Illinois State Board of Education

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1 Illinois State Board of Education 100 North First Street Springfield, Illinois James T. Meeks Chairman Tony Smith, Ph.D. State Superintendent of Education June 23, 2017 Brad Black Archdiocese of Chicago 5343 West Roscoe Street Chicago, Illinois Agreement No P-00 Dear Mr. Black: Enclosed is the report of the School Nutrition Programs administrative review conducted on March 13 through 17, 20 through 22, and 24, The report identifies the problems cited during the review and the corrective action recommended. A corrective action plan to the review report must be received in our office by July 24, This response must detail the specific actions taken to correct any problems cited and must be signed by the appropriate school official. Technical assistance materials and/or training opportunities may be available to assist in correcting problems identified in the review. The cooperation of personnel during the visit was appreciated. If you have questions regarding your review, please contact Matthew Whitaker at mwhitake@isbe.net. For all other program questions, please contact our office at 800/ Sincerely, Mark R. Haller, SNS Division Administrator Nutrition and Wellness Programs Enclosure cc: File

2 SCHOOL NUTRITION PROGRAMS ADMINISTRATIVE REVIEW REPORT This report summarizes the results of the administrative review of the School Nutrition Programs sponsored by Archdiocese of Chicago, Agreement # P-00, conducted on March 13 through 17 and 20 through 22, and 24, 2017, by Matthew Whitaker, Jeanette Andrews, John Burton, Kathryn Dundon, Jorge Nieves, and Tess Smith, Principal Consultants. The results of the review were discussed at an exit conference on March 24, 2017, with Brad Black, Director; Joanie Lombardo, VP Operations; Kelly Lothian, Senior Customer Relations Manager; Jennifer Psyhogios, Dietician; Chad Hemminger, Quality Assurance; Kathy Tentler, Regional Manager; Pat Pugh, Support Services; Virginia Sanchez, Customer Service Representative; and Cindy Roberts, Nadine Schauwecker, Aneeka Cognolatti, Deb Cole, Rose Kaczanowski and Patty Ridge, District Managers. The following schools were visited during this review: Asian Human Services Passages Charter CICS Northtown Campus CICS Ralph Ellison Campus Leo High School Our Lady of Tepayec High School Prince of Peace Queen of Martyrs San Miguel/Back of the Yards St. Christopher St. Collette St. Dominic St. Mary of the Annunciation St. Patrick St. Sabina 1

3 The purpose of the review was to monitor the school food authority's compliance with the federal and state program regulations. The following areas of program compliance were evaluated: Certification and Benefit Issuance Verification Meal Counting and Claiming Meal Components and Quantities Offer Versus Serve Dietary Specifications and Nutrient Analysis Civil Rights On-Site Monitoring Local School Wellness Policy Smart Snacks Professional Standards Water Food Safety Reporting and Recordkeeping Outreach Afterschool Snack Fresh Fruit and Vegetable Program Special Milk Program During the review, technical assistance was provided in the following areas: Verification Meal Counting and Claiming Meal Components and Quantities Offer Versus Serve Smart Snacks Professional Standards Water Food Safety Afterschool Snack Fresh Fruit and Vegetable Program Problems cited may require a joint corrective action effort between the sponsor and the contractor of the meals. The sponsor must establish the necessary procedures to ensure that the contractor works cooperatively to develop corrective action for those specific problems. As a result of the review, the following problems were identified. All other areas were found to be in compliance with program requirements. 2

4 Certification and Benefit Issuance The written documentation to support the direct certification efforts was not always valid. At times, the Excel download was the maintained file. The printed reports from the Electronic Direct Certification must be maintained and cannot be the excel download. Verification Documentation submitted by households selected for verification has not been accurately evaluated. All incomes reported on the household eligibility application were not fully verified. A check for an occasional promotional incentive was accepted instead of income documentation that was consistently received, and income from child support received on another application was not verified. Verification documentation must be obtained for each reported income. Professional Standards Training requirements have not been met for all of the managers. For school year , the managers were required to have a minimum of 6 hours of training. For the current school year, the minimum hours of training has increased to 10 hours annually. The response must identify how the manager will meet the current annual training requirements. Training requirements have not been met for school nutrition staff (excluding the director and manager). For school year , school nutrition staff were required to have a minimum of 4 hours of training. For the current school year, the minimum hours of training has increased to 6 hours annually for staff who work 20 or more hours per week and staff who work less than 20 hours per week are required to have a minimum of 4 hours training annually. The response must identify how school nutrition staff will meet the current annual training requirements. Training hours were not consistently documented. A method to track the number of training hours must be implemented. The USDA Professional Standards Training Tracking Tool may be utilized to document training hours. School staff who work with the School Nutrition Programs, such as program substitutes, did not meet the training requirements. For school year , staff working with the School Nutrition Programs were required to have a minimum of 4 hours of training. For the current school year, the minimum hours of training has increased to 6 hours annually for staff who work with School Nutrition Programs 20 or more hours per week. Staff who work less than 20 hours per week with School Nutrition Programs are required to have a minimum of 4 hours training annually. The response must identify how staff who work with the School Nutrition Programs will meet the current annual training requirements. 3

5 Food Safety The food safety plan on file does not contain Standard Operating Procedures for transporting food to the secondary cafeteria at St. Patrick School. A food safety plan specific to the district and each site, including standard operating procedures, must be developed and implemented. Asian Human Services Passages Charter School As a result of the review at Asian Human Services Passages Charter School on March 16, 2017, the following problems were identified. All other areas were found to be in compliance. Meal Components and Quantities Day of On-Site Observation Two lunches observed did not contain all required components. All meals must contain the required number of components. A reimbursable lunch must contain a meat/meat alternate, a fruit, a vegetable, a grain/bread, and milk in the required serving sizes. When participating in "Offer versus Serve", children must take at least three of the five components including a minimum of ½ cup fruit or vegetable. Students unable to consume cow s milk must be served a milk substitution nutritionally equivalent to cow s milk. One breakfast observed did not contain all required components. All meals must contain the required number of components. A reimbursable breakfast must contain a fruit, a grain/bread, and milk in the required serving sizes. When "Offer versus Serve" is implemented, children must take at least three of the four food items including a minimum of ½ cup fruit or vegetable. Students unable to consume cow s milk must be served a milk substitution nutritionally equivalent to cow s milk. Food Safety Based upon a review of the storage areas, the following problems were identified: All foods were not issued a date of receipt to ensure the items are served on a firstin/first-out basis. All stored foods were not elevated a minimum of six inches from the floor. Opened foods were not stored properly. Frozen foods were not properly sealed. To ensure the safeguarding of all foods, food items must be stored properly. Afterschool Snack Program The site does not take an accurate count of snacks on a daily basis. On the day of review, more snacks were recorded than children present. Snack counts must be taken on a daily basis at the point of service where a determination can accurately be made that a complete snack has been served to an eligible child. 4

6 Fresh Fruit and Vegetable Program Unallowable products were offered during the service of the Fresh Fruit and Vegetable Program. On the day of review, graham and cheddar goldfish crackers were served along with the fresh fruit of the day. To maintain the integrity of the Fresh Fruit and Vegetable Program, unallowable products must not be served. CICS Northtown Campus As a result of the review at CICS Northtown Campus on March 20, 2017, the following problems were identified. All other areas were found to be in compliance. Meal Components and Quantities Day of On-Site Observation One lunch observed did not contain all required components. All meals must contain the required number of components. A reimbursable lunch must contain a meat/meat alternate, a fruit, a vegetable, a grain/bread, and milk in the required serving sizes. When participating in "Offer versus Serve", children must take at least three of the five components including a minimum of ½ cup fruit or vegetable. Students unable to consume cow s milk must be served a milk substitution nutritionally equivalent to cow s milk. Production Records/Standardized Recipes Production records do not contain the required information for the day of review. The following details were missing: All specific foods, including salad bar items served, were not included. Portion sizes were not recorded for all items, including substitutions. Production records must accurately reflect the specific foods/condiments used, recipe or product name, grade groups, portion sizes, student and total projected servings, amount of food used, and the number of leftovers. Food Safety Temperature logs are not completed for all refrigerators, including those units were a la carte items are stored. Also, temperature logs were discarded and were not maintained as required. On a daily basis, the temperatures of prepared cold/hot foods and all storage areas must be recorded. All temperature logs must be maintained on file for six months. 5

7 CICS Ralph Ellison Campus As a result of the review at CICS Ralph Ellison Campus on March 17, 2017, the following problems were identified. All other areas were found to be in compliance. Water Drinking water was not made available to the students throughout lunch and breakfast. Throughout the meal service, water must be made available to students. Prince of Peace As a result of the review at Prince of Peace on March 16, 2017, the following problems were identified. All other areas were found to be in compliance. Production Records/Standardized Recipes Production records do not contain the required information for the day of review. Portion sizes were not always recorded accurately. Production records must accurately reflect the specific foods/condiments used, recipe or product name, grade groups, portion sizes, student and total projected servings, amount of food used, and the number of leftovers. Offer Versus Serve Signage is not posted at lunch to explain a reimbursable meal under Offer vs. Serve. When implementing Offer vs. Serve, adequate signage must be posted to explain what constitutes a reimbursable meal. Food Safety The established HACCP plan was not available at Prince of Peace. The HACCP plan must be available on site and training must be implemented to ensure site personnel are following the plan. 6

8 Queen of Martyrs As a result of the review at Prince of Peace on March 17, 2017, the following problems were identified. All other areas were found to be in compliance. Production Records/Standardized Recipes Production records do not contain the required information for the day of review and selected week. All specific condiments served were not included. Production records must accurately reflect the specific foods/condiments used, recipe or product name, grade groups, portion sizes, student and total projected servings, amount of food used, and the number of leftovers. Food Safety Temperature logs are not completed for all refrigerators. On a daily basis, the temperatures of prepared cold/hot foods and all storage areas must be recorded. Also, temperature logs were discarded and were not maintained as required. These temperature logs must be maintained on file for six months. San Miguel/Back of the Yards As a result of the review at San Miguel/Back of the Yards on March 16, 2017, the following problems were identified. All other areas were found to be in compliance. Production Records/Standardized Recipes Production records do not contain the required information for the day of review and selected week. All specific condiments served were not included and, at some times, were not correctly identified. For example, production records indicated that fat-free mayonnaise would be served, however, on the day of review, full-fat mayonnaise was served instead. Production records must accurately reflect the specific foods/condiments used, recipe or product name, grade groups, portion sizes, student and total projected servings, amount of food used, and the number of leftovers. Smart Snacks Beverages sold to students during the school day do not meet Smart Snack standards. On the day of review, soda machines were turned on and operable during the meal service time. Foods and beverages sold to students during the school day must meet Smart Snack standards. Food Safety A copy of the most recent health inspection was not posted. The site must post a copy of the most recent health inspection in a prominent viewing area. 7

9 Thermometers were not present in the dry storage area. Thermometers must be placed in the dry storage area. Fresh Fruit and Vegetable Program Based upon the review of the December 2016 Fresh Fruit and Vegetable Program claim, more than 10 percent of the total grant is spent on administrative costs. No more than 10 percent of the grant may be spent on administrative costs. St. Christopher As a result of the review at St. Christopher on March 20 and 22, 2017, the following problems were identified. All other areas were found to be in compliance. Offer Versus Serve "Offer versus Serve" has not been implemented correctly at lunch. Some meal trays were pre-set and, as a result, children were required to take all five components. At other times, some children were required to take more items than required. When implementing "Offer versus Serve", children are only required to take three of the five required components. A fruit and/or vegetable must be one of the three components taken. Adequate signage is not posted at lunch to explain a reimbursable meal under Offer vs. Serve. The sign does not state that students must take the required ½ cup portion of 100% juice, fruit, or vegetable. When implementing Offer vs. Serve, adequate signage must be posted to explain what constitutes a reimbursable meal. Food Safety A copy of the most recent health inspection was not posted. The site must post a copy of the most recent health inspection in a prominent viewing area. Based upon a review of the storage areas, all foods were not issued a date of receipt. To ensure the items are served on a first-in/first-out basis, all foods must be dated when received. 8

10 St. Collette As a result of the review at St. Collette on March 16, 2017, the following problems were identified. All other areas were found to be in compliance. Meal Components and Quantities Day of On-Site Observation Two breakfasts observed did not contain all required components. All meals must contain the required number of components. A reimbursable breakfast must contain a fruit, a grain/bread, and milk in the required serving sizes. When "Offer versus Serve" is implemented, children must take at least three of the four food items including a minimum of ½ cup fruit or vegetable. Students unable to consume cow s milk must be served a milk substitution nutritionally equivalent to cow s milk. Production Records/Standardized Recipes Production records do not contain the required information for the day of review. Portion sizes were not recorded accurately. Production records must accurately reflect the specific foods/condiments used, recipe or product name, grade groups, portion sizes, student and total projected servings, amount of food used, and the number of leftovers. Offer Versus Serve Adequate signage is not posted at lunch to explain a reimbursable meal under Offer vs. Serve. The sign does not state that students must take the required ½ cup portion of 100% juice, fruit, or vegetable. When implementing Offer vs. Serve, adequate signage must be posted to explain what constitutes a reimbursable meal. St. Dominic As a result of the review at St. Dominic on March 17, 2017, the following problems were identified. All other areas were found to be in compliance. Offer Versus Serve "Offer versus Serve" has not been implemented correctly at lunch. Some children were required to take more items than required. When implementing "Offer versus Serve", children are only required to take three of the five required components. A fruit and/or vegetable must be one of the three components taken. Adequate signage is not posted at lunch to explain a reimbursable meal under Offer vs. Serve. The sign does not state that students must take the required ½ cup portion of 100% juice, fruit, or vegetable. When implementing Offer vs. Serve, adequate signage must be posted to explain what constitutes a reimbursable meal. 9

11 St. Patrick As a result of the review at St. Patrick on March 20, 2017, the following problems were identified. All other areas were found to be in compliance. Production Records/Standardized Recipes Production records do not contain the required information for the selected week. All specific foods served, including milk, were not included. Production records must accurately reflect the specific foods/condiments used, recipe or product name, grade groups, portion sizes, student and total projected servings, amount of food used, and the number of leftovers. Water Drinking water was not made available to the students throughout lunch. Throughout the meal service, water must be made available to students. St. Sabina As a result of the review at St. Sabina on March 16, 2017, the following problems were identified. All other areas were found to be in compliance. Meal Counting and Claiming At lunch, meal counts by category were not correctly combined and recorded on the day of review. The on-site staff member charged with recording the day s meal count was also tasked with restocking the meal components on the meal service line and few children passed through the line without being counted. Daily meal counts must be accurately combined by category and recorded each day. Meal Components and Quantities Day of On-Site Observation Twenty children were not offered the daily minimum required components at lunch. The missing components were the fruit, vegetable, and milk. These components were missing as a result of an insufficient quantity of food being delivered, as well as instructions the students received to take all of the meal items offered, despite normally adhering to Offer Versus Serve requirements. When shortages of a component occur, appropriate substitutions must be made. 10

12 Eleven lunches observed did not contain all required components. All meals must contain the required number of components. A reimbursable lunch must contain a meat/meat alternate, a fruit, a vegetable, a grain/bread, and milk in the required serving sizes. When participating in "Offer versus Serve", children must take at least three of the five components including a minimum of ½ cup fruit or vegetable. Students unable to consume cow s milk must be served a milk substitution nutritionally equivalent to cow s milk. At breakfast, the site does not offer two fat-free (unflavored or flavored) or a low-fat (1% milk fat or less) unflavored and a fat-free milk (unflavored or flavored). Students must be offered the appropriate milk choices. Offer Versus Serve "Offer versus Serve" has not been implemented correctly at lunch. Children were required to take all five components. When implementing "Offer versus Serve", children are only required to take three of the five required components. A fruit and/or vegetable must be one of the three components taken. Fiscal Action As a result of the problems cited, an overclaim for March 2017 has been identified for the following programs: National School Lunch Program - $ School Breakfast Program - $4.37 Federal regulations allow this office to waive overclaims less than $600.00; therefore, the National School Lunch Program and School Breakfast Program overclaims will not be assessed. However, if you participate in the Seamless Summer Option (SSO) and an overclaim is identified with a future SSO Claim for Reimbursement, the overclaim amount will be added to the above assessment and a new fiscal adjustment amount will be calculated. If the new assessment exceeds the $ threshold, fiscal action will be required. 11

Illinois State Board of Education

May 11, 2016 Illinois State Board of Education 100 North First Street Springfield, Illinois 62777-0001 www.isbe.net James T. Meeks Chairman Tony Smith, Ph.D. State Superintendent of Education Donaldo Batiste