Administrative Review Summary Report

Date: 11-22-24

Name of Agency: Unity Point Counseling and Resource Center Date of off-site review: 09-11-24

Reviewer: Matthew Smith Date of on-site review: 10-16-24

Persons interviewed: Yolanda Cummings and Date of exit conference: 11-20-24

Jeanette Matthews

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

Fiscal Action: None. OKDHS is exercising its discretion to not assess fiscal action for performance standard two violations as permitted by federal regulation [7 CFR Part 210.18 (g) (2)].

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

Buy American Provision: During the day of review the lunch menu included pineapple that was a product of Indonesia in violation of the Buy American Provision [per federal regulations 7 CFR Part 210.21 (d) and 7 CFR Part 220.16 (d)]. Unity Point Counseling and Resource Center (UPCRC) did not have documentation of the use of a limited circumstance permitting the purchase of non-domestic food products [as permitted by federal regulation 7 CFR Part 210.21 (d) (5) and 7 CFR Part 220.16 (d) (5)]. Prior to the completion of the on-site portion of this AR, documentation of the limited circumstance permitting the purchase of non-domestic products was provided OKDHS School Nutrition Programs (SNP).
Civil Rights – Procedure for Handling Civil Rights Complaints: The written procedures for handling civil rights complaints provided at the time of the off-site portion of this AR did not have the current protected classes [as required by USDA FNS Instruction 113-1]. Prior to the completion of this AR, Unity Point Counseling and Resource Center (UPCRC) took corrective action by adopting a written procedure complaint with federal requirements.
Meal Patterns: During the menu week assessed 08/19/24 through 08/25/24 some insufficient serving sizes were discovered for the lunch menus served [7 CFR Part 210.10 (c)]. OKDHS SNP is using its discretion to not assess fiscal action for the insufficient serving size as permitted by federal regulation [7 CFR Part 210.18 (g) (2)]. Prior to the completion of on-site portion of this AR, UPCRC took corrective action by bringing the insufficient servings into compliance.

No further action is required for the above.

Findings and Recommendations Identified During the Off-Site Portion of the Review Conducted September 11, 2024:

Local Wellness Policy: The local wellness policy provided during the off-site portion of this AR contained an incomplete local wellness committee list when compared to the most recent triennial wellness assessment report. Federal regulations [7 CFR Part

210.31 (c) (5) and 7 CFR Part 210.31 (d) (1)] as part of community involvement requires the listing of the committee membership in the local wellness policy.

To demonstrate compliance with local wellness policy requirements:

Update UPCRC’s local wellness policy to contain the committee listed on the triennial wellness assessment report.
Provide a copy of the updated local wellness policy
Post the updated local wellness policy publicly.
Provide a copy of the updated local wellness policy along with UPCRC’s plan for corrective action to demonstrate understanding and compliance.

Production Records: UPCRC was not documenting the following for breakfast and lunch on the production records:

Documenting two varieties of milk being offered to the children with each breakfast and lunch meal service
Yogurt is a meat alternate and must be listed in the meat/meat alternate area of the production record
The production record for the menu served on 08/25/24, did not document the green beans served size.

Federal regulations [7 CFR Part 210.10 (a) (3) and 7 CFR Part 210.8 (a) (3)] require SFA to be kept on how the meals produced are compliant with the meal patterns, as well as to be filled out in a manner providing data for proper meal planning.

To demonstrate compliance with production record requirements:

On production records document how the meals produced are compliant with the meal patterns.
Provide one breakfast production record and one lunch production record.
Provide UPCRC’s plan for corrective action demonstrating understanding and compliance.

Professional Standards – Annual Training Hours: During school year 2023 – 2024, UPCRC’s school food services director completed 8.5 hours crediting toward the annual training requirements for the school year. Federal regulation [7 CFR Part 210.30 (c)] requires school food services directors to complete at least 12 hours of training crediting toward the annual training requirements each school year.

To demonstrate compliance with the annual training requirements for school food services director:

Provide UPCRC’s plan for corrective action demonstrating understanding and compliance.

Findings and Recommendations Identified During the On-Site Portion of the Review Conducted October 16, 2024:

Health Inspections: Unity Point Counseling and Resource Center (UPCRC) did not receive two inspections from the local health department during school year 2023 – 2024 as required by federal regulation [7 CFR Part 210.13 (b)]. During school year 2023 – 2024, UPCRC contacted the local health department to request a second inspection. The local health

department denied the request. UPCRC failed to retain documentation of this request as required by federal regulation [7 CFR Part 210.13 (b)] and the USDA FNS Administrative Review Manual.

To demonstrate compliance with health inspection requirements:

Begin to retain documentation of annual contact to request a second inspection for three school years plus the current school yea.
Provide UPCRC’s plan for corrective action demonstrating understanding and compliance.

Reviewer’s Comments: I would like to commend the staff members with duties within UPCRC’s school food services programs for all the hard work they do daily. This review demonstrated the good work being done by these staff members.

Procurement Review Summary Report

Date: 11-22-24

Name of Agency: Unity Point Counseling and Resource Center Date of AR off-site review: 09-11-24

Reviewer: Matthew Smith Date of AR on-site review: 10-16-24

Persons interviewed: Yolanda Cummings and Date of exit conference: 11-20-24

Jeanette Matthews

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

Findings for the Procurement Review (PR)

Record Retention: During this review it was discovered Unity Point Counseling and Resource Center (UPCRC) failed to retain invoices (receipts) from one vendor (Costco) sufficiently document the history of procurement with this vendor as required by federal regulations [2 CFR Part 200.318 (i), 7 CFR Part 210.21, and 7 CFR Part 220.16]. Documentation of the history of procurement activities is required [by federal regulation 2 CFR Part 200.334] to be retained for three school years plus the current school year.

To demonstrate compliance with Buy American Provision requirements:

Begin to retain all procurement records for at least three school years plus the current school year.
Provide UPCRC’s plan for corrective action to demonstrate understanding and compliance.