The nuts and bolts of an administrative review
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THE NUTS AND BOLTS OF AN ADMINISTRATIVE REVIEW. Vijay K. Ummadi Andrea Segura Health Educators Student Nutrition Bureau. Review Cycle. SFAs will be reviewed at least once during the established three year cycle

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The nuts and bolts of an administrative review

Vijay K. Ummadi

Andrea Segura

Health Educators

Student Nutrition Bureau

Review Cycle

  • SFAs will be reviewed at least once during the established three year cycle

  • The review period must include the most recent month for which a claim for reimbursement was submitted

Program areas to be reviewed
Program Areas To Be Reviewed

Critical Areas

  • Performance Standard 1 – Meal Access and Reimbursement

    - Certification and Benefit Issuance, - Verification

    - Meal Counting and Claiming

Program areas to be reviewed1
Program Areas To Be Reviewed

Critical Areas

  • Performance Standard II – Nutritional Quality and Meal Pattern

    - Meal Components and quantities - Offer vs. Serve

    - Dietary specifications and Nutrient Analysis

Program areas to be reviewed2
Program Areas To Be Reviewed

  • Resource Management module

  • General Program Compliance

  • Other Federal Program Reviews

The administrative review process
The Administrative Review Process

1. Administrative review confirmation/ introductory letter is issued to SFA 30 days prior to review date.

2. Conduct entrance conference at Superintendent’s or Principal’s office

3. Conduct on-site visits to selected schools and FSD’s office

4. Conduct exit conference

Administrative review process
Administrative Review Process

5. State agency will issue a corrective action plan within 30 days from the exit conference date

6. SFA has 30 days to adequately respond to all findings noted in the administrative review letter

7. If there are no findings or every aspect of the review has been adequately addressed, the state agency will issue a Letter of Closure

Performance standard i certification benefit issuance process
Performance Standard I – Certification/Benefit Issuance Process

  • Applications should be readily retrievable by School

  • Free and Reduced-price applications will be reviewed including the ones which are temporary and denied

  • Applications will be checked for correct approval based on income guidelines & family size, food stamps and direct certification

  • Determine if questionable applications were researched before eligibility determination made

  • Official Direct Certified list will also be reviewed

Performance standard i benefit issuance roster list
Performance Standard I - Benefit Issuance/Roster list

  • Benefit Issuance/ Roster list:

    Is there a listing of all students and their approved categories by school?

  • Benefit issuance / Roster:

    should include the Child’s name, approved status, date approved and date noting a change (such as drop, transfer, status change) should reflect on the roster or application

Performance standard i benefit issuance roster list1
Performance Standard I -- Benefit Issuance/Roster list

  • School benefit issuance /roster list will be compared to all the Free/Reduced/Paid applications and direct certification list to make sure approval is correct.

  • Any change on the benefit issuance list or application or other documents must be initialed and dated by the person making the change.

Performance standard i verification process
Performance Standard I -Verification process

  • Verification of the free/reduced applications should be completed by November 15 of each school year:

    - Selected sample pool based on Oct.1 count of applications

    - Household notification of selection

    - Sources of verification (in the form of paystubs,

    award letters, employer letters)

    - Notice of adverse action (if change in benefits)

Performance standard i meal count claiming procedures
Performance Standard I: Meal Count/Claiming procedures

  • Is the system used providing an accurate point of service count of reimbursable meals served by category(F/R/P) each day without overtly identifying students eligibility? (for Standard and Provision 2 base year Schools)

  • Is the system utilizing base year percentages to point of service total lunch counts? (for Provision 2 Schools)

  • Is the counting, recording, and claiming of the number of meals served to students by category accurate and reported through a system that consistently yields correct claims?

Performance standard i meal count claiming procedures1
Performance Standard I: Meal Count/Claiming procedures

  • Is the collection procedure observed the same as the one submitted and approved by the State agency?

  • Is the coded medium of exchange used correctly?

  • Is there adequate documentation to support the claim?

  • Is on-site review of meal counting and recording procedures in each school is performed annually?

Ps i meal counting claiming
PS I: Meal counting & claiming

  • Point of service should be at the end of serving line to ensure that a reimbursable meal has been served

  • Only one meal type (1 lunch & 1 breakfast) per student per day can be claimed for


  • Adult meals and second meals are not reimbursable and should be accounted for separately.

  • School meal counts, by category, are submitted to the SFA on a daily, weekly, and monthly basis.

  • Meal counts should equal the number of reimbursable meals served to eligible students by category (i.e., free, reduced-price, or paid)

Performance standard i meal counting claiming contd
Performance Standard I: Meal counting & claiming (contd.)

  • The counts from all schools are combined to generate a monthly claim for reimbursement.

  • Is the reimbursement claim submitted on or before the 10th of each month but no later than 60 days following the completion of the claim month?

  • All the records (including applications, edit checks and supportive documentation) should be maintained for three years

Performance standard ii new meal pattern
Performance PatternStandard II: New Meal Pattern

  • The new meal pattern is the foundation of federal school nutrition programs, so it is imperative that SFAs are offering reimbursable meals at breakfast and lunch according to the regulations.

  • SFAs are required to follow the new meal pattern requirements for each age/grade group within all meal service lines diligently.

Ps ii meal components and quantities milk requirements
PS II - Meal Components and Quantities: Milk Requirements Pattern

  • At least two varieties of fluid milk

    • fat free, flavored or unflavored

    • 1% or less, unflavored

      Non-dairy substitutes for students with special dietary needs should meet the nutrition standards

Vegetable subgroup requirements
Vegetable Subgroup Requirements Pattern

  • Schools must offer vegetables from five vegetable subgroups over the course of the week:

    • Dark green

    • Red/Orange

    • Beans/peas

    • Starchy

    • Other

Whole grain rich requirements
Whole Grain-Rich Requirements Pattern

  • Current Requirement (NSLP)

    ½ grains offered over the week must be whole grain rich

    Starting July 1, 2013 (SBP)

    ½ grains offered over the week must be whole grain rich in SBP

    Starting July 1, 2014

    All grains must be whole grain-rich in SBP and NSLP

Fruit requirements
Fruit requirements Pattern

  • No more than ½ of the fruit or vegetable offerings may be in the form of juice. All juice must be 100% full strength

  • ¼ cup of dried fruit = ½ cup of fruit

  • 1 cup of leafy vegetables = ½ cup of vegetable

  • For breakfast vegetables may be substituted for fruits

Meat meat alternate requirement
Meat / Meat Alternate requirement Pattern

  • There is no separate meat / meat alternate

    component in SBP

  • Beginning July 1, 2013, Schools may substitute 1 oz eq. meat/meat alternate for

    1 oz eq. of grains after the minimum daily grain requirement is met.

Ps ii meal components and quantities module contd
PS II - Meal Components and Quantities module (contd.) Pattern

  • Menus / Food production records will be reviewed to assess the new meal pattern compliance

  • Production records should be documented correctly showing daily and weekly meal component requirements being met on a consistent basis for each meal service line and age/grade group served.

Ps ii meal components and quantities module contd1
PS II - Meal Components and Quantities module (contd.) Pattern

  • At the point of service, ensure all the reimbursable meal lines offer all required components and correct portion sizes according to the age/grade groups.

Ps ii meal components and quantities module contd2
PS II - Meal Components and Quantities module (contd.) Pattern

  • Corrective action measures should be taken if vegetable subgroups, milk types, whole grain rich foods, fruit, meat/meat alternate are either missing or served in insufficient quantities.

  • Fiscal action would be taken if repeat violations of missing meal components and/or insufficient portion sizes for different age/grade groups

Offer vs serve
Offer vs. Serve Pattern

  • School is offering enough food on all reimbursable meal service lines

  • Offer vs. Serve signage is posted on the service line

  • Students are selecting enough food components/items to make a reimbursable meal; and

  • Food service staff at the point of service are trained and can recognize a reimbursable meal

Dietary specifications and nutrient analysis
Dietary Specifications and Nutrient Analysis Pattern

  • SFA should serve reimbursable meals according to four dietary specifications:

    • calories (range)

    • sodium (maximum)

    • saturated fats (maximum)

    • trans fat (not allowed, except minimal amount of natural occurring)

General program compliance civil rights
General Program Compliance: PatternCivil Rights

  • Is the nondiscrimination poster posted?

  • Is the nondiscrimination statement printed on correspondence?

  • Is the district handling complaints of discrimination?

  • Is there equal access for all students? (Including accommodating the feeding of disabled students).

  • Is overt identification being prevented during lunch and breakfast serving periods?

  • There should be no separation by race, color, national origin, sex, age or disability in the eating areas and serving lines.

General program compliance
General Program Compliance: Pattern

  • Foods of Minimal Nutritional Value (FMNV) should not be available to students in the food service area during meal periods

  • Is there a Wellness policy in place? Is there a parent/student/school and community involvement in implementing your wellness policy? Is there documentation of activities?

General program compliance1
General Program Compliance: Pattern

  • Is there a HACCP (Hazard Analysis Critical Control Points) policy or food safety plan in place? Are HACCP principles being implemented correctly and in its entirety?

  • Are food temperature logs being maintained?

  • Are they HACCP training sessions for the kitchen staff?

  • Is the School cafeteria being inspected by the Environmental department? Are violations addressed, if noted on inspection?

General program compliance2
General Program Compliance: Pattern

  • SFA on-site monitoring:

    • Each SFA with more than one school should perform at least one on-site review of the lunch counting and claiming system in use in each school under its jurisdiction by Feb.1 of each year

    • SFA need to take corrective action measures

      for any deficiencies in their system

General program compliance3
General Program Compliance Pattern

  • Menus and Food Production Records should be maintained correctly with all the areas documented daily on a consistent basis

  • Program reports and records should be maintained for minimum period of three years.

  • SFA should have free water available to students at each school during meal service

Provision 2 base year
Provision 2 Base year Pattern

  • Are 100% of applications from Provision 2 base year

    for schools selected retrievable?

  • Are the applications approved correctly ? Is direct certification being used properly?

  • Is there a benefit issuance / roster list of eligible students for the base year?

  • Are there point of service breakfast and lunch counts of F/R/P categories for the base year retrievable? (Because, they determine/establish the base year percentages which will have an impact on subsequent years reimbursement claims)

  • Is verification of the selected applications done correctly during the base year?

  • Adult meals and second meals should not be claimed

Other federal programs
Other Federal Programs Pattern

  • Afterschool snacks

  • Seamless summer option

  • Fresh fruit and vegetable program

What triggers a follow up review
What Triggers a Follow-up Review Pattern

Follow-up Reviews:

  • Non-systemic – which means the contributing factors are unusual or are not part of the normal operating procedure, and the system does not have to be changed to achieve accurate results

  • Systemic – means if any of the contributing factors are built into the process and would likely reoccur if the process is not changed. Systemic errors will result in fiscal action

Review threshold
Review Threshold Pattern

Performance Standard 1 violations:

  • Meal counting and claiming violation at School and SFA level due to inadequate system for certification, benefit issuance or updating eligibility status

  • Meal counting and claiming violation at SFA level due to inadequate system for counting, recording, consolidating and reporting lunch counts by category

  • If 10% or more of the F/R lunches were claimed incorrectly for the review period due to errors of certification, benefit issuance or updating of eligibility status

Review threshold1
Review Pattern Threshold

Performance Standard 2 violation:

  • Meal components: If 10% or more of the total number of lunches/breakfast observed in a school are missing one or more of the required components or have insufficient portion sizes, the school has violated Performance Standard 2

Acknowledgement Pattern

  • USDA Administrative Review Guidance Manual was used as a reference for this presentation