Home‎ > ‎Food and Nutrition‎ > ‎

Food Service Review Findings - December, 2016


101 Pleasant Street 
Concord, N.H. 03301 
FAX 603-271-1953

New Hampshire Department of Education
Bureau of Nutrition Programs and Services
101 Pleasant Street, Concord, NH 03301 
Phone: (603) 271-3860
Fax: (603) 271-1953

Letter of Finding: Action Summary Report      

National School Lunch Program Administrative Review Effort (NSLP AR)

 First review conducted at SAU #7 on December 14-16, 2016.

This document represents written notification regarding the findings of the administrative review with required corrective action and timeframes. Upon further examination of the documents and review of requested information following the AR, there may be additional technical assistance or findings requiring corrective actions.

 This information should be shared with the appropriate administrative personnel.

 Key terms:

Findings: the area reviewed was found to be out of compliance based on federal and/or state regulation. A plan of Corrective Action is required.

 Technical Assistance (TA): guidance and recommendations provided to improve and strengthen overall operations and systems for increased efficiency and accuracy.Corrective Action (CA): Federal and/or State regulation compliance errors mandating follow-up corrections with a timeframe for completion. Some Corrective Action plans may also include a possible fiscal action. Failure to respond and provide the necessary corrections may result in the holding of a claim.

Fiscal Action (FA):  recovery of overpayment due to errors in critical review areas associated with federal dollars or repeat Findings.

Recommendation:  The review area did not rise to a required Corrective Action Plan, but there were operational or managerial systems that the State agency felt could use review and consideration.



Please refer to the Code of Federal Regulations, Agriculture, January 1, 2008 manual for specific regulations and rules governing the National School Lunch Program as outlined in this document:


 Part 210          National School Lunch Program

Part 227          Nutrition Education and Training Program

Part 245          Determining eligibility for free and reduced price meals and free milk in schools


 Website links cited in this document are found on the New Hampshire Department of Education Bureau of Nutrition Program and Services (NH DOE-BNPS) website at: http://education.nh.gov/program/nutrition/index.htm

 Accommodating Children with Special Dietary in the School Nutrition Programs Manual

  • After School Snack Program
  • Community Eligibility Provision
  • Dietary Guidelines for Americans
  • Eligibility Manual For School Meals- updated in July 2016
  • Federal Office of Business and Management (OMB) Cost Principles for State, Local, and Indian Tribal Governments is the official federal regulations for National Child Nutrition Program funds.
  • Food Allergies and Anaphylaxis Network (FAAN)
  • Food Buying Guide for Child Nutrition Programs
  • Food Service Management Company Contract information
  • Hazard Analysis and Critical Control Plan (HACCP)
  • Healthy Meals Resource System (HMRS)
  • Managing Life Threatening Allergies in Schools
  • Institute of Child Nutrition (ICN formerly NSFSMI)
  • NH – Farm to School
  • NH School Nutrition Association (SNA)
  • Offer Versus Serve (OVS) in School Meals
  • Sanitation
  • Sanitation Inspections and the related Federal Requirements
  • School Breakfast Program (SBP)
  • School Nutrition Association (SNA)
  • SNA Credentialing Programs
  • School related Code of Federal Regulations (USDA 7 CFR Part 210-250)
  • Special Milk Program (SMP)
  • Team Nutrition
  • Technical Advisory #13
  • Technical Advisory #21
  • USDA Child Nutrition Information Center
  • USDA Child Nutrition Programs
  • USDA Recipes for Schools
  • USDA Special Needs Resources
  • Wellness Policies

NH DOE, Bureau of Nutrition Programs and Services

NSLP/SBP/FFVP Administrative Review and Procurement Review Report for SAU #7

 (Colebrook Elementary School)

Conducted on December 14-16, 2016

 This report addresses areas of the USDA Administrative Review (AR) and Procurement Review (PR) for the National School Lunch Program (NSLP), School Breakfast Program (SBP), and Fresh Fruit and Vegetables Program (FFVP) that had Findings of noncompliance requiring a Plan of Corrective Action (CA) with potential Fiscal Action (FA) or Technical Assistance (TA) provided to strengthen current systems and understanding of USDA regulations. FA is the recovery of overpayment due to errors in critical review areas associated with federal dollars or repeat Findings.  The School Food Authority (SFA) is responsible for overseeing all aspects of the administration of the USDA Child Nutrition Programs.  Findings must be corrected system wide (all schools in SAU).  At the exit conference held on December 16, 2016, a copy of the Draft Action Summary Plan of the AR/PR outcome was provided to Cheryl Covill, Business Administrator, and Steve Learned, The Abbey Group Food Service Director.

 The 6 cents per lunch meal claimed was found to be in compliance and will be maintained.

 Review Areas:

Meal Access and Reimbursement

 Certification and Benefit Issuance


For the Review Month of October:  there were application errors resulting in incorrect meal benefits being assigned; 2 students’ eligibility status was determined incorrectly due to having incomplete applications.  There may be a fiscal action for errors associated with eligibility status.  The State Agency discussed the SFA-1 document (Eligibility Certification and Benefit Issuance Error Worksheet) and SFA-2 (Other Eligibility Certification and Benefit Issuance Error Worksheet) and they were corrected before the end of the on-site visit; no further action needed.

Technical Assistance:

The Eligibility Manual for School Meals, July 2016 (http://education.nh.gov/program/nutrition/documents/2016_eligibility_manual_school_meals.pdf  ) is the resource for Certification and Benefit Issuance.



No Findings


Meal Counting and Claiming

Point of Service (POS)


Milk was available after the POS at Colebrook Elementary School.  However, the cooler was in view of the cashier and easily monitored except when pre-K/K students are going through the line (cashier is helping to serve); before the end of the on-site visit it was decided to keep the milk cold in tubs on the line when these groups were being served; no further Corrective Action needed.

Meal Pattern and Nutritional Quality

Meal Components and Quantities

Menu and Meal Pattern


Acceptable supportive documentation was not initially available for crediting of food components but was available prior to the on-site.

Technical Assistance:

Ensure that meals offered, including condiments, meet dietary specifications regarding fat, sodium and calories; copy of Dietary Specifications Assessment tool with “yellow” flags was reviewed with Steve Learned. 

 http://www.fns.usda.gov/cnd/Governance/Legislation/dietaryspecs.pdf Final Rule Nutrition Standards in the National School Lunch and School Breakfast Programs – Jan. 2012


Production Records (PRs)

“Taste Test” during Review Week of Review Month was not on Production Records even though the item was on the menu and the menu worksheet.

Technical Assistance:

Production Records are a federal requirement.  Proper documentation on Production Records validates the meal pattern, reflects all food items served, including milk types and condiments, and supports menus and claims.

Production Records must match the menu, with any changes noted.

Sample food item production record from Connecticut:  http://www.sde.ct.gov/sde/cwp/view.asp?a=2626&q=320672

OVS (Offer vs Serve)

No Findings


Resource Management

Revenue from Non-program Foods


Currently under a Corrective Action for Revenue from Non-Program Foods; plan is to monitor status at six months.

Technical Assistance:

Regulation 7 CFR 210.14(f) and FNS Instruction 782-5 REV.1

Revenues from the sale of non-program foods must generate at least the same percentage of total school food service account revenues that expenditures from the purchase of non-program foods contribute to total school food service account costs.

Adult meals must be priced so that adult payments are sufficient to cover the overall costs of meals, including the value of any USDA Foods used in the production of adult meals.


General Program Compliance

Civil Rights


Annual Civil Rights training has been scheduled for those who haven’t attended this school year.


There is no written procedure for receiving and processing discrimination complaints for the School Meals Program.

Most current nondiscrimination statement was not on menu but was before the on-site visit; no further Corrective Action needed.

Technical Assistance:  

Food Service should either be added to the existing district discrimination complaint procedure or a separate one specifically for Food Service should be created.

Civil Rights Training for all staff is required annually, including any non-food service staff who work with students, Point of Service, applications, etc. and documentation of training must be maintained.

Corrective Action: By January 27, 2017, please submit a Plan of Corrective Action that will address how SAU #7 will ensure that there is a written discrimination complaint procedure for Food Service.

On-site Monitoring (formerly Accuclaim)


On-site monitoring was completed by February 4 during the last school year.

Technical Assistance:

 A SAU with more than one school must conduct an onsite review of the lunch meal counting and claiming system at each school and 50% of schools operating the breakfast program under its jurisdiction and act upon any Corrective Actions required, by February 1 of each year.  Best practice is to ensure that Corrective Actions address identified issues before the February 1 deadline.

School Food Authority (SFA) On-site Review Checklists http://education.nh.gov/program/nutrition/accuclaim.htm

 School Wellness Policy (LWP)


There is a very active SAU wellness team and the LWP is in process of being updated.

Technical Assistance:

Each local educational agency that participates in the National School Lunch Program or other federal Child Nutrition programs is required by federal law to establish a local school wellness policy for all schools under its jurisdiction.


Please note additional requirements have been added to Local School Wellness Policy Implementation. This information is located on our website:  http://www.education.nh.gov/program/nutrition/school_lunch.htm  under Local Wellness Policy Toolkit and related resources.  This includes:

Review and update the Wellness Policy to set goals, document meetings/activities and track progress toward attaining objectives.

The LEA should be moving towards strengthening local wellness policies, by

1.       Making efforts to include teachers of physical education, school health professionals, and school  


           in the development, implementation and periodic review and update of the policy

2.       Expand the scope of the local wellness policy to include nutrition promotion; and

3.       Required steps regarding implementation, transparency, public input and assessment available to the public.

Smart Snacks

No Findings

Professional Standards

No Findings


No Findings

 Food Safety and Buy American

Case of turkey corn dogs was on floor in Colebrook Elementary School walk-in; moved before end of on-site visit.

Documentation was not available for non-domestic product at Colebrook Elementary School:  pineapple tidbits (Indonesia); granulated garlic (China); raspberries (Mexico); blueberries (Argentina); cucumbers (Canada, Mexico); carrots (Canada); celery roots (Canada); FFVP apples (Canada).

Monitoring component of Standard Operating Procedures involving Food Safety Checklist was revised from daily to monthly so that practice matched the procedure.


Food Safety Plan didn’t include all recipes/menu items in process approach; updated by end of on-site visit; no further Corrective Action needed.

Colebrook Elementary School did not have 2 food safety inspections during the last school year and there was no documentation of a request for a second inspection.

Most recent food safety inspection at Colebrook Elementary School was not posted in a publicly visible location; moved by end of on-site visit; no further Corrective Action needed.

Technical Assistance:

Items must be stored away from walls and at least 6 inches off the floor.

Recordkeeping and monitoring are essential elements in a Food Safety Plan based on Hazard Analysis Critical Control Point (HACCP) principles.

 Schools participating in NSLP and/or SBP are required to implement a Food Safety Plan based on HACCP principles.  This became a requirement in the school year beginning July 1, 2005.  Section 111 of the Child Nutrition and WIC Reauthorization Act of 2004 (Public Law 108-265) amended section 9(h) of the Richard B. Russell National School Lunch Act.

 http://www.nfsmi.org/documentlibraryfiles/PDF/20080220092722.pdf USDA HACCP Guidance

http://www.nfsmi.org/ResourceOverview.aspx?ID=57 National Food Service Management Institute (NFSMI) Developing a School Food Safety Plan resources

http://sop.nfsmi.org/sop_list.php NFSMI SOPs

If a non-domestic product is used in Child Nutrition Programs, documentation must be kept supporting the exception to Buy American regulations.

Policy Memo SP-24-2016; Compliance with, and Enforcement, of the Buy American Provision in the National School Lunch Program.

Corrective Action: By January 27, 2017, please provide a Plan of Corrective Action for addressing two food safety inspections per school year. 

Reporting and Recordkeeping

No Findings

Other Federal Program Reviews

Fresh Fruit and Vegetable Program (FFVP)


Colebrook Elementary School October claim food costs from “Big Papa’s” were not supported by an invoice, only a spreadsheet with no name/address.  The SAU and The Abbey Group are working with the vendor for acceptable source documentation; no further Corrective Action needed.

Technical Assistance:

Remember:  There are no appeals for the identification of Findings requiring plans of Corrective Action. However, if this review includes a financial finding you may appeal the financial amount, 7 CFR 210.18(q). Financial findings will be determined upon receipt of all plans of Corrective Action.

 Procurement Review

Procurement Procedures


The Procurement Procedures did not contain statement to assure that small, minority and women’s business enterprises and labor surplus firms are used when possible per 2 CFR 200.321.

Technical Assistance with Action:

Written Procurement Procedures must include steps to assure that small, minority and women’s business enterprises and labor surplus firms are used when possible.

Food Service Management Companies


Most of the procurements by The Abbey Group were from Reinhardt; The Abbey Group must follow appropriate procurement procedures as the SAU since they are procuring on the SAU’s behalf; some appropriate questions for the SAU to ask would be – does Reinhardt have a contract with The Abbey Group?  How was that contract developed?  Did they go out to bid?  Were there other respondents?  How were the bids evaluated?  Why was Reinhardt chosen?


Documentation had not been maintained for periodic on-site monitoring.

Unallowed milk type was purchased by FSMC.

FSMC mixed up SAU 7’s billings by sending another SAU’s invoice for payment.

Value of USDA Foods for the billing cycle is not disclosed to the SAU by FSMC.

Pursuit of variance with the FSMC with regard to full value of USDA Foods is not included in the procurement procedures.

Technical Assistance with Action:

FSMC monitoring efforts must be documented.

SAU must review all invoices prior to payment and confirm that they are being billed for only allowable costs.

SAU must review all invoices and confirm that they are paying for only their own expenses.

FSMC must disclose value of USDA Foods used within the billing cycle per contract provision.

Pursuit of variance with regard to full value of USDA Foods must be included in the procurement procedures.


State Agency Reviewer:  Nancy Bradford-Sisson