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Agency of Education

education.vermont.gov

Child Nutrition Programs Child Nutrition Programs Administrative Review Report This form represents written notification of the findings of this review, required corrective action (CA), and timeframe for the corrective action. This information will be shared with the Superintendent, Business Manager, and other appropriate program personnel. Once the CA materials are received and approved, any fiscal action will be determined and the SFA will be notified of the results in a final closure letter. SFA Name:

LEA Number:

Schools/Sites Reviewed

Date(s) on Site

State Reviewers

1. Bellows Falls UHSD

3/22/17

2. Saxtons River Elementary

3/23/17

Marianna Charalabopoulos Jamie Curley

Windham Northeast Supervisory Union

Review Date(s):

S047

3/22/17-3/23/17

3. 4. 5. 6.

x x

CN Programs Reviewed National School Lunch Program School Breakfast Program

x

Type of Review First

Check if Applicable Provision 2

Follow-Up

Community Eligibility Provision

After School Snack Program

x

Fresh Fruit & Vegetable Program

At-Risk Snack/Supper (CACFP)

Seamless Summer Program Special Milk Programs Date of Exit Conference: 3/23/17

Response Due Date: 5/19/17

The Response Due Date is the date the SFA’s response and written Corrective Action Plan are due to the lead reviewer. Note: Failure to respond by this date will result in payments for Claims for Reimbursement being suspended. (30 calendar days) Reviewer, Child Nutrition Programs:

Date: 4/19/2017

SFA Representative:

Date:

Review Year: 16-17________________ Review Month: January 2017_____ Lead Reviewer: Marianna Charalabopoulos The SFA must ensure the Corrective Action documentation outlines the following information for each finding: a. Who is/was responsible for the action? b. What changes or corrections were made? c. When were the corrections or changes made? d. Where were the corrections or changes implemented? e. How did the SFA ensure the corrections were complete? f. Provide documentation or evidence of the correction or implementation to the State Agency. SFAs should clearly note on their submitted documentation which finding and site is addressed. All corrective action documentation must be submitted to the Lead Reviewer indicated above. It is preferred that all CA be submitted together and submitted electronically when possible. Area

Findings #

Finding Description

Required Corrective Action

A statistical sample of 288 students receiving free and reduced price meals was reviewed to ensure correct determination.

The SFA is in the process of obtaining the information missing from the applications.

SFA Level 100 – Certification & Benefit Issuance

There were applications that were incomplete. Income applications must contain the last 4 digits of the Social Security of the person completing the application. They also must contain the number of Household Members and the number of Household Members indicated must match the number of names listed on the application. 100 – Certification & Benefit Issuance

N/A

100 – Certification & Benefit Issuance

N/A

Further training on application approval is needed. The Child Nutrition Programs Summer Institute offered the week of August 7th, 2017 includes training on this topic.

Area

Findings #

200 – Verification

Finding Description

Required Corrective Action

The Verification Process was not completed. Verification sample must be based on applications on file as of October 1st. There was an application selected from October 25th. Any telephone communication with households needs to be documented. The required Confirmation Review did not take place. This process ensures that applications were approved correctly initially. The next step in the Verification process is to check to see if any of the students are on the Direct Certification list and this was not done.

Immediately notify households of change in benefit status. The SFA will be placed on the Verification Ameliorative Action list which requires the use of the error prone method of Verification in SY 2017-2018. More information about this process is provided in Vermont Appendix.

The Verification Report in the online VT-CNP System was not completed correctly. 300 – Meal Counting & Claiming

N/A

600 – Dietary Specifications

N/A

700 – Resource Management

1. Westminster

The non program revenue tool calculated for the 15-16 school year, showed that the Westminster School district was not charging adequately for their non program foods and therefore have to increase their prices for their non program items to ensure that their costs are being covered. However, since the tracking system for the non program revenue food items including second entrees, milks, and adult meals is not as accurate as it should be, the tool may not be representative of the actual revenues and costs. The tracking system must be updated so that the school district can accurately calculate whether or not the revenue from the non program foods is in fact covering the costs of these same non program foods.

1. Please track in detail, one week of a la carte purchases at the Westminster Schools detailing how many second entrees, second milks, adult meals, and freezer meals were purchased each day of the week. This tracking system will help to delineate exactly how much of reimbursable meal menu items are being sold a la carte instead of with a reimbursable meal. Once this has been tracked, calculate the costs for each of these items and recreate the non program revenue tool for that week same week to establish whether or not the district is earning adequate revenue to cover the costs of the non-program foods. Please submit both the completed tool as well as the aforementioned tracking and cost documentation.

Area

Findings #

Finding Description

Required Corrective Action

TA:

Westminster schools have a high total of student account balances, totaling $2512 from school year 15-16. Although there is a meal charge procedure in place for the entire SFA, it will need to be updated upon release of the soon to be released State Agency guidance. It is highly recommended, that someone be designated to follow up with families that have overdue balances to try to recuperate some of the funds.

No corrective action required. The AOE is in the process of creating Meal Charge policy guidance that will help aid SFAs with creating an adequate policy.

The non program foods revenue tool was not completed properly for the 15-16 school year and therefore could not be validated. The non program revenue tool was re-created by the information supplied to the State Agency and it was found that the Rockingham SD food service program needs to increase it non program revenue by $5913. The revenue ratio is 9.8% versus the cost ratio of 11.13%.

2. Please submit a detailed plan of action as to how non program revenue will be increased for the 1718 school year.

1.

The non-discrimination statement provided on both the off-site assessment tool and the Bellows Falls Union High School eligibility letters is outdated and needs to be updated to the current statement “This institution is an equal opportunity provider.”

1. The letters have been updated as part of the renewal process. This finding has been corrected.

2.

All staff involved in any aspect of the Child Nutrition programs need to receive Civil Rights training as well as training on their relevant tasks.

800 – Civil Rights

TA:

The SFA is required to have Civil Rights complaint procedures. The Vermont State Agency Civil Rights complaint procedures template has been emailed to the SFA.

2. Staff must read through the Civil Rights PowerPoint provided by the State Agency and document training with names, signatures, and dates. Please submit the attendance sheet once the presentation has been viewed. No corrective action is required. The SA is currently working on additional guidance and will distribute said guidance when it is finalized.

900 – SFA Onsite Monitoring

1.

The on-site monitorings are incomplete in that some of questions have not been answered and one monitoring has to be signed by the site representative.

2. Rockingham

800 – Civil Rights

Please submit copies of the fully completed on-site monitoring forms.

Area

Findings #

Finding Description

Required Corrective Action

1000 – School Wellness Policy

TA:

We suggest including the FSMC as part of the nutrition and wellness meetings and also supply them with the completed version of the WP. It is highly recommended that the SFA incorporate a limit on the number of Smart Snacks that a student can purchase, so excessive amounts of sugary snacks are not consumed.

No corrective action is required.

1100 – Smart Snacks

N/A

1200 Professional Standards

1.

Currently, the required training hours have not been met by the site lead at BFUHS and the Food Service Director for Rockingham SD. However, based on the planned training documentation, the training hours will be completed by the end of the year.

1 – 2: Using the AOE created Professional Standards tracking tool or other similar tool, please record and submit all FSMC staff training hours to date with their respective Key Areas, Topics, and Subjects noted.

2.

The training hours for the FSMC employees were not tracked using the required Key Areas, Topics, or Subjects.

TA:

As both of the Finance Specialist at the SU and the Food Service Director at Westminster SD are still considered new, it is highly recommended that both receive more professional development with respect to their current roles. It is highly recommended that the finance specialist participate in the Institute of Child Nutrition’s Financial Management class and that the FSD for Westminster attend the New Manager’s training presented at the VT Child Nutrition Program’s Summer Institute the week of August 7th.

1500 – Reporting & Recordkeeping

N/A

No corrective action required.

Area

Findings #

1600 – School Breakfast & Summer Outreach

N/A

2100 – Special Provisions

N/A

Finding Description

Required Corrective Action

Site/School Name: Bellows Falls UHS Area 300 – Meal Counting & Claiming

Finding #

Finding Description

Required Corrective Action

1.

One breakfast meal at Bellows Falls UHS was not reimbursable as the meal did not include fruit. This meal was voided and was charged as an a la carte purchase.

No corrective action required.

400 – Meal Components & Quantities Breakfast

N/A

400 – Meal Components & Quantities Lunch

1.

The Macaroni and Cheese recipe needs to be updated either to include 4 more ounces of dry pasta or to 48 servings instead of 50. The current recipe only credits as 1.75 ounce equivalents of grain.

Recipes have been updated and submitted. Finding has been corrected.

2.

The Buffalo Chicken Pizza only credits as 1.5 ounce equivalents of meat/meat alternate. The review of the menu certification revealed that one meal offered during the week of review offered a grain component that did not meet the 2 ounce equivalent requirement unless it was paired with another menu item on that same day. While 2 ounce equivalents were technically offered, it is highly recommended that a full 2 ounce equivalent of a component be offered within one single food item so the student isn't made to take two separate items. Clarification was provided to the cashier that the milk component was not a component that the students were required to take.

400 – Meal Components & Quantities

TA:

500 – Offer vs Serve

TA:

600 – Dietary Specifications

N/A

No corrective action required.

As the cashier is considered new, it is highly recommended that the cashier receive additional Offer vs Serve training.

Area 800 – Civil Rights

Finding #

900 – On-site Monitoring

N/A

1100 – Smart Snacks

N/A

1400 – Food Safety

1.

Finding Description

Required Corrective Action

Buy American: There were only a few items found at Bellows Falls Union High School whose country of origin was not the USA. The items included: a) Tuna b) Ardmore Juices There were many items whose country of origin could not be determined.

Please submit a written plan for ensuring that domestic products are purchased going forward, as well as justification for the nondomestic items purchased.

N/A

2. 1500 – Reporting & Recordkeeping

N/A

1700 – Afterschool Snack Program

N/A

Area 1900 – FFVP

Finding #

Inventory Management

TA:

Finding Description

Required Corrective Action

Upon inspection of the dry storage, cooler and freezer units, it was discovered that there was a lot of excess inventory being kept on hand. Although some of the inventory belongs to the Middle School as the school does not have adequate storage space, it is important to be mindful of only keeping enough inventory on hand to produce the required menu items so that program funds are available when needed and not sitting on shelves.

No corrective action required.

N/A

Site/School Name: Saxtons River Elementary Area 300 – Meal Counting & Claiming

Findings #

400 – Meal Components & Quantities Breakfast

N/A

400 – Meal Components & Quantities Lunch

N/A

400 – Meal Components & Quantities

1.

500 – Offer vs Serve

N/A

600 – Dietary Specifications

TA:

Finding Description

Required Corrective Action

Breakfast and lunch signage must include the requirement to select at least ½ cup fruit or vegetable.

Updated signage was posted during the on-site review. No further action required.

The salad bar offered a wide selection including banana peppers, pats of butter to accompany bread, and multiple varieties of cheese. Students were offered regular mayonnaise on the condiment station and bacon as part of a salad choice.

It is recommended that reduced-fat or calorie mayonnaise be offered instead and efforts made to reduce the amount of highsodium items available to students.

N/A

Area 800 – Civil Rights

Findings #

900 – On-site Monitoring

N/A

1100 – Smart Snacks

N/A

1400 – Food Safety

1500 – Reporting & Recordkeeping

Finding Description

Required Corrective Action

1.

The kitchen had HACCP-based Standard Operating Procedures (SOP), however they need to be customized to reflect actual practices. They need to read through by staff and initialed and date to reflect this. The Thermometer Calibration SOP will be edited to reflect use of the ice-bath method. The Personal Hygiene SOP will be edited to allow wearing of jewelry. The Satelliting SOP will be edited to reflect the actual practices used to deliver food to Grafton. Food sent to Grafton must be temped before leaving Saxtons River and upon arrival at Grafton.

1. Please submit the updated SOPs for Personal Hygiene and Satelliting Foods.

2.

The delivery from Sysco arrived during the on-site review. Boxes were placed directly on the floor of the walk-in freezer. Food needs to be stored at least six inches off of the ground to allow for proper air circulation.

2. The boxes were placed on shelves upon instruction from the SA reviewer. No further action is required.

N/A

N/A

Area 1700 – Afterschool Snack Program

Findings #

Required Corrective Action

N/A

The Fresh Fruit and Vegetable Program service was No corrective action not observed at this school due to an unforeseen required. delay from a field trip. FFVP preparation for 3/24/17 was observed and proper food safety and sanitation procedures were followed.

1900 – FFVP

T.A.

Buy American Provision

Finding Description

During the month of review, there were 13 fruits served and only 4 vegetables served. The program should strive to offer a more even balance of both fruits and vegetables. The Buy American Provision requires food purchase for the meal programs to be predominantly domestically produced. There were products observed in storage that were not in compliance. This includes: - Ardmore juice from various countries - Lolita canned pineapple from China There were many items whose country of origin could not be determined.

The SFA needs to purchase products predominantly produced in the US or if for domestic products are unavailable or substantially more expensive, documentation needs to be maintained to justify the foreign purchase. Please submit a written plan for ensuring that domestic products are purchased going forward, as well as justification for the nondomestic items purchased.

Site/School Name: ________________________________________ Area 300 – Meal Counting & Claiming

Findings #

400 – Meal Components & Quantities Breakfast

N/A

400 – Meal Components & Quantities Lunch

N/A

400 – Meal Components & Quantities

N/A

500 – Offer vs Serve

N/A

600 – Dietary Specifications

N/A

800 – Civil Rights

N/A

N/A

Finding Description

Required Corrective Action

Area 900 – On-site Monitoring

Findings #

1100 – Smart Snacks

N/A

1400 – Food Safety

N/A

1500 – Reporting & Recordkeeping

N/A

1700 – Afterschool Snack Program

N/A

1900 – FFVP

N/A

N/A

N/A

Finding Description

Required Corrective Action