Transcript Administrative Review

Administrative Review
Virginia Department of Health
Special Nutrition Programs
2014
Module #8: Administrative Review
State Agency Monitoring Requirements
• Pre-approval visits are conducted for new sponsors.
• Unannounced sites reviews are conducted to observe meal service
and claiming procedures.
• End-of-season administrative reviews of sponsor operations.
Module #8: Administrative Review
State Agency Monitoring Requirements
• Administrative reviews are scheduled by an SNP Liaison in advance
are conducted:
oFor all new sponsors in their first year
oFor returning sponsors at least once every three years
oFor problematic sponsors
oAs needed to meet federal review requirements
Module #8: Administrative Review
Purpose of an Administrative Review
• To evaluate your SFSP for compliance with federal and state
regulations
• To provide technical assistance on implementing Corrective Action
for program areas not in compliance
• To provide technical assistance on best practices for operating your
program
Module #8: Administrative Review
Entrance Conference
• The Administrative review entrance conference is conducted to
discuss the program operational areas that will be examined during
the review
• During the entrance conference, the reviewer will discuss the
Administrative Review Guidance Tool with the sponsor.
Module #8: Administrative Review
Administrative Review Guidance
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Compliance Area 1 – Program Eligibility
Compliance Area 2 – Meal Counts
Compliance Area 3 – Meal Requirements
Compliance Area 4 – Fiscal Accountability
Compliance Area 5 – Site Monitoring and Training by Sponsor
Compliance Area 6 – Sanitation and Safety
Compliance Area 7 – Civil Rights
Compliance Area 8 – USDA Food Program
Compliance Area 9 – Vended Programs
Module #8:
Administrative Review
Compliance Area 1 – Program Eligibility
Required program eligibility documentation includes:
 Open and closed-enrolled sites in needy area:
 Copy of annual public media release
 List of media outlet(s) receiving the release
 Date(s) sent
 Other outreach activities informing community of free meal locations
Module #8:
Administrative Review
Compliance Area 1 – Program Eligibility
Required program eligibility documentation includes:
 Eligibility documents for camps and closed-enrolled sites in a non-needy
area:
 Total number of children enrolled
 Total number of children eligible
 Certified eligibility forms or other approved alternative documentation verifying
children’s eligibility
 Income eligibility scale for the current year
Module #8:
Administrative Review
Compliance Area 2 – Meal Counts
Required meal count documents include:
 For open and closed-enrolled sites:
 Original recorded daily meal count sheets by meal type for each site
 Separate meal count sheets for field trips
 Documentation for second meals claimed at sites that have fluctuations in
attendance (not more than 2% of the first meals served by sponsor).
 System used to consolidate meal counts prior to claim submission.
Module #8:
Administrative Review
Compliance Area 2 – Meal Counts
Required meal count documents include:
 For camps:
 Meal count record
Module #8:
Administrative Review
Compliance Area 3 – Meal Requirements
Required documents include:
 Menus listing food items served to meet component requirements. It is recommended to
include portion sizes and contribution to the meal pattern.
 Recipes for self-prep sponsors
 Child Nutrition (CN labels for commercially prepared items (e.g., pizza, chicken nuggets,
etc.)
 Transport records that have been signed and dated. These are required for vended sites
and should be utilized in self-prep sites
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Administrative Review
Compliance Area 4 – Fiscal Accountability
Required documents include:
 Daily Meal Count forms
 Receipts and disbursements of income to the SFSP
 Costs incurred for operation and administration of the SFSP
 SFSP ledger of income and costs in a consolidated summary
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Administrative Review
Compliance Area 4 – Fiscal Accountability
Required documents include:
 Invoices and payment records for purchase, storage, handling,
processing, and transport of food and supplies
 Inventory of foods and supplies
 Timesheet and payroll records for staff involved in the daily functions
of the SFSP operations, such as preparation and supervision of the
meal.
Module #8:
Administrative Review
Compliance Area 4 – Fiscal Accountability
Required documents include:
 Timesheet and payroll records for administrative and monitoring
staff that do not perform operational duties pertaining to SFSP, but
are changing their time to the SFSP
 Invoices for printing, office supplies, postage, and mileage log
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Compliance Area 4 – Fiscal Accountability
Required documents include:
 Balance sheets that outline SFSP income and expenses to account
for SFSP funds on allowable expenses
 Cash advance documentation such as bank account records
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Compliance Area 4 – Fiscal Accountability
Allowable Costs:
 Operational costs are allowable costs incurred by the sponsor for
preparing and serving meals to eligible children
oFood service labor
oFood
oOther costs
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Administrative Review
Compliance Area 4 – Fiscal Accountability
Allowable Costs:
 Administrative Costs are allowable costs incurred by the sponsor for activities
related to planning, organizing, and administering the program
oLabor for planning and oversight
oMileage
oPrinting and advertising
oOther costs
Module #8:
Administrative Review
Compliance Area 4 – Fiscal Accountability
Unallowable Costs:
Unallowable costs are costs for which program funds may NOT be used. They
include, but are not limited to:
o Costs for excess meals ordered or prepared but not served to eligible
children, e.g., meals in excess of legitimate program adult meals and
reimbursable meals, unless specifically approved by the State agency.
Module #8:
Administrative Review
Compliance Area 4 – Fiscal Accountability
Unallowable Costs:
o Meals served in violation of program requirements; i.e., additional foods
served that are not compliant with the meal patterns, meals or components
consumed off-site, second meals served in excess of the 2% tolerance
o Rental costs for periods beyond the close-out date for program operation
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Compliance Area 4 – Fiscal Accountability
Unallowable Costs:
o The cost to purchase food (including coffee, etc.) for use outside of the SFSP
o The cost of meals served to administrative adult personnel, or any other
adults that are not in the operation of the food service.
o Bad debts, which are any losses arising from non-collectable accounts and
other claims and related cost
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Compliance Area 4 – Fiscal Accountability
Unallowable Costs:
o For vended sponsors, the cost of meals delivered by a food service
management company to a non-approved site, or for meals not delivered
within the agreed upon delivery time, meals served in excess of the approved
cap, spoiled or unwholesome meals, or meals that do not meet meal
requirements or quality standards.
o Entertainment and fundraising costs
Module #8:
Administrative Review
Compliance Area 5 – Site Monitoring & Training by Sponsor
Required documents include:
• Site pre-operational visit reports for new sites and sites with operation
problems
• Site monitoring visit reports
o First Week Site Visit report completed within the first week of operation for
new sites and sites with operation problems
o Site Review report completed by the end of the 4 th week of operation
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Administrative Review
Compliance Area 5 – Site Monitoring & Training by Sponsor
Required documents include:
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Follow-up review reports as warranted
Dates and agendas for staff training on program requirements
Staff training attendance roster with staff sign-in
Documentation supporting additional training and corrective actions provided
at sites with identified problems.
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Compliance Area 6 – Sanitation and Safety
Required documents include:
• Notification letter to the local health authority of the sites participating in
the SFSP including addresses, contact information, dates of operation, and
meal times
• Inspection reports from health authority and documents of corrective actions
• Current health/kitchen permit of the facility used for preparation of meals
for SFSP
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Compliance Area 6 – Sanitation and Safety
Required documents include:
• Each site where meals need preparation. This may include, but is not
limited to serving food on plates, reheating unwrapped food, washing fruits,
or assembling unwrapped foods into unitized meals before serving.
• Best Practice: food safety certification for a minimum of one employee at
each self-preparation site where meals are prepared
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Compliance Area 6 – Sanitation and Safety
Recommend daily:
• Temperature logs for refrigeration and freezer units
• Delivery records for time and temperature of food to verify meals
served were safe for consumption
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Compliance Area 7 – Civil Rights
Required documents include:
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Civil rights complaint procedures
Name of Civil rights coordinator
Ethnic or racial data form of participants at each site
Documentation for accommodating persons with disabilities or special dietary
needs (medical statement)
• “And Justice for All” poster visible at all participating sites.
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Administrative Review
Compliance Area 8 – USDA Food Program
Required documents for utilizing USDA Foods at self-preparation and/or
food service management company sites include:
• Inventory system to monitor USDA Foods
• Ending inventory report of USDA Foods to be utilized in other Child
Nutrition Programs
• Evidence of accepted donated food is used in menu records
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Administrative Review
Compliance Area 9 – Vended Programs
Required documents include (if applicable):
• Contract or Agreement for purchasing meals from a commercial food vendor,
school district, or other SFSP sponsor
• Contract for other services such as consultants, equipment rental, kitchen
facilities, or vehicle rental
• Bid procedures for those sponsors with contracts over the current dollar
threshold per State and federal laws.
Module #8: Administrative Review
Exit Conference
• The exit conference is conducted to discuss the review findings and
any required corrective action.
• Sponsors are provided with a written report summarizing the
review findings and required corrective action
Module #8: Administrative Review
Corrective Action Documentation
• Sponsors will provide to the reviewer a written corrective action
plan explaining new procedures that will be permanently
implemented and followed to ensure compliance with regulations
Module #8: Administrative Review
Corrective Action Documentation
• VDH reviewer will determine if corrective actions are met
satisfactorily once written correction action is received
• Fiscal action adjustments will be process for any over-claimed or
under-claimed meal count.
Module #8: Administrative Review
Fiscal Sanctions for Unallowable Activities:
The following is a list of unallowable activities that will lead to fiscal sanctions.
• Claiming meals taken off-site (except for reported field trips with complete
meals accurately claimed)
• Claiming meals served on-site or on a field trip that did not have prior
approval from VDH.
• Claiming adult meals
Module #8: Administrative Review
Fiscal Sanctions for Unallowable Activities:
The following is a list of unallowable activities that will lead to fiscal sanctions.
• Serving incomplete meals (i.e., meals lacking minimum acceptable
components and/or quantities)
• Serving meals outside the approved meal timeframes
Module #8: Administrative Review
Fiscal Sanctions for Unallowable Activities:
The following is a list of unallowable activities that will lead to fiscal sanctions.
• Serving meals over the VDH approved maximum number of meals that may
be served
• Claiming meals on days or at sites not approved to operate
• Claiming meals with no supporting documentation
Module #8: Administrative Review
Records to Keep:
Document program activities and maintain the following records for three additional
yeas after the end of program year:
• Site information and eligibility
• Meal counts
• Menus
• Fiscal accountability
• Site monitoring and training
Module #8: Administrative Review
Records to Keep:
Document program activities and maintain the following records for three additional
yeas after the end of program year:
• Safety and sanitation
• Civil rights USDA Foods
• Food Service Agreement/Contract