Any potential fiscal action will be calculated once the corrective action responses have been received and approved.

Transcription

1 Administrative Review Summary and Corrective Actions SFA Name: Prairie Du Rocher Community Cons School District 134 Administrative Review Conducted on: 12/9/2016 SFA Contact Name and Title: Evelyn Marquardt, Administrative Assistant CNR Reviewer: Gavin Mack The purpose of this spreadsheet is to inform you of the results of the Administrative Review that was conducted on December 9, 2016; an exit conference summarizing the findings took place on December 9, The Administrative Review is a comprehensive evaluation of the Local Education Agency s (LEA s) National School Lunch Program (NSLP) and School Breakfast Program (SBP). The AR consists of two performance standards. The two performance standards reviewed were found to be satisfactory. During the Administrative Review, compliance with the new meal pattern requirements is also evaluated, at this time there are no menu findings that warrant the termination of the performance based reimbursement. This summary includes a comprehensive list of the technical assistance that was provided throughout the review as well as all findings that require a written response from the SFA. All items listed in the Corrective Action Plan must be submitted in writing to CN Resource, by February 24, Please complete the chart, an electronic version or a hand written response will be acceptable. If any additional responses are needed, please respond on district letterhead. Failure to submit the required materials by the due date may result in the withholding of claims. Should corrective actions not be submitted, a follow-up review may take place to ensure all required corrective actions were completed and implemented system-wide as appropriate. Any potential fiscal action will be calculated once the corrective action responses have been received and approved. I appreciate the courtesies extended by you and your personnel during the review. If you have questions or need assistance concerning the school food service program, please call our office. Please respond to the AR Corrective Action Document by February 24, Thank you,

2 Administrative Review Summary and Corrective Actions SFA Name: Prairie Du Rocher Community Cons School District 134 Administrative Review Conducted on: 12/9/2016 SFA Contact Name and title: Evelyn Marquardt, Administrative Assistant CNR Reviewer: Gavin Mack Commendations & Suggestions Thank you for being so accommodating during the review. The staff accepted technical assistance and wanted to make the required changes. Other areas of Technical Assistance (NOT requiring Corrective Action) Menu Review- Additional technical assistance was provided in an to the SFA with the menu review results. Suggestions were provided to bring the menus into compliance.

3 3 15 SFA Name: Administrative Review Conducted on: Sites Selected for Review: Prairie Du Rocher Community Cons School District /9/2016 Prairie Du Rocher Community Consolidated School Date Corrective Action Plan was provided to SFA: Thursday, January 26, 2017 Due Date for Corrective Action Plan: Friday, February 24, 2017 The following pages address the findings that were identified during your Administrative Review. For each finding you will be presented with the following: The finding, and details specific to the SFA regarding the finding The Code of Federal Regulations citation number or alternate resource citation A summary of the regulation / requirement Suggested guidance for the SFA in order to achieve compliance SFA area for reply to state how, when and by whom corrections will be made Please provide a detailed response to each finding in the spaces provided. Finding #1 Meal Components and Quantities Review Period For the week of menu review, the K-8 breakfast menu did not meet the minimum daily requirement of 1 ounce equivalent grain. A grain was provided, however not all grains were whole grain rich and creditable. During the review, the portion sizes required by the meal patterns were discussed with the SFA. The SFA must ensure that all meals counted for reimbursement contain the required components in the minimum portion size required for the specific grade group. The SFA should review all menus to ensure that at least the minimum portion size is planned for the specific grade group. The SFA should also provide additional training to the kitchen staff on the requirements of a reimbursable meal. The training should include what to do if a certain planned menu item is not available or if the item runs out during service. The USDA FNS website can be used for training materials, resources and guidance on the meal pattern.

4 (c) Meal pattern for school breakfasts. A school must offer the food components and quantities required in the breakfast meal pattern established. K-12: 1 oz. equivalent of grains daily. To come into compliance with meal pattern requirements, the SFA must provide a written plan that will be implemented to ensure future compliance. The plan should include; a statement that all menus will be reviewed to ensure that all portion sizes planned meet at least the minimum required amount for the specific grade group, a process for sites to reference when they do not have one of the planned menu items or there is insufficient quantities, a statement that the serving line will be visually reviewed prior to service to confirm that all required components are available and that additional menu training for all SFA staff will be provided. Provide the outline and dates for the trainings that will be completed. In addition please submit the name(s) and title(s) of the SFA representative(s) that will oversee this area and ensure future compliance. Submit the menu from the week of review with the corrections that were made to the menu to bring it into compliance moving forward. Provide any needed documentation to support the changes such as labels, recipes, production records, etc. Finding #2 Meal Components and Quantities Review Period For the week of menu review, the K-8 breakfast menu did not meet the minimum weekly requirement of 8 ounce equivalent grain. During the review, the portion sizes required by the meal patterns were discussed with the SFA. The SFA must ensure that all meals counted for reimbursement meet the weekly requirements as well as the daily requirements for grains required for the specific grade group. The SFA should review all menus to ensure that at least the minimum daily and weekly requirement is planned for the specific grade group. The SFA should also provide additional training to the kitchen staff on the requirements of a reimbursable meal. The training should include how to determine the total number of weekly servings if there are multiple menu items each day. The USDA FNS website can be used for training materials, resources and guidance on the meal pattern (c) Meal pattern for school breakfasts. A school must offer the food components and quantities required in the breakfast meal pattern established. K-8: minimum 8 oz. equivalents of grain weekly.

5 5 15 To come into compliance with meal pattern requirements, the SFA must provide a written plan that will be implemented to ensure future compliance. The plan should include; a statement that all menus will be reviewed to ensure that all weekly requirements for grains are met for the specific grade group, a process for sites to reference when they do not have one of the planned menu items or there is insufficient quantities, a statement that the serving line will be visually reviewed prior to service to confirm that all required components are available and that additional menu training for all SFA staff will be provided. Provide the outline and dates for the trainings that will be completed. In addition please submit the name(s) and title(s) of the SFA representative(s) that will oversee this area and ensure future compliance. Submit the menu from the week of review with the corrections that were made to the menu to bring it into compliance moving forward. Provide any needed documentation to support the changes such as labels, recipes, production records, etc. Finding #3 Meal Components and Quantities Review Period For the menu review week, the K-8 breakfast menu did not meet the 100% Whole Grain Rich requirement. Not all grains provided were Whole Grain Rich. During the review requirements for the meal pattern were reviewed with the SFA. All grains provided as part of the reimbursable meal must be Whole Grain Rich. To be considered Whole Grain Rich the item it must be comprised of at least 50% whole grain ingredients. An easy way to determine if a pre-purchased item is whole grain is to look at the ingredient list. If the first ingredient is whole grain, it is a Whole Grain Rich product. If the first ingredient is water, but the second is a whole grain it is also a Whole Grain Rich product. If the SFA is using a recipe as long as the whole grain ingredient is the largest by weight of all of the grain ingredients combined it is a Whole Grain Rich product. For additional information on whole grains visit the USDA FNS website (c)(2)(iv) Grains component. (A) Enriched and whole grains. All grains must be made with enriched and whole grain meal or flour, in accordance with the most recent FNS guidance on grains. Whole grain-rich products must contain at least 50 percent whole grains and the remaining grains in the product must be enriched. Effective July 1, 2013 (SY ), schools may substitute meats/meat alternates for grains, after the daily grains requirement is met, to meet the weekly grains requirement. One ounce equivalent of meat/meat alternate is equivalent to one ounce equivalent of grains.

6 6 15 To come into compliance with meal pattern requirements, the SFA must provide a written plan that will be implemented to ensure future compliance with the Whole Grain Rich requirements. The plan should include; a statement that only Whole Grain Rich grain products will be used as part of the reimbursable meal, a statement that all labels/recipes/manufacturer statements will be kept on file to document the Whole Grain Rich compliance, and a statement that additional menu training will be provided to SFA staff. Provide the outline for the training and the dates that the training(s) will be completed. In the plan include the name(s) and title(s) of the SFA representative(s) that will oversee this area and ensure future compliance. In addition to the plan please submit a revised menu from the week of review that clearly identifies the products that have been changed to bring the menu into compliance, submit any needed supporting documentation such as labels, recipes, and/or manufacturer statements. Finding #4 Meal Components and Quantities Review Period For the week of menu review, the K-8 lunch menu did not meet the minimum daily requirement of 1 ounce equivalent grain. A grain was provided, however not all grains were whole grain rich and creditable. During the review, the portion sizes required by the meal patterns were discussed with the SFA. The SFA must ensure that all meals counted for reimbursement contain the required components in the minimum portion size required for the specific grade group. The SFA should review all menus to ensure that at least the minimum portion size is planned for the specific grade group. The SFA should also provide additional training to the kitchen staff on the requirements of a reimbursable meal. The training should include what to do if a certain planned menu item is not available or if the item runs out during service. The USDA FNS website can be used for training materials, resources and guidance on the meal pattern (c) Meal pattern for school lunches. Schools must offer the food components and quantities required in the lunch meal pattern established: K-8: 1 oz. equivalent daily grain.

7 7 15 To come into compliance with meal pattern requirements, the SFA must provide a written plan that will be implemented to ensure future compliance. The plan should include; a statement that all menus will be reviewed to ensure that all portion sizes planned meet at least the minimum required amount for the specific grade group, a process for sites to reference when they do not have one of the planned menu items or there is insufficient quantities, a statement that the serving line will be visually reviewed prior to service to confirm that all required components are available and that additional menu training for all SFA staff will be provided. Provide the outline and dates for the trainings that will be completed. In addition please submit the name(s) and title(s) of the SFA representative(s) that will oversee this area and ensure future compliance. Submit the menu from the week of review with the corrections that were made to the menu to bring it into compliance moving forward. Provide any needed documentation to support the changes such as labels, recipes, production records, etc. Finding #5 Meal Components and Quantities Review Period For the week of menu review, the K-8 lunch menu did not meet the minimum daily requirement of 3/4 cup vegetable. Vegetables were provided, however the minimum required portion size was not met. During the review, the portion sizes required by the meal patterns were discussed with the SFA. The SFA must ensure that all meals counted for reimbursement contain the required components in the minimum portion size required for the specific grade group. The SFA should review all menus to ensure that at least the minimum portion size is planned for the specific grade group. The SFA should also provide additional training to the kitchen staff on the requirements of a reimbursable meal. The training should include what to do if a certain planned menu item is not available or if the item runs out during service. The USDA FNS website can be used for training materials, resources and guidance on the meal pattern (c) Meal pattern for school lunches. Schools must offer the food components and quantities required in the lunch meal pattern established: K-8: 3/4 cup of vegetable.

8 8 15 To come into compliance with meal pattern requirements, the SFA must provide a written plan that will be implemented to ensure future compliance. The plan should include; a statement that all menus will be reviewed to ensure that all portion sizes planned meet at least the minimum required amount for the specific grade group, a process for sites to reference when they do not have one of the planned menu items or there is insufficient quantities, a statement that the serving line will be visually reviewed prior to service to confirm that all required components are available and that additional menu training for all SFA staff will be provided. Provide the outline and dates for the trainings that will be completed. In addition please submit the name(s) and title(s) of the SFA representative(s) that will oversee this area and ensure future compliance. Submit the menu from the week of review with the corrections that were made to the menu to bring it into compliance moving forward. Provide any needed documentation to support the changes such as labels, recipes, production records, etc. Finding #6 Meal Components and Quantities Review Period For the week of menu review, the K-8 lunch menu did not meet the minimum weekly requirement of 3/4 cup red/orange vegetable subgroup. During the review, the portion sizes required by the meal patterns were discussed with the SFA. The SFA must ensure that all meals counted for reimbursement contain the required components in the minimum portion size required for the specific grade group. This includes meeting the weekly requirements for the vegetables sub-groups. Over the course of the standard school week the SFA must at a minimum meet the required servings for each sub-group. The SFA should review all menus to ensure that at least the minimum serving for each sub-group is planned for the specific grade group. The SFA should also provide additional training to the kitchen staff on the requirements of a reimbursable meal. The training should include what to do if a certain planned menu item is not available or if the item runs out during service. The USDA FNS website can be used for training materials, resources and guidance on the meal pattern (c)(iii) Vegetables component. Vegetable offerings at lunch over the course of the week must include the vegetable subgroups, as defined in this section in the quantities specified in the meal pattern in paragraph (c) of this section: K-8: 3/4 C red/orange.

9 9 15 To come into compliance with meal pattern requirements, the SFA must provide a written plan that will be implemented to ensure future compliance. The plan should include; a statement that all menus will be reviewed to ensure that all weekly requirements for vegetable subgroups are met for the specific grade group, a process for sites to reference when they do not have one of the planned menu items or there is insufficient quantities, a statement that the serving line will be visually reviewed prior to service to confirm that all required components are available and that additional menu training for all SFA staff will be provided. Provide the outline and dates for the trainings that will be completed. In addition please submit the name(s) and title(s) of the SFA representative(s) that will oversee this area and ensure future compliance. Submit the menu from the week of review with the corrections that were made to the menu to bring it into compliance moving forward. Provide any needed documentation to support the changes such as labels, recipes, production records, etc. Finding #7 Meal Components and Quantities Review Period For the week of menu review, the K-8 lunch menu did not meet the 100% Whole Grain Rich requirement for grains. Not all grains provided were Whole Grain Rich. During the review requirements for the meal pattern were reviewed with the SFA. All grains provided as part of the reimbursable meal must be Whole Grain Rich. To be considered Whole Grain Rich the item it must be comprised of at least 50% whole grain ingredients. An easy way to determine if a pre-purchased item is whole grain is to look at the ingredient list. If the first ingredient is whole grain, it is a Whole Grain Rich product. If the first ingredient is water, but the second is a whole grain it is also a Whole Grain Rich product. If the SFA is using a recipe as long as the whole grain ingredient is the largest by weight of all of the grain ingredients combined it is a Whole Grain Rich product. For additional information on whole grains visit the USDA FNS website (c)(2)(iv) Grains component. (A) Enriched and whole grains. All grains must be made with enriched and whole grain meal or flour, in accordance with the most recent grains FNS guidance. Whole grain-rich products must contain at least 50 percent whole grains and the remaining grains in the product must be enriched.

10 10 15 To come into compliance with meal pattern requirements, the SFA must provide a written plan that will be implemented to ensure future compliance with the Whole Grain Rich requirements. The plan should include; a statement that only Whole Grain Rich grain products will be used as part of the reimbursable meal, a statement that all labels/recipes/manufacturer statements will be kept on file to document the Whole Grain Rich compliance, and a statement that additional menu training will be provided to SFA staff. Provide the outline for the training and the dates that the training(s) will be completed. In the plan include the name(s) and title(s) of the SFA representative(s) that will oversee this area and ensure future compliance. In addition to the plan please submit a revised menu from the week of review that clearly identifies the products that have been changed to bring the menu into compliance, submit any needed supporting documentation such as labels, recipes, and/or manufacturer statements. Finding #8 Certification and Benefits Issuance Changes are not being made to the point of service benefit issuance document in a correct manner regarding the 30 days of carryover eligibility. When a new eligibility is established (either through direct certification or a meal benefit application), the new status takes precedence over the status of the prior year s eligibility. However, the SFA is not updating the eligibility until the 30th operating day. During the review, updating the point of service and allowing a full 30 days of prior eligibility was discussed with the SFA. Students must be allowed a full 30 operating days of prior eligibility, and when this expires, the SFA must make the appropriate updates at the point of service (c)(2) Applications and documentation of direct certification from the preceding year shall be used only to determine eligibility for the first 30 operating days following the first operating day at the beginning of the school year, or until a new eligibility determination is made in the current school year, whichever comes first.

11 11 15 To come into compliance with the requirements for carryover benefits and for updating eligibility at the point of service, the SFA must put a plan in place to ensure future compliance. The plan should include: a statement that the SFA understands the requirements for 30 day carryover benefits and updating eligibility status, a process that will be implemented to ensure that all students eligibility for carryover status are provided that benefit, a statement that the 30 day carryover period will not be less than or exceed 30 days, a statement that once a new determination has been made for the student the new eligibility will take precedence over the carryover status, a statement that the benefit issuance list and the point of service documents will be updated as needed to reflect accurate eligibility determinations. In addition the plan should include the name and title of the SFA representative that will ensure compliance with this area. The SFA also needs to provide additional training to all applicable staff. Please submit the plan. Eligibility statuses found to be incorrectly listed during the review must be corrected, and the date of the correction must be submitted. Finding #9 Offer versus Serve The cafeteria staff has not been trained on Offer versus Serve. If the SFA is going to implement Offer vs. Serve, they should annually train their staff and train new staff as needed. On going training should be provided depending on needs to staff in order to be incompliance with Offer vs. Serve procedures. It was determined during the review that the SFA is not offering training on Offer vs. Serve to the cafeteria staff. Offer vs. Serve training found in the School Nutrition Toolbox was discussed with the SFA and completing the training was recommended. Offer vs. Serve Guidance Manual (Page 4) Schools are expected to conduct training for cashiers and serving line staff so they can help students select the required food components/food items in the quantities needed for reimbursable lunches and breakfasts. Annual training is required to meet the professional standards requirements. To come into compliance with the requirements of Offer vs. Serve, the SFA must submit a written statement that training for all kitchen staff will be provided.. In addition the SFA must also provide the name and title of the SFA representative that will ensure compliance with this finding moving forward, an outline of the training that was provided to staff to inform them of the requirements and the date the training was completed.

12 12 15 Finding #10 Civil Rights The SFA is attempting to resolve complaints alleging discrimination within the FNS School Meal Programs. During the review the process for receiving and processing complaints alleging discrimination was discussed with the SFA. The SFA should not attempt to resolve complaints in-house and should forward all complaints to the appropriate outside agency. FNS Instruction Section XV All complaints, written or verbal, must be forwarded to the appropriate Regional or FNS OCR Director, unless an approved State complaint procedure is in place. Anonymous complaints will be handled as any other complaints, to the extent feasible, based on available information. To come into compliance with civil rights requirements, the SFA must develop a procedure that will be put into place to handle any discrimination complaints and to forward them to an appropriate agency. The process must outline the steps that will be taken when a complaint is received, the name and contact information of the agency that the complaint will be forwarded to, and the name(s) and title(s) of the person(s) who will be responsible for forwarding complaints to the appropriate agency. Please submit the procedure. Finding #11 Civil Rights The SFA is not maintaining a medical statement on file for students with special dietary needs that do not rise to the level of a disability. During the review, medical statements were discussed with the SFA. The medical statement for students with special dietary needs that do not rise to the level of a disability must be signed by a physician, physician assistant, nurse practitioner, or other professional specified by the State agency. Accommodating Children With Special Dietary Needs In The School Nutrition Programs: School food

13 13 15 authorities, institutions or sponsors may, at their discretion, make substitutions for individual participants who are not "handicapped persons", as defined in 7 CFR Part 15b.3(i), but who are unable to consume a food item because of medical or other special dietary needs. Such substitutions may only be made on a case-by-case basis when supported by a statement signed by a recognized medical authority. For these nonhandicapped participants, the supporting statement shall include: A. An identification of the medical or other special dietary need which restricts the participant's diet; and B. The food or foods to be omitted from the participant's diet, and the food or choice of foods that may be substituted. To come into compliance with this requirements for special dietary needs, the SFA must provide an assurance that appropriate staff understand the requirement, and the SFA must put a plan in place to ensure future compliance. The plan must include the SFA's process for students that have life threatening allergies and the SFA's process for student with special dietary needs that do not rise to a level of a disability. Each process should include; the type of documentation that must be maintained on file, how the sites will be informed of the child's specific needs, the process that will be used to ensure that the SFA is meeting the requirements for both groups of dietary needs, and the name and title of the SFA representative that will oversee compliance. Finding #12 Food Safety Storage violations were observed on-site. The SFA had food that was not dated upon delivery. During the review, storage requirements were discussed with the SFA. The SFA must ensure that all food is dated upon delivery (a) Health standards. The school food authority shall ensure that food storage, preparation and service is in accordance with the sanitation and health standards established under State and local law and regulations (d) (d) Storage. The school food authority shall ensure that the necessary facilities for storage, preparation and service of food are maintained. Facilities for the handling, storage, and distribution of purchased and donated foods shall be such as to properly safeguard against theft, spoilage and other loss.

14 14 15 To come into compliance with this finding the SFA must submit an assurance that the SFA is aware of the requirements for food storage and holding within the food safety guidelines. The assurance must include: a statement that all food and chemicals will be kept separately; a statement that all food items will be dated with the delivery date as well as the date the product was opened; a statement that all food will be stored at least 6 inches off of the floor; and a statement that all storage areas including coolers, freezers and storage rooms will be kept within the allowable temperature ranges. The assurance should also include a statement that temperature logs will be maintained for all storage areas. Submit copies of completed temperature logs with the corrective action response. Finding #13 Production records do not demonstrate that the components and planned portion sizes met the meal pattern requirements on each day of the review period. The SFA is only serving 1/2 cup of fruit, which does not meet the after school care snack program menu pattern. The SFA must serve at least 3/4 cup of fruit/vegetable in order to meet the after school care snack program menu pattern. During the review, production record, component, and portion size requirements were discussed with the SFA. The SFA must complete production records and serve snacks as described in 7 CFR (a)(3) and 7 CFR (o)(2). How to review nutrition labels, ingredient labels, CN labels, and use the food buying guide was discussed for meal pattern compliance. This finding may result in fiscal action (a)(3) Production and menu records. Schools or school food authorities, as applicable, must keep production and menu records for the meals they produce. These records must show how the meals offered contribute to the required food components and food quantities for each age/grade group every day. To come into compliance with milk fat and flavor requirements, the SFA must provide an assurance that staff administering the Afterschool Care Snack Program understand these requirements, and the SFA must put a plan in place to ensure future compliance. Please submit the assurance and plan Training for all afterschool snack program staff must be completed. Submit a copy of the completed sign in sheet and agenda for the training along with the date that the training was completed. The SFA must also submit revised snack menus for the next time this menu would be offered to show compliance with the snack meal pattern.

15 15 15 Signature of Reviewer: Date: 12/14/2016 Signature of SFA Representative: Date: If you have any questions, feel free to contact CN Resource at your convenience. Thank you. Administrative Review Team CN Resource P.O. Box Mesa, AZ Please insert your detailed responses, save, print, sign, scan and upload the signed copy to cnrsupport.com by the due date indicated. Thank you.