Welcome to the Administrative Review Webinar, which will help you prepare for the Administrative review process.

Transcription

1 Welcome to the Administrative Review Webinar, which will help you prepare for the Administrative review process. 1

2 USDA has established minimum professional standards requirements for school nutrition professionals who manage and operate the National School Lunch and School Breakfast Programs. Professional Standards for State and Local Nutrition Program Personnel Final Rule became effective July 1, The standards aim to institute minimum education standards for new State and local school nutrition directors as well as annual training standards for all school nutrition professionals. These new standards will ensure school nutrition personnel have the knowledge, training and tools they need to plan, prepare, and purchase healthy products to create nutritious, safe, and enjoyable school meals. The Final Rule requires all school food service personnel to complete annual continuing education/training requirements. The number of required training hours varies depending on the position of the school food personnel. This webinar will contribute up to 2 Training Hours towards the professional standards training requirements. You are required to track the number of training hours you earn each year and maintain documentation of the trainings that you have attended. Our office has developed a simple excel document that you may use to do this. SFAs may use this excel document to track staff training hours and may add columns and other necessary information specific to the SFA. Our tool may be found within the Professional Standards training memo located on the Child Nutrition Knowledge Center. You may also use the USDA s version or your own tracking method to track staff training hours. If you are using USDA Learning Topic Codes, the topic codes for today s Preparing for the Administrative Review webinar are 3200 Program Management and 3260 Administrative Review. 2

3 These are program regulations that are important for you to be aware of and familiar with. Regulatory Authority for the Administrative Review can be found in 7 CFR 210 and 220, the Richard B. Russell National School Lunch Act, the Child Nutrition Act of 1966, and Section 201 of the Healthy, Hunger Free Kids Act of 2010 (Pub. L , HHFKA). It is important for you to keep current on Federal and state regulations, policies, instructions and memos. 3

4 This is a general outline of the Administrative Review. The New York State Education Department Child Nutrition Program, also known as SED, will contact every School Food Authority referred to as an SFA at the beginning of the school year during their review year. SFAs must be reviewed every three years. Reviews are based on an SFA s participation in SBP and NSLP. The current cycle (cycle 1year 3) began July 1, There are pre visit procedures that every SFA will need to complete prior to their on site administrative review date that include an off site assessment which we will discuss in more detail in the next slide. Other additional off site monitoring tools which we will discuss in the presentation, are also required as part of the review process. SFAs are expected to work with their Child Nutrition Program representative if they need assistance completing the pre visit procedures. After pre visit procedures are complete the SFAs Child Nutrition Program representative will begin scheduling the on site portion of the Administrative Review. SFAs will receive a formal notification of review letter which lists information about the on site review; including selected sites, programs to be reviewed, dates of the on site review, the review period and if a Resource Management Comprehensive Review or a Nutrient analysis is required. SFAs will also receive a checklist with their notification of review that has details about on site review documents which will be requested during the on site review. On the day of review, the reviewer will conduct an entrance conference with SFA administration, perform meal service observations, review documents requested of each Administrative Review Component and hold an exit conference with SFA administration. We will discuss all findings, provide technical assistance 4

5 and develop the agreed upon corrective action plan required. Following the review, SFAs will receive a letter stating the agreed upon corrective action if corrective action is required. The letter will detail the technical assistance provided and the corrective action that is needed as a result of off site and on site findings. Depending upon the findings, fiscal action may be required. These procedures will be explored more thoroughly throughout this presentation. 4

6 This flow chart is a general outline of the administrative review process from start to finish and is available as a handout. 5

7 The Off site Assessment tool will be mailed to the FSD, Business Official and Superintendent) for each SFA that is scheduled for an Administrative Review in the SY. All responses must be submitted to SED by October 30, If you do not submit the Off site Assessment Tool to SED by October 30, you will be subject to a more comprehensive review. For ease of completing this process, there is a fillable Off site Assessment tool in the resource download. The tool allows SED to gain a better understanding of SFA operations prior to the on site review, thus providing for a more thorough review while decreasing SED s on site review time. The Offsite Assessment Tool contains questions pertaining to the five areas noted on the next slide. The completion of the tool might require collaboration with other SFA staff, such as Food Service Director, Fiscal Contact and Business Official. SFAs should note that the Resource Management section of this tool requires answers from prior school year operations while the other sections will use data from the current school year. The SED Auditing Team will be contacting SFAs for any information and/or clarification related to the Resource Management section of the Off Site Assessment Tool and will be determining your SFA s risk level. 6

8 The five main components of the Administrative Review are: resource management, meal access and reimbursement, meal pattern and nutritional quality, general program compliance, and other federal program components. The areas included in each component are listed on the slide. 7

9 This chart shows the minimum number of SFA sites that must be reviewed. For example, if the SFA has 25 sites, this table indicates that at least 4 National School Lunch Program (NSLP) sites must be reviewed. Criteria used to select the Recipient Agencies, also known as RA s, to be reviewed include: RAs with the highest free participation which is a federal criteria, as well as State criteria such as, findings from previous reviews, a new FSD, significant changes in enrollment and/or average daily participation. SED will identify and notify each SFA which sites will be reviewed. School Breakfast Program reviews will be conducted at 50% of the sites selected for review. The breakfast review is just as important as the NSLP review and findings may also be subject to corrective action and fiscal action if necessary. SED reserves the right to conduct reviews of your program operations, which may include announced or unannounced on site visits. 8

10 These are other pre visit procedures that SFAs will need to complete prior to their on site administrative review date. Additional Off Site Monitoring Documents include: submission of the SFA wide benefit issuance list to SED, submission of the completed Meal Compliance Assessment tool, and submission of the dietary specification assessment tool. SFAs are expected to work with their Child Nutrition Program representative if they need assistance completing these documents. 9

11 SED will ask you to submit the benefit issuance document or documents for each school under the SFA (not just for the schools selected for review) The list has some specific requirements: The list must only include all free and reduced price students no paid or denied students; The list must be coded by benefit status and SED must be supplied with the code separately to maintain the confidentiality of the data (for example, separate e mail or fax. The list should not be grouped by free and reduced price student names The list must have the student name, school name, method of certification (i.e. application, direct cert, etc.) and list whether the student was selected for verification The list should not have any duplicate names The benefit issuance document may be from any day in the review period and must be available on the day of review. An excel document is the preferred method, although, it is not required. This section is not applicable for CEP and provision 2 schools that are in non base years since this data has already been reviewed at the beginning of their provisions; or for RCCI s with no day students and jails. After SED receives the benefit issuance list, the sample size reviewed will be determined. SED will contact the SFA with the exact names and number of students to be reviewed on site. This will allow the SFA time to prepare and organize the certification documents prior to SED arrival. SED would like to see that on site documents are organized by free applications, reduced applications, direct certification list, eligibility letters, and students that are certified as foster, homeless, etc Please note that you should highlight the students on the DCMP list that are selected as part of the sample size 10

12 Here is an example of abenefit Issuance Document using an Excel Spreadsheet. You can see that it is coded to maintain the confidentiality of the information. 11

13 Prior to the on site review, SED will ask every SFA to complete the Dietary Specifications Assessment Tool. SED will validate the information and risk level and has the discretion to conduct a nutrient analysis. Larger SFAs may have to complete the Meal Compliance Assessment Tool as well. The nutrient analysis would then need to be completed in order for SED to close the Administrative Review. We will review the dietary specification and nutrient analysis section in more detail. 12

14 This is a screen shot of the Meal Compliance Risk Assessment Tool. SED will e mail this to all SFAs scheduled for review in who have more than one RA being reviewed. This is an excel document that includes an informational tab to help you answer the questions as well as several Risk Questionnaire tabs for each RA. This tool will assess error prone areas where nutrition related violations could occur. The RAs will be ranked according to the total scores and the site with the highest score must complete the Dietary Specifications Assessment Tool. 13

15 This is a screen shot of the Dietary Specifications Assessment Tool. The SFA must answer the questions on the tool and submit the results to SED. SED will validate the dietary specification assessment tool on site. This tool captures information about the operational and menu planning practices and enables the State Agency to further examine the school s compliance with the meal pattern requirements for breakfast and lunch. If SED has concerns about the SFA s food service practices, SED has the discretion to conduct a nutrient analysis. It is important to note that not all of the questions associated with the Tool imply that the related activity is prohibited, rather they reflect the possibility of a need for further review. 14

16 Now we are going to answer questions on the topic area that we ve just covered, which included the pre visit procedures, completing the Benefit Issuance document, Meal Compliance Assessment Tool and Dietary Specification Assessment Tool. If you have additional questions, there will be time at the end of the presentation to answer those questions as well. Type questions that you have into the Q and A box located on the right hand side of your screen. We will answer questions for the next 5 minutes and then proceed to the next topic. 15

17 We have just reviewed the pre visit procedures, various tools, and the benefit issuance document. We will now discuss the remaining sections of the Administrative Review Components. 16

18 The scope of this section will focus on the SFA level. Ultimately, this will allow certification and benefit issuance systems to be assessed SFA wide and errors applied across the SFA. The administrative review encompasses the entire SFA s process for reviewing certifications, verification, and updating applications. The Meal Counting and Claiming process looks at meal consolidations at both the RA level and the SFA level. However, validation of meal counts is assessed at the RA level. 17

19 We will be evaluating the following: Your systems for determining eligibility including direct certification, issuing, updating, and transferring benefits. Your back up system to ensure eligibility information is maintained should your primary system break down. A sample of SFA wide denied applications to ensure they are denied correctly. We will also review each denial letter to ensure that all households have been notified of: the reason for denial of benefits, right to appeal, instructions on how to appeal and a statement that the family may re apply benefits at any time during the school year. The prototype letter that includes these requirements can be found in the Policy Booklet available on our website. 18

20 For each student selected for review, SED must examine the following: The eligibility determination by reviewing the free and reduced application, or other categorical eligibility determinations, to ensure the SFA certification was completed properly. Documentation to establish whether households were notified of benefit eligibility, in accordance with the required timeframes. Any verification activity related to the selected student to ensure the verification was properly conducted and any changes in the eligibility status were properly made in accordance with the required timeframes. Documentation to establish whether households were notified of changes in eligibility status due to verification within the required timeframes. As a reminder, income applications must be signed by the designated reviewing official individually or a signed cover page must be attached to batches of processed applications, to document that all applications were reviewed and benefits assigned. 19

21 New this year SFAs must report the number of students directly certified by RA on CNMS prior to submitting their September claim for reimbursement. Report students directly certified through SNAP separately from students directly certified through Medicaid SNAP is the highest level of direct certification and supersedes all other certification methods, including the SNAP letter method. If you find that a student is certified on the DCMP list as SNAP and MEDI they should be documented as directly certified through SNAP. If your SFA is utilizing a computer software program to conduct DCMP, please ensure that SNAP is chosen when a student is found to be enrolled in both Medicaid and SNAP Eligibility for free meals is extended to all children in a household if any member is found on the DCMP list. These children are also considered directly certified. SFAs are encouraged to take appropriate steps to identify these children who are part of the family but were not identified through direct certification through other means. This may include, but are not limited to, the use of school district enrollment records. If a match is found for a student who already has an application on file, the student must be designated as direct cert (SNAP or MEDI) and benefits must be extended to all children in the household. The application should still be maintained just not used as the eligibility determination. Categorical Eligibility includes: The Letter Method which includes households who have submitted an Eligibility Letter that they received from the NYS Education Office and Office of Temporary and Disability Assistance. These students should be certified as categorically eligible through the SNAP letter method and the letters should be maintained on file. This is not considered direct certification for reporting purposes. Other categorically eligible students include students documented as homeless, 20

22 migrant, runaway, foster, Head Start, Even Start, or non applicant but approved by local officials Categorical Eligible Applications include: All students listed on an application approved as categorically free eligible based on the household providing documentation (For example: a case number for SNAP, TANF or FDPIR). Determining officials must ensure that the Assistance Program s case number or other identifier listed on the application is consistent with the format used by the Assistance Program in that State. Determining officials need to be familiar with the format of valid case numbers or other identifiers. If the case number seems incorrect, the SFA should contact the household or the local Assistance Program to confirm the household s eligibility. SFAs are encouraged to review the direct certification list to determine whether any of the applications with case numbers can be matched with children on the direct certification list. If a match is found, categorical eligibility must be applied to all children within the household. When a match is not found, the SFA should contact the household for further clarification. If the SFA still considers the application to be questionable, the determining official may verify the application for cause Only the SNAP case number may be used to determine eligibility. The electronic benefit transfer (EBT) card number cannot be used to establish categorical eligibility on an application. 20

23 This slide lists the certification documents that are needed for SFAs with special situations. Benefit issuance documents are required for SFAs that are Residential Child Care Institutions or RCCIs with day students. RCCIs with no day students and jails must maintain a resident eligibility list that includes student name, date of birth, admission and discharge time and date. Benefit issuance documents are required during the base year for SFAs operating Provision II or Community Eligibility Provision. This not does apply to SFAs operating in their non base year. 21

24 Corrective action must be applied system wide for benefit issuance and certification errors, including at non reviewed schools, if applicable. Corrective action means actions required to correct any violation identified under the Administrative Review and must be applied to all schools in the SFA, as appropriate, to ensure that previously deficient practices and procedures are revised system wide. Fiscal action may be taken for errors resulting from the following: Miscategorized certifications (For Example: certified free but the application should be reduced) Benefit issuance errors (For example: certified as reduced but assigned free benefits on the benefit issuance document and being claimed as free) Failure to update a change in status resulting from verification (For example: due to documents reviewed during verification, a households benefits changed from free to paid; however, the status was not changed, the family was not notified and student was continuing to receive free meals) Applications with missing information are considered incomplete. This does not include applications that do not report zero income (either with a 0 or checked the no income box) Beginning in SY , applications must still request that applicants write a zero when there is no income to report, but will no longer require a separate indication of no income from the applicant. Instead, applications must include a clear and easy to understand instruction that communicates to applicants that any income field left blank is a positive indication of no income and certifies that there is no income to report (our prototype application includes this statement). As such, applications with blank income fields should be processed by the school district as complete. However, should local officials have known or available information that the household has intentionally misreported its income, they must verify any such application for cause. 22

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26 SFAs with 10% or more certification/benefit issuance errors found during an administrative review will be required to conduct the Independent Review of Application process. The SFA will be required to submit an annual report (FNS 742a) to SED, detailing the number of free and reduced price applications subject to a second review, the number and percentage of reviewed applications for which the eligibility determination was changed, and a summary of the type of changes that were made. Selected SFAs must conduct a second review of all applications annually until the SFA provides documentation that demonstrates to the satisfaction of SED that no more than 5 percent of the reviewed applications required a change in eligibility determinations. 23

27 Now let s go over the verification portion of the Access and Reimbursement section. Verification is the confirmation of eligibility for free and reduced price meals under the National School Lunch Program and School Breakfast Program. Income Verification must be done annually. Federal regulations require that all SFAs participating in the School Breakfast Program or National School Lunch Program select and verify a sample of their approved free and reduced price meal applications on file as of October 1 st by November 15 th of each year. Verification is only required when eligibility is determined through the application process, not through DCMP. Prototype forms and letters are in the income verification booklet. We suggest you use these forms because they contain the most current and correct information. If you are using a computerized Point Of Sale system, make sure that the letters they produce contain the most up to date forms. Keep all supporting documentation on file. This includes the number of applications on file as of October 1 st, number to verify, documentation of the confirmation review, and the summary of the process and results. The verification documentation that will be reviewed will depend on the date of the On site Review. If the review is conducted prior to the SFA s submission of the Verification Summary report, then documents from the 2014/15 school year must be reviewed in addition to the documents that are being used for the 2015/16 school year. If the review is conducted after the verification summary report has been submitted, then the documents for the current, 2015/16 school year must be reviewed. 24

28 If the SFA does not have an electronic point of service system to conduct the confirmation review, the SFA must have an individual other than the original reviewing official, review each approved application selected for verification to ensure that the initial determination was accurate, prior to any verification activity being conducted. The confirmation review must be documented, for example, the confirmation official could initial each selected application after reviewing it. 24

29 All SFAs, with the exception of those SFAs that operate the Special Milk Program Only, must complete the Verification Summary Report, even if you are exempt from conducting verification. SFA s are required to submit this report on CNMS. Failure to submit this report by December 15 th will result in your Programs being placed on reimbursement hold. It is important to submit this form on time because SED has to report the results to USDA. Community Eligibility Provision and Provision 2 schools only need to complete section 2 and mark section 3 1 and 5 1 (if all schools in the SFA are under this Provision) and submit the form by December 15 th. 25

30 This is a screen shot of the Verification Summary Report that you will complete on CNMS. It is very important to read the instructions and fill out each applicable section accurately. As we stated, this data is provided to USDA to evaluate Program participation and benefits of SNAP and Medicaid data in providing more children with access to meals. We covered Verification and Reporting in a previous webinar and have it available on the CNKC. 26

31 If SED determines that the SFA accurately completed the verification process, the verification portion of the review is complete. If SED finds errors, we will provide technical assistance and require corrective action for those findings. If SED finds errors in the verification sample and cannot be sure that eligibility determinations were made appropriately, we may choose to expand the sample of verified applications. SED will require corrective action and provide technical assistance for areas of verification resulting in errors. Identified errors related to issues in the SFA s verification process cited during the off site or onsite portions of the Administrative Review will require the SFA to take corrective action. Corrective actions may include: Requiring the SFA to attend SED verification training, such as our verification webinar, as well as, Changing the benefit status of students on any applications verified under this Module that results in a change in application status. The SFA must notify the household and follow all required procedures 27

32 Now lets discuss the Meal Counting and Claiming portion of the administrative review. The purpose of the review in this area is to ensure that: The meal counting and claiming system(s) provides accurate meal counts by category (free, reduced, and paid) at the point of service. Meal counts are correctly counted, consolidated and recorded; and The meal counting and claiming system yields accurate claims for reimbursement. At a minimum, the review period must include the most recent month for which a claim was submitted, as long as it contains at least 10 operating days. All meal counting and claiming systems must provide an accurate daily count of reimbursable meals at the point of service by eligibility category without overt identification. Jails, RCCIs with no day students, CEP, and Provision 2 schools do not require collection by category but still must have accurate POS meal counts. 28

33 On the day of review, SED will ensure that daily meal counts are consolidated into a monthly count by eligibility status for each RA. These RAs monthly counts are reported on the claim for reimbursement. A second party review of all meal count consolidations helps prevent and identify meal count/claim errors. Non systemic and systemic errors are subject to fiscal action. If systemic errors are found, previous review period documentation will be reviewed and will also be subject to fiscal action. Federally required edit checks prevent potential over claims and is the process used by the SFA to compare each school s daily counts of free, reduced price and paid lunches against the number of children currently eligible for free, reduced price and paid lunches, respectively, times an attendance factor. Discrepancies should investigated and resolved before filing a claim. Document any discrepancies, as well as the corrective action implemented, and keep on file for no less than 3 years plus the current year. 29

34 Corrective action must result if: The SFA s system does not properly count students eligibility by category; The SFA does not have a backup system for counting and claiming, or the backup system cannot render accurate meal counts for eligible meals; The SFA s system does not have appropriate edit checks; The SFA s policies for incomplete meals, second meals, adult meals, a la carte items, field trip meals, or pre paid meals are not in line with policy and regulations or require additional information to be appropriate; The SFA s alternate point of service does not yield accurate counts The cashiers are not appropriately trained Fiscal Action must be assessed for: Meal count consolidation errors. These are mathematical mistakes that result in the school reporting incorrect meal counts to the SFA. Fiscal action is taken on the difference between the incorrect and the correct meal counts. When meal counts do not equal the number of reimbursable meals served to eligible children; When meal counts exceed the number of eligible students by category (i.e., free, reduced price or paid); or When second and/or other ineligible meals (e.g., adult meals or a la carte) were counted. 30

35 Now we are going to answer questions of the topic area that we just covered which includes the Meal Access and Reimbursement Component of the Administrative Review. If you have other questions there will be time at the end of the presentation to answer those questions as well. Type questions that you have into the Q and A box located on the right hand side of your screen. We will answer questions for the next 5 minutes and then proceed to the next topic. 31

36 Now we re moving into the Meal Pattern & Nutritional Quality area of the review. In this area there are three sections: (1) Meal Components & Quantities (2) Offer vs. Serve, and (3) Dietary Specifications & Nutrient Analysis. 32

37 SED will conduct an on site assessment of the SFA s meal service for breakfast and lunch to determine whether meals claimed for reimbursement contain the required components and quantities. SED will: Conduct a visual observation of meal service lines and review menu documentation on the day of review; Ensure that signage is posted and students know how to select a reimbursable meal Review menus, production records, standardized recipes, product formulation statements, CN labels, Nutrition Facts labels, etc. for the review month and day of review for breakfast and lunch. SED will notify you prior to the on site review of what the review month will be. Please have all documents organized by week for the month. A nutrient analysis may be required (which can be conducted on site or off site) 33

38 Technical assistance and corrective action will be required if: The weekly menu is not meeting the vegetable subgroup requirements for all age/grade groups being served, At least two choices of fluid milk in the allowable varieties are not offered, Food quantities are not offered in sufficient amounts based on the age/grade group being served (for example, The SFA must be offering at least a 2 oz equivalent of a meat/meat alternate daily for 9 12 age/grade group). All of the grains offered as part of the reimbursable meal are not whole grain rich unless you have the whole grain rich waiver Production records are missing required information such as serving size or menu item. SED must require immediate corrective action for any missing meal components found during an onsite observation on the day of review. The SFA must immediately add the missing meal components before any additional meals are claimed for reimbursement on the day of review, and on future days on which the deficient menu is offered. For example: a missing meal component would be if only 4 components were offered: Meat, Fruit, Vegetable, and Milk but the grain component is not offered at all. 34

39 If a milk type, vegetable subgroup, or whole grain rich violation is found on an initial review and then again in a subsequent review, this would be considered a repeat violation and fiscal action will be assessed. 34

40 Offer versus serve is a provision in the National School Lunch and School Breakfast Programs that allows students to decline some of the food offered. The ultimate goal is to reduce food waste in the school meals programs. It is required to identify reimbursable meals to students through the use of appropriate signage. Menu information should be placed in an area that allows students to be able to identify at or near the beginning of the serving line the food items that contribute to the reimbursable meal. SFAs may want to also post reimbursable meal guidelines and/or nutritional messages. Meal specific signage is required for both breakfast and lunch however signage is not required for field trips. Students exiting the Point Of Service area must select enough components in the proper quantities to make a reimbursable meal. All reimbursable meals must contain at least ½ cup of fruit or vegetables at breakfast and lunch under Offer vs Serve. Food service staff at the point of service must be trained and be able to identify a reimbursable meal, including the appropriate quantities. 35

41 If there are offer vs. serve violations, a corrective action plan is required. All corrective action plans must be submitted to SED, whether the corrective action is taken immediately or at a later date. Fiscal action is required when a meal component is missing. If the fruit or vegetable is offered in a quantity that is less than ½ cup, it is considered a non reimbursable meal and is subject to fiscal action. [7 CFR (g)(2)] 36

42 As we discussed in the pre visit procedures section, your SFA will answer the off site portion of the Dietary Specifications Assessment Tool and submit this to SED. We will use that tool to verify the information during the on site portion of the review for the RA selected. We will observe meal preparation and service, review food storage, review all menu documentation, which includes Food labels, product formulation Statements, standardized recipes, production records, and menus. This information will also be used if a nutrient analysis is conducted. If this review indicates high risk for non compliance with the meal components and dietary specifications (calories, saturated fat and sodium), SED must conduct an nutrient analysis. If high risk is not indicated but SED has concerns about the SFA s food service practices, SED has the discretion to conduct a nutrient analysis. 37

43 Fiscal action is limited to the review site where the violation is found, even if the same cycle menu is being served at other sites All violations will require a Corrective Action Plan 38

44 Now we are going to answer questions of the topic area that we just covered which includes the Meal Pattern & Nutritional Quality Component of the Administrative Review. If you have other questions there will be time at the end of the presentation to answer those questions as well. Type questions that you have into the Q and A box located on the right hand side of your screen. We will answer questions for the next 5 minutes and then proceed to the next topic. 39

45 The next topic area is the General Program Compliance, which includes Civil Rights, SFA Onsite reviews, Local School Wellness Policy, Smart Snacks in School, Professional standards, Water, Food Safety, Reporting and Record Keeping, SBP and SFSP outreach 40

46 During the Administrative review, SED will evaluate civil rights compliance through offsite questions and on site observation at each site chosen for review. For example, SED will confirm that the And Justice for All poster is visible in the meal service area and that students can read the information. SFAs are allowed to print off and use the 8 X 11 poster from the Child Nutrition Knowledge Center All program materials must contain the full USDA non discrimination statement. This statement was updated in 2013 and previous versions are outdated. Include the disclaimer on all Child Nutrition Program related materials including, the public release, the school website, correspondence with families, etc. SFAs are not required to include the USDA nondiscrimination statement on child nutrition menus. SED will observe if students are receiving equal benefits without discrimination during the lunch and breakfast meal observation and will also determine compliance with required Annual Civil Rights Training. All documentation of the training such as agenda, sign in sheets, etc. will be reviewed. There is a Civil Rights Training PowerPoint available on our website for your reference. SED will determine if the Civil Rights Compliance Report is completed and maintained on file with annual program records (this is applicable only if data is not collected by another department within SED). 41

47 SFAs with more than one school must perform a minimum of one on site selfreview per building prior to February 1 of each school year to evaluate the school's procedures for counting and claiming meals for reimbursement. SED will determine if the SFA has conducted the on site self review and ensure that it was conducted within the required timeframe. For any findings that require follow up, the SFA is required to conduct a second self review of the site within 45 days to confirm the corrective action taken resolved the problems. Further, SED will determine if the monitoring form has been used to conduct the on site self review. SED recommends using the monitoring forms that are available on the our website in the Forms tab under Annual Self Review. 42

48 The Healthy, Hunger Free Kids Act of 2010 strengthened local school wellness policy requirements by adding provisions regarding content, public input, implementation, evaluation and transparency. The Local School Wellness Policy, is evaluated during an administrative review. SED will ask for this documentation in the off site assessment tool. Representatives from the SED Student Support Services office will be evaluating your Local Wellness Policies and may contact you for information to provide technical assistance. Please be cooperative as they are assisting our office with this review process. Each SFA should have a Local School Wellness Policy committee which should periodically assess your SFAs compliance with the policy to determine if you are making progress toward attaining goals or if changes or additions are necessary. This assessment should be made public as well. 43

49 SED is required to review SFA compliance with Smart Snacks in Schools. There are questions pertaining to Smart Snacks in Schools in the off site assessment tool. During the on site review SED will: Review nutrition documentation and whether that nutrition documentation is consistent with the foods and beverages offered to students for sale, including foods sold a la carte during meal services and fundraisers if food fundraisers are held during the school day. Documentation may include nutrition facts labels and/or print outs of the Smart Snacks Product Calculator Interview school food service staff and administration to determine if staff are familiar with requirements and Will ensure that leftover breakfast and lunch entrees are only sold to students the same day, or the day after they were initially offered. ASFA s Local School Wellness Policy may include information about the schools regulations for all foods and beverages sold during the school day. 44

50 SED will review documentation to support that professional standards requirements for school nutrition staff are met. SFA must be prepared to provide information requested that includes at minimum, a current list of school nutrition staff personnel and individual documentation for each of those individuals showing the following: name of staff person, date hired, title/position, a brief list of core duties, employment status (full time, part time, or substitute), include average hours per week for each part time employee, and professional standards employee category/position (such as: Nutrition Program Director, Manager, or Staff). All training hours must be logged and readily available upon request. Training records should include the employee name, school, training title, name and title of instructor, topic/objectives, training source (webinar, PowerPoint, conference call etc.), dates and total training hours. For , School Nutrition Program Directors must have at least 6 hours of annual continuing training in addition to at least 8 hours of food safety training completed within 5 years prior to the starting date, or within 30 calendar days of the starting date. All program staff (full and part time) must have at least 4 hours of annual continuing training. 45

51 The Healthy Hunger Free Kids Act of 2010 requires that water be made available to all students with lunch and breakfast when breakfast is served in the cafeteria. If a school is serving breakfast in an alternate location, such as in classrooms, free potable water is not required, although it is strongly encouraged. The water is not in competition with milk and is not considered a beverage choice, because no beverage can compete with milk. Water availability is in addition to milk. The SFA cannot charge for water and is not required to serve bottled water. Potable tap water is adequate to fulfill this requirement. A drinking fountain located right outside of the cafeteria can be used to fulfill this mandate if students have free access to the fountain. Water availability is also Recommended for Snack 46

52 SED will assess if proper food safety practices are followed at each RA selected for review Food safety compliance is assessed in the following areas: Each site must have a written food safety plan for food preparation, service and storage facilities based on HACCP. The food safety plan should be a working document that has been modified to your site s specific operations and reviewed by kitchen staff periodically or when changes to your operation occur. Documentation requesting two annual food safety inspections from the health department, with the most recent inspection posted in a publicly visible location. Proper recordkeeping, and Temperature logs (include food, refrigerator and freezer temperature logs) A school found to be operating without the necessary health; safety and sanitation permits will be placed on hold and may be subject to fiscal action 47

53 All reports must be submitted to SED timely which includes submitting annual reports such as the SFA Profile/Renewal, health inspection report, income verification report, claims, and analysis of cash resources. SFA s must maintain accurate records of all Child Nutrition Program (CNP) operations and documentation supporting program operations and participation pursuant to the Single Permanent Agreement and CNP laws, regulation and policy. These records must be maintained for a period of three (3) years after the end of the fiscal year to which they pertain and must be readily retrievable or immediately available upon request whether such request is due to an announced or unannounced review. Please see the Annual Checklist handout that we have provided for you today for all requirements 48

54 SED will evaluate how the SFA conducts required outreach activities in an effort to increase participation in both the School Breakfast Program and Summer Food Service Program. SFAs must send reminders regarding the availability of the School Breakfast Program regularly during the school year. The reviewer must be able to validate that information about the Summer Food Service Program was provided to families prior to the end of each school year. If your administrative review is conducted early in the school year and you have not conducted SFSP outreach yet, you must communicate to SED your SFA s plan to provide outreach to families before the end of the school year. 49

55 The SFA must prepare a written corrective action plan addressing any general area findings. No fiscal action will be required if the corrective action plan is submitted and approved by SED. If an SFA either failed to submit a written corrective action plan or did not implement the corrective action as required, then SED may withhold program payments until corrective action occurs. 50

56 Now we are going to answer questions of the topic area that we just covered which includes the General Program Component of the Administrative Review. If you have other questions there will be time at the end of the presentation to answer those questions as well. Type questions that you have into the Q and A box located on the right hand side of your screen. We will answer questions for the next 5 minutes and then proceed to the next topic. 51

57 The next topic area is Other Federal Programs Which includes Afterschool Snacks served in After School Care Programs, Fresh Fruit, and Vegetable and the Special Milk Programs and Food Service Management Companies. 52

58 For Schools offering afterschool snacks in afterschool care programs, SED will conduct a review of afterschool snack documentation for each site selected that operates the afterschool care program. SED will evaluate that students are served a nutritionally balanced snack, appropriate enrichment activities are offered, site eligibility is determined accurately, and the program is well managed. SED will review: Site documentation of regularly scheduled activities, including educational or enrichment activities (e.g., mentoring or tutoring programs) Point of service counts Menu and production record documentation Snack program on site self review documentation, found on our website in the forms tab (as a reminder, the SFA must conduct a self review of each snack program twice per year, the first self review must be conducted within the first 4 weeks of operation and the second review is conducted before the prior to the program ending) And that the food service staff are practicing food safety and civil rights requirements are met. If area eligible, snack should be served free to all children and will be reimbursed at the free rate. If the site is not area eligible, snacks must be served by the approved student eligibility and claimed at the free, reduced price or paid category. SFAs cannot charge more than $0.15 for reduced price snack. 53

59 SED will conduct a review of Fresh Fruit and Vegetable Program documentation for each RA selected that operates the program. SED will review the claim and supporting documentation on site and will observe the operation of the program to ensure Fresh fruit and vegetables are available to all children, free of charge, and offered during correct times Outreach is provided to families Only allowable fruits/vegetables and accompaniments are offered And good Food safety practices are followed 54

60 SED will conduct a review of Special Milk Program documentation for each RA selected that operates the program. The pricing policy, counting and claiming, civil rights and record keeping will be reviewed 55

61 The SFA must prepare a written corrective action plan addressing any findings for other federal programs the SFA is operating. If an SFA either failed to submit a written corrective action plan or did not implement the corrective action as required, then SED may withhold program payments until corrective action occurs. Common findings that may result in fiscal action for these other Federal programs would be: If snacks are not being counted and claimed correctly Snacks that are missing meal components on the meal service line during the day of review or Production records showing missing snack components If the SFA could not substantiate purchases or if the SFA purchased unallowable items with Fresh Fruit and Vegetable funds If any claim for reimbursement is not properly payable or if certification and counting and claiming errors occur in the SMP. 56

62 If your SFA operates using a FSMC, we will ensure that the SFA has retained signature authority on the claim for reimbursement and that the SFA is performing all tasks related to the application and verification process. The SFA must conduct a reconciliation at least annually to ensure that the FSMC has credited it for the value of all USDA foods received, discounts, rebates, and credits. The SFA must maintain the applicable health certification(s) necessary. The SFA must maintain an advisory board composed of parents, teachers and students to assist in menu planning. The SFA should be conducting periodic on site visits to ensure that the Food Service Management Company (FSMC) is following all requirements set forth in the contract, as the SFA is ultimately responsible that all requirements are being met. 57

63 Now we are going to answer questions of the topic area that we just covered which includes the Other Federal Programs and Food Service Management Companies of the Administrative Review and any other questions that you have. Type questions that you have into the Q and A box located on the right hand side of your screen. We will answer questions for the next 5 minutes. 58

64 SFA s are required to follow procurement procedures for ALL purchases made with CN funds, regardless of the dollar amount, including services. The federal small purchase threshold is $150,000; however, the SFAs purchasing threshold determines what form the procurement process must take, i.e. formal vs. informal procurements. Competition must be free and open to allow an all vendors to participate in the procurement bid/quote process. USDA is creating a separate procurement review. We will be required to review procurement procedures and related documents in beginning of next school year. Goods and services purchased with federal child nutrition funds should be acquired according to the procurement procedures in the uniform requirements listed here. Depending on your organization type, there are different procedures to follow. All organizations should have a written procedure of how procurement is conducted and who from the organization conducts the procurement. There should be no conflict of interest. For example, the choice to purchase bread from the bakery that the uncle of a school employee owns is considered to be a conflict of interest. All SFAs are required to have written procurement procedures and maintain documentation to support that these procedures are followed. All aspects of each procurement, including the rationale for the procurement method selected, contract type selected, and basis for contract price must be documented. Failing to maintain required records can result in audit and review findings, cost disallowances and could prevent organizations from effectively responding to bid protests and disputes. 59

65 The comprehensive resource management review process is the fiscal section of the administrative review. Let s discuss the process. 60

66 The review cycle begins when the Child Nutrition office sends the off site assessment to school food authorities scheduled for administrative reviews in the current cycle. The SFA returns the off site assessment and the responses are entered into a risk assessment tool to determine if there are any potential weaknesses in the nonprofit food service account. The audit team will contact you if we need to clarify your responses or if necessary, to schedule a comprehensive resource management review. Any findings or recommended corrective action will be given to the Child Nutrition program person assigned to your SFA to incorporate into the overall administrative review letter. 61

67 The comprehensive resource management section is comprised of four main parts Maintenance of the Nonprofit Food Service Account, Paid Lunch Equity, Nonprogram Food Revenue and Indirect Costs. The child nutrition auditors will be focusing on these parts in detail during a review, and you will be directed to provide data for each section to assist the CNP in determining if your school is following and meeting Federal guidelines specific to the maintenance and operation of the NSLP and requirements of the nonprofit school food service account. 62

68 Two of the sections Paid Lunch Equity (PLE) and Nonprogram Food Revenue require a Microsoft Excel file referred to as a tool to be utilized in assisting you with answering questions on the off site assessment. When your off site assessment is reviewed by CNP s audit staff, we may request you send us your completed PLE tool and/or Nonprogram Food Revenue tool to support any findings or questioned costs. 63

69 If the CNP s audit staff conduct a comprehensive resource management review, the SFA will most likely be asked to respond to specific questions regarding: Revenues and expenditures in the nonprofit food service account for the last closed out school year or fiscal year A general overview of the SFA s food service program and how it operates. 64

70 What will be reviewed? As previously mentioned, we will be looking at four sections Maintenance of the Nonprofit Food Service Account, Paid Lunch Equity (PLE) & Tool, Revenue from Nonprogram Foods & Tool and Indirect Costs. 65

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72 The maintenance of the nonprofit food service account is reviewed for compliance with the regulations listed here. SFAs should familiarize themselves with these regulations, as well as their own accounting procedures specific to the nonprofit food service account. 67

73 As part of our review of the nonprofit food service account, we will review expenditure reports, itemized costs and select documentation. We will send the SFA a letter approximately four weeks before the review with a list of things to gather. Please note that the PLE and Nonprogram Food Revenue tools will be mentioned in the letter and should be sent to Child Nutrition prior to our visit. During the on site review, the audit staff will review these items to determine if the costs are allowable. 68

74 Costs charged to the nonprofit food service account should be necessary, reasonable and allocable. 69

75 Specific to 7 CFR (b), net cash resources will be reviewed to verify if the SFA is meeting the requirement to limit its net cash resources to an amount that does not exceed three months of average expenditures. Excess revenue must be used in support of the operation or improvement of the nonprofit food service. Please provide a clear record of where excess revenues are being utilized. SFAs cannot carry negative fund balances from year to year. Negative fund balances are an indication of bad debt, which is an unallowable expense. Documentation must be provided showing a transfer from another fund, such as the general fund, to the nonprofit food service to cover any losses. 70

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77 The data from the PLE tool is required when CNP is conducting a comprehensive resource management review of the NSLP. SFAs use this tool to determine if they comply with the paid lunch equity provision found in 7 CFR (e). If Federal requirements are not met, the SFA must raise their paid lunch prices or add money from a non Federal source to the school food service account. This tool should be used on an annual basis to verify if the SFA is charging enough for paid lunches compared with Federal paid and free reimbursement rates. The tool and associated monitoring are intended to ensure support for paid lunches is in compliance with Section 205 of the Healthy, Hunger Free Kids Act of

78 The tool utilizes lunch pricing from October of the previous school year and from the prior school year weighted average price. Please note that a new version of the tool is updated every year. Check the CNP home page (typically the end of June) for the annual Paid Lunch Equity memo. The tool can be accessed through the annual PLE memo and includes updated annual instructions for completing the tool. The tool should be utilized in determining the paid lunch price for the new school year. Remember you will be asked for the completed PLE Tool (or other method used), along with a copy of the data used to determine the paid lunch price. Therefore, it is in the SFA s best interest to establish a tracking mechanism to capture the required data on a monthly and annual basis. Failure to do this may result in future review findings that could possibly lead to Federal funds being withheld. 73

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80 This tool is used to verify the requirements in Section 206 of the Healthy, Hunger Free Kids Act of 2010 to ensure that the revenue generated from the sale of non program foods complies with the requirements in 7 CFR (f). You can download the tool through the CNP website. The tool data is required if CNP is conducting a comprehensive resource management review of the National School Lunch Program. Verifies if the SFA is sufficiently pricing non program foods and a la carte items. Please note that USDA Food and Nutrition Services (FNS) defines non program foods as those foods and beverages sold in a participating school other than reimbursable meals and meal supplements that are purchased using funds from the non profit school food service account. Non program foods include a la carte items and adult meals. They also include items purchased with non profit school food service account funds for vending machines, fundraisers, school stores and for catered and vended meals. 75

81 Please set up a tracking mechanism to capture the data required to complete the tool on an annual basis. Remember program food costs must be tracked separately from non program food costs, as well as, revenues from the sale of non program food. This requirement may be a new procedure for many SFAs. Please note that this specific data will be requested in the future. The data is very difficult to isolate after the fact, and we strongly encourage you to establish a system that works best for your food program/s, accounting procedures and accounting software. Failure to do this may result in future review findings that could possibly lead to Federal funds being withheld. 76

82 Things to remember: Adult meals are not eligible for reimbursement and they do not earn donated food assistance for the SFA. Food service revenues cannot subsidize program meals served to adults. The current per meal value of entitlement and/or bonus donated foods must be accounted for in adult meal pricing 77

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84 Indirect costs may be charged to a food service account as long as certain requirements and processes are met. The SFA must have an approved indirect cost rate agreement on file with SED in order to apply an indirect cost rate. The SFA must make certain the indirect cost charged to the non profit school food service account is consistent with the approved indirect cost rate to the direct cost base found in the SED approved indirect cost rate agreement. Application of indirect cost rates must be consistent in all activities of the SFA. SFAs cannot bill the nonprofit food service account for indirect costs previously paid by the general fund in previous years. Costs to the food service account must be consistently treated as direct or indirect without double dipping. 79

85 You will be asked for your indirect cost agreement and supporting documentation as part of the comprehensive resource management review process. Be prepared to explain how the indirect costs were calculated. If it is determined the SFA incorrectly calculated or applied an incorrect rate, the SFA must recalculate the indirect cost expense and correct it in the nonprofit food service account. 80

86 Now we will discuss the Post Review process. Once the Administrative Review is complete, we will conduct an exit conference. This occurs after all off site and on site portions of the review are completed, including the comprehensive resource management review and the nutrient analysis, if necessary. The intent of the exit conference is for the SED reviewer to go over the extent of the violations and provide a preliminary assessment of the actions needed to correct the violations. The exit conference is an opportunity to establish an agreed upon Corrective Action Plan (CAP) that identifies the needed corrective action and the timeframes for those actions. To be specific, the corrective action plan must identify... the violation(s) found the corrective action(s) required the timeframe(s) by which the corrective action(s) must be completed any documentation that SED expects the SFA to provide to demonstrate completed corrective action In order for SED to close out the Administrative Review, SED must receive documented corrective action from the SFA for any degree of finding in either the Critical or General Areas that was identified during the Administrative Review. Corrective action is required to be applied to all schools under the jurisdiction of the SFA, as appropriate, to ensure that previously deficient practices and procedures are revised. Unless the SFA provides documented corrective action at the time of the Administrative Review, the SFA must send written notification to the SED certifying that it has completed the corrective action required for each finding, and has met the corresponding dates of completion. SED makes the determination as to whether/when the SFA adequately corrects the violation(s). Finally, the SFA must postmark or submit documented corrective action to SED no later than 30 days after the established deadline for completion of each required corrective action SED may withhold funds if a corrective action plan is not submitted according to mutually agreed upon time frames. 81

87 Fiscal action includes, but is not limited to, the recovery of overpayment through direct assessment or offset of future claims, disallowance of over claims as reflected in unpaid Claims for 81

88 Reimbursement, submission of a revised Claim for Reimbursement, and correction of records to ensure that unfiled Claims for Reimbursement are corrected when filed. It also includes 81

89 disallowance of funds for failure to take corrective action to meet the meal requirements. SED reserves the right to conduct additional reviews, either announced or 81

90 unannounced, for any irregularities and/or to verify corrective action was completed and applied to all schools under the jurisdiction of the SFA, as appropriate. Again, failure to fully and permanently 81

91 correct all findings to SED s satisfaction and within the allotted timeframes established will result in issuance of a Notice of Proposed Termination and funds being withheld and/or denied. 81

92 Now we are going to answer questions of the topic area that we just covered which includes the Resource Management and the Post Review Procedures of the Administrative Review. Type questions that you have into the Q and A box located on the right hand side of your screen. We will answer questions for the next 5 minutes. We will then open up the Q &A for any questions related to the administrative review process. As a reminder, To print or save the presentation slides or resources go to File at the top of your screen and select Transfer. Click on the file that appears in the file transfer screen and select Download to open the zipped file and to print or save the files to your computer. 82

93 If you still have questions you can contact our program office at the phone number listed on this slide. 83