complete breakfast production record.

·       Provide a copy of one complete lunch production record.

·       Provide the above documentation along with MICH’s plan for correction action to demonstrate understanding and compliance.

Professional Standards – Annual Training Requirements: During the off-site portion of this AR, compliance with the annual training hour requirements for school year 2024 – 2025 was reviewed.  The school food services director failed to complete at least 12 hours of training crediting toward the annual training requirements during school year 2024 – 2025 as required by federal regulation [7 CFR Part 210.30 (c)].

Two employees with part-time duties failed to complete at least four hours of training crediting toward the annual training requirements during school year 2024 – 2025, as required by federal regulation [7 CFR Part 210.30 (e)].

To demonstrate compliance with annual training requirements:

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

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted September 18, 2026, and October 17, 2025:

Count and Claiming: During this AR, OKDHS School Nutrition Programs (SNP) is required to review one month’s reimbursement claim.  For this review, July 2025 reimbursement claim was reviewed for the National School Lunch Program (NSLP) and the School Breakfast Program (SBP).  October 2025 is the review period for the Afterschool Snack Programs.  Errors were only discovered in the review for the Afterschool Snack Program for the month of August 2025.  These errors caused an over claim of eight snacks. 

Federal regulation [7 CFR Part 210.8 (a) (2)] requires School Food Authorities (SFA) to review their claims prior to submitting them to 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.

·       Provide copies of the following: snack meal rosters for January 2026 and the edit checks for snack for January 2026.

·       Provide the above documentation above along with MICH’ plan for corrective action to demonstrate understanding and compliance.

Edit Checks: During the on-site portion of this AR, it was discovered MICH was not completing daily edit checks for their participation in the National School Lunch Program (NSLP) and the School Breakfast Program (SBP).  Federal regulations [7 CFR 210.8 (a) (3) and 7 CFR Part 220.11 (d)] require daily edit checks to be completed for each program School Food Authority (SFA) participates in (NSLP, SBP, and the Afterschool Snack Program).

To demonstrate compliance with edit check requirements:

·       Provide January 2026’s edit check for the snack.

·       Provide the above documentation along with MICH’s plan for corrective action to demonstrate understanding and compliance.

 

Procurement Review Summary Report

Date: 01-15-26

Name of Agency: Murrow Indian Children’s Home                      Date of AR off-site review: 08-07-25

Reviewer: Matthew Smith                                                              Date of AR on-site review: 09-18-25

                                                                                                and 10-17-25

Persons interviewed: Dawn Hibbard and                                                Date of exit conference: 01-09-26

                                    Margret Anderson

Programs Operated by the School Food Authority (SFA): This SFA operates the National School Lunch Program, the School Breakfast Program, and the After School Snack Program.

 

The following areas were corrected during the Procurement Review (PR):

·       Procurement Plan: At the time of the PR was commenced, the procurement plan did not address the use of the micro-purchase method of procurement.  Federal regulation [2 CFR Part 200.318 (a)] requires School Food Authorities to document procurement procedures for procurement activities using funds from the Nonprofit School Food Services Account (NSFSA).  Prior to the completion of the on-site portion of the Administration Review, Murrow Indian Children’s Home took corrective action by adopting an amendment for their procurement plan addressing the micro-purchase method of procurement.

No further action is required for the above.

 

Findings for the Procurement Review (PR)

There were no additional findings for the PR.

Job Category*	Annual Requirements
Directors	12 hours
Managers	10 hours
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 1^st to June 30).  

OKDHS School Nutrition Programs recommends tracking training on an approved training tracking tool.  MICH began tracking training using a training tacking tool provided by OKDHS School Nutrition Programs during this AR.

Trainings that can be credited toward the professional standards annual training requirements include [7 CFR Part 210.30 (b) (3), 7 CFR Part 210.30 (c), and 7 CFR Part 210.30 (d)]:

• Meal counting and the reimbursement claim procedures
• Identification of reimbursable meals at the point of service
• Annual civil rights training
• Nutrition
• Health and safety standards

To demonstrate compliance with professional standard requirements:

• Provided documentation of the director’s completion of eight hours of food safety training.
• Provide the above along with MICH’s plan for corrective action to demonstrate understanding and compliance.

Professional Standards – Eight Hour Food Safety Training:  MICH’s new school food services director did not complete eight hours of food safety within 30 days of starting in the position or within five years of starting in the position as required by federal regulation [7 CFR Part 210.30 (b) (1) (v)].  MICH was provided with information by email (on 06/08/21, and 08/23/21) on an online eight hour food safety training offered for free through the Institute of Child Nutrition’s (ICN) iLearn app. 

To demonstrate compliance with professional standard requirements:

• Have the school food services director complete eight hours of food safety training.
• Provided documentation of the director’s completion of eight hours of food safety training.
• Provide the above along with MICH’s plan for corrective action to demonstrate understanding and compliance.

Whole Grain-Rich (WGR) Bread/Grain: For the reviewed menu week of June 14 through 20, 2021; your agency did not meet the 100% Whole Grain-Rich (WGR) requirement for bread/grain products served at breakfast and lunch, 7 CFR Part 220.8 (c) (2) (iv) and 7 CFR Part 210.10 (c) (2) (iv).   The percentage for meeting the whole grain rich requirement for breakfast was 19%.  The percentage for the meeting the whole grain rich requirement for lunch was 39.4%.  Your agency has opted into the COVID-19 meal pattern flexibility waiver permitting at least half of the weekly serving being met by WGR items [as permitted by USDA Memo COVID-19: Child Nutrition Response #90].

The following items were determined not to be WGR:

• For Breakfast Menus:
  • The pancake mix used to make the pancakes served with the menu on 06/14/21.
  • The bread used to make the toast with the menus served on 06/15/21, 06/16/21, and 06/18/21.
  • The French toast served with the menu for 06/19/21.
  • The bread for the sandwiches served with the menu for 06/20/21.
• For Lunch  Menus:
  • The macaroni and cheese served with the menu for 06/15/21.
  • The bread sticks served with the menu on 06/16/21.
  • The rolls served with the menu for 06/17/21.
  • The bread served with the menu for 06/18/21.       

The percentage of the weekly servings met with WGR items must be brought up to 50% for both breakfast and lunch to be in compliance with the COVID-19 nationwide waiver your agency opted into.

In order for an item to be WGR it must contain 50% whole grains by weight. The easiest way to tell is to look at the ingredients on the label. If the first ingredient is a Whole Wheat Flour or a Whole Grain, you’re good. If a Whole Grain product is not listed first, you need to choose a different product that lists the correct grain first. The key is the word Whole.

To demonstrate compliance with Whole Grain Rich Bread/Grain Requirements:

• Evaluate your products to determine if they meet the whole grain rich requirement. Replace any products you determine don’t meet the WGR requirement.  
• Provide a copy of your corrective action plan to demonstrate understanding and compliance.

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted August 26, 2021 and October 1, 2021:

Counting and Claiming: A review of the counting system demonstrates systemic counting and claiming errors for the review period (January 2017), which results in a Performance Standard

Violation I (PSI), 7 CFR Part 210.18 (g) (1) (ii).  The error was systemic in nature and was found for breakfast, lunch, and snack monthly counts. 

The errors resulted from the manual consolidation of the daily meal counts into the monthly meal counts.  The monthly meal counts were not calculated correctly, which caused the meals to be under claimed for breakfast, lunch, and snack. 

Below are the differences, our reviewer identified, in your June Lunch counts, when comparing the meal roster to the meals listed on your agency’s claim:

	MICH	OKDHS SNP	Diff.
Free	195	217	-22

Free lunch meals were under claimed by 22 meals.

Below are the differences, our reviewer identified, in your June breakfast counts, when comparing the meal roster to the meals listed on your agency’s claim:

	MICH	OKDHS SNP	Diff.
Free	308	382	-74

	MICH	OKDHS SNP	Diff.
Free	219	236	17