Section 23, Administrative Review - squaremeals · Texas Department of Agriculture—October 17,...

Texas Department of Agriculture—October 17, 2014 Administrative Review 23.1

Section 23, Administrative Review

National School Lunch Program, School Breakfast Program, and Other Federal Programs

Section 23, Update Guide

October 17, 2014 Updated Section 23, Administrative Review to incorporate the following USDA

memos and guidance:

USDA Memo, SP 44-2014, Questions and Answers Related to the Independent

Review of Applications (April 30, 2014)

USDA Memo, SP 24-2014, Additional Administrative Reviews Guidance

(March 6, 2014)

National School Lunch Program: Independent Review of Applications Required

by Healthy, Hunger-Free Kids Action of 2010, Final Rule (February 6, 2014)

USDA Administrative Review Manual (September 20, 2013)

USDA Memo, SP 42-2013, School Nutrition Programs Updated

Administrative Review Process (May 30, 2013)

USDA Memo, SP 12-2013, School Year 2012-2013 Administrative Review

Procedures and New Three Year Administrative Review Cycle Beginning in

School Year 2013-2014 (December 6, 2012)

Provided clarification on the following topics in addition to incorporating

guidance from USDA:

Additional sources for information on program requirements

Contact information for the Texas Department of Agriculture (TDA)

Information and documentation needed for administrative review

Information on the offsite and onsite process for the administrative

review

Records retention

Review cycle and review timeline


Table of Contents

Administrative Review Process Starting SY 2014-2015 ............................................................... 23.6

Focus Areas for the Review ................................................................................................................ 23.7

Definitions for This Section .............................................................................................................. 23.8

Review Cycle ....................................................................................................................................... 23.10

Review Timeline .............................................................................................................................. 23.11

Review Period .................................................................................................................................. 23.12

Special Situation, Review Scheduled Early in the School Year ............................................................ 23.12

Number of Sites to Be Reviewed .................................................................................................... 23.12

Site Selection Required Criteria ................................................................................................................ 23.12

USDA Additional Site Selection Criteria ................................................................................................. 23.12

Other Program Criteria .............................................................................................................................. 23.13

USDA/TDA Additional Site Selection Criteria ....................................................................................... 23.13

Offsite Review Processes .................................................................................................................. 23.14

Assessments ................................................................................................................................................. 23.14

High Risk School ......................................................................................................................................... 23.14

Onsite Review Processes .................................................................................................................. 23.15

Assessments ................................................................................................................................................. 23.15

Records and Documentation Needed for an AR .......................................................................... 23.16

Corrective Action Documents (CAD) ............................................................................................. 23.17

Independent or Second Review of Household Applications ................................................................ 23.17

Follow-up or Second Follow-up Review ....................................................................................... 23.17

Records Retention .............................................................................................................................. 23.18

Compliance.......................................................................................................................................... 23.18

Fiscal Action ..................................................................................................................................... 23.18

Appeals ............................................................................................................................................. 23.19

TDA Termination of an Contracting Entity (CE) from Participating in School Nutrition

Programs .......................................................................................................................................... 23.19


Chart and Information Box Table of Contents

Review Timeline Chart .......................................................................................................................... 23.11

Number of School Selected for Onsite Review Chart ............................................................................ 23.12

Resources to Assist in Preparing Documentation Chart ........................................................................ 23.16

Information Box 1, Records Retention ................................................................................................... 23.18


Contact Information for the

Texas Department of Agriculture (TDA), Food and Nutrition

When contacting TDA by phone, Contracting Entities (CEs) need to have their CE Identification Number (CE ID)

(and site ID if applicable). CEs should include their name and CE ID (and site name and ID if applicable) in all

communication or documentation.

Website: http://www.squaremeals.org

Phone: 877-TEXMEAL, (877) 839 -6985 | Fax: (888) 203-6593

Physical Address: 1700 N. Congress, 11th Floor, Austin, TX 78701

Mailing Address: PO Box 12847, Austin, TX 78711-2847

Email Contact:

[email protected]

Email Contact for Issues Related to Applications:

National School Lunch Program, School Breakfast Program, & Special Milk Program

[email protected]

Seamless Summer Option:

[email protected]

Child & Adult Care Food Program

[email protected]

Summer Food Service Program:

[email protected]

mailto:[email protected]






Administrative Review National School Lunch Program, School Breakfast Program, and Other

Federal Programs

An Administrative Review (AR) is a standardized review process developed by the United

States Department of Agriculture (USDA) that includes a comprehensive offsite and onsite

evaluation of contracting entities (CEs) participating in the following programs:1

National School Lunch Program (NSLP)

School Breakfast Program (SBP)

Other Federal Programs

Afterschool Care Program (AFCP)

At Risk Child and Adult Care Food Program (At Risk CACFP).

Fresh Fruit and Vegetables (FFVP)

Seamless Summer Option (SSO)

Special Milk Program (SMP)

USDA provides specific guidance and instructions for the review process so that all CEs

administering NSLP and SBP across the nation are evaluated in the same manner.

Beginning with School Year (SY) 2014-2015, the scope of the AR has been expanded to include a

risk-based review of program operations to address the following objectives:

1. Determine whether the contracting entity (CE) meets program requirements

2. Provide the CE with technical assistance

3. Secure needed corrective action

4. Assess fiscal action, and when applicable, recover improperly paid funds

1 Administrative Review regulations are set forth in 7 CFR 210.18.


Administrative Review Process Starting SY 2014-2015

TDA will contact the CE eight to twelve weeks before the review to request

information or documentation.

While the information and documentation collected for an AR covers the same

topics, there are new ways of collecting that information and documentation—some

will be collected offsite and some will be collected onsite.

As part of this change, CEs will use TDA’s online system, the Texas Unified

Nutrition Programs System (TX-UNPS), much more extensively to provide

information and submit documentation to TDA.

School nutrition staff may need to reach out to technology staff for assistance

in completing some tasks. This might include saving files into PDF format,

scanning, and attaching files in a web-based environment.

School nutrition staff may also need to reach out to other CE staff to gather

information or identify procedures related to compliance issues.

While the focus areas for the review are not new, the way the questions are asked

may be.

Staff members who have never had to interact with TDA during an AR may

have to do so now. Some staff may need preparation for interacting with

TDA if they have never done so before.

TDA will observe both meal preparation and meal service.

While TDA will continue to collect information specific to sites, much of the focus is

shifting to a CE-wide process-oriented, risk-based review.

If there is finding, the CE must implement corrective action at all sites,

whether the sites were selected for review or not, to ensure that all

corrections are made CE-wide.


Focus Areas for the Review

The review includes the following areas of review:

Critical Areas of Review

- Critical Area 1 (Performance Standard 1), Meal Access and Reimbursement

Certification and Benefit Issuance

Verification

Meal Counting and Claiming

- Critical Area 2 (Performance Standard 2), Meal Pattern and Nutritional Quality

Meal Components and Quantities

Offer versus Serve

Dietary Specifications and Nutrient Analysis

General Areas of Review

- Resource Management

Resource Management

- General Program Compliance

Civil Rights

CE Onsite Monitoring

Local School Wellness Policy

Competitive Food Services

School Meal Environment

Water

Food Safety

Reporting and Recordkeeping

School Breakfast Program (SBP) and Summer Food Service Program (SFSP)

Outreach

- Other Federal Program Reviews

Afterschool Care Program (ASCP)

At Risk Child and Adult Care Food Program (At Risk CACFP)

Fresh Fruit & Vegetable Program (FFVP)

Seamless Summer Option (SSO)

Special Milk Program (SMP)

Other Areas as Determined by TDA

- Areas TDA determines to be relevant, including nutrition policy in Texas schools


Definitions for This Section

For this section, the following terms will be used:

Administrative

Review (AR)

A standardized review process developed by the U.S. Department of Agriculture

(USDA) that includes comprehensive offsite and onsite evaluations of a

contracting entity (CE) participating in the School Nutrition Programs (SNP).

The review includes both critical and general areas of review, as well as areas the

state agency deems as important. USDA provides specific guidance and

instructions for the review process so that all contacting entities (CEs) are

evaluated in the same manner.

Authorized

Representative

(AR)

A person who is authorized to make decisions and sign legally binding

documents on behalf of the CE.

Corrective Action

Documents

(CAD)

Corrective Action Documents, documentation that demonstrates that the CE has

implemented corrective action to adequately address AR findings.

(NOTE: USDA uses the term Corrective Action Plan (CAP); however, the Texas

Unified Nutrition Programs System (TX-UNPS) uses the term Corrective Action

Documents (CAD). Therefore, TDA uses the term CAD in place of CAP in its

procedures and guidance.)

Critical Areas of

Review

One of two areas of review specified by USDA that includes the following topic

areas:

1. Performance Standard 1(PS1), Meal Access and Reimbursement—A

Critical Area of Review that includes certification and benefit issuance,

verification, and meal counting and claiming.

2. Performance Standard 2 (PS2), Meal Pattern and Nutritional Quality—

A Critical Area of Review that includes meal components and quantities,

offer versus serve, and dietary specification and nutrient analysis.

Dietary

Specifications

Tools

A tool used to determine the CE’s level of risk related to the meal pattern. This

assessment is conducted offsite as well as onsite.

Fifteen-Day

Letter (15-Day

Letter)

A letter sent to a CE after an initial inadequate CAD providing notice that the

CE has an additional 15 calendar days to provide adequate evidence of correction

or funds for the CE will be placed on hold.

Fiscal Action

Recovery of overpayment through direct assessment or offset of future claims,

disallowance of overclaims as reflected in unpaid claims for reimbursement,

submission of a revised claim for reimbursement, and correction of records to

ensure that unfiled claims for reimbursement are corrected when filed.

Follow-up

Administrative

Review (Follow-

up AR)—

A targeted review process or desk audit that focuses on verifying corrective action

for findings from any review conducted in the current review cycle. This review

is initiated when a CE receives repeated or systemic critical area or general area

findings that are not corrected systemically; has not submitted adequate CAD in

response to the AR findings; is found to be willfully and egregiously non-

compliant; or has been placed on financial hold.


General Areas of

Review

One of two areas of review specified by USDA that includes the following topic

areas:

1. Resource Management which includes maintenance of the nonprofit

school food service account, paid lunch equity, revenue from nonprogram

foods, indirect costs, and USDA Foods.

2. General Program Compliance that includes civil rights, CE onsite

monitoring, local school wellness policy, competitive food services, school

meal environment, water, food safety, reporting and recordkeeping, and

School Breakfast Program and Summer Food Service Program outreach.

3. Other Federal Programs that includes Afterschool Care Program

(ASCP), Fresh Fruit and Vegetable Program (FFVP), Seamless Summer

Option (SSO), Special Milk Program (SMP), and At Risk Child and

Adult Center Food Program (At Risk CACFP).

General Program

Compliance

A General Area of Review that includes civil rights, CE onsite monitoring, local

school wellness policy, competitive food services, school meal environment,

water, food safety, reporting and recordkeeping, and School Breakfast Program

and Summer Food Service Program outreach.

Independent or

Second Review of

Applications

A requirement to conduct an independent or second review of initial eligibility

determinations for free and reduced-price meals that occurs when a CE has an

error rate of more than 9% household application approvals or denials.

Month of Review

(MOR)

The most recent month for which a claim for reimbursement has been submitted

which has at least 10 operating days.

Non-Systemic

Findings

A finding for which the contributing factors are unusual, not part of the normal

operating procedure—the system does not require changes to achieve accurate

results.

Offsite

Assessment Tool

A tool used to determine the CE’s level of risk related to meal service, program

administration, and other topics. This assessment is conducted offsite before the

onsite review takes place at the CE.

Onsite

Assessment Tool

A tool used to validate the information collected in the offsite assessment and

determine compliance related to meal service, program administration, and other

topics. This assessment is conducted at the CE (onsite).

Other Federal

Programs Review

A General Area of Review that that includes Afterschool Care Program (ASCP),

Fresh Fruit and Vegetable Program (FFVP), Seamless Summer Option (SSO),

Special Milk Program (SMP) , and At Risk Child and Adult Center Food

Program (At Risk CACFP).

Performance

Standard 1 (PS1),

Meal Access and

Reimbursement

A Critical Area of Review that includes certification and benefit issuance,

verification, and meal counting and claiming.


Performance

Standard 2(PS2),

Meal Pattern and

Nutritional

Quality

A Critical Area of Review that includes meal components and quantities, offer

versus serve, and dietary specification and nutrient analysis.

Repeated Finding

Finding determined at the CE level that is the same type of critical area finding

or general area finding that is noted in more than one review during the same

review cycle or across multiple review cycles. This type of finding may occur at

different sites or the same site.

Resource

Management

A General Area of Review that includes maintenance of the nonprofit school food

service account, paid lunch equity, revenue from nonprogram foods, indirect

costs, and USDA Foods.

Resource

Management

Tools

A tool used to determine the CE’s level of risk related to resource management.

Significant portions of this process occur offsite.

Review Cycle A three-year cycle in which each CE in the state is reviewed at least one time.

Second Follow-up

Administrative

Review (Second

Follow-up AR)

A targeted review process or desk audit that focuses on verifying corrective

action for findings from any review conducted in the current review cycle. This

review is initiated at the request of the CE after all corrective actions have been

implemented. This review is initiated when a CE receives repeated or systemic

critical area or general area findings that are not corrected systemically; has not

submitted adequate CAD in response to AR findings; is found to be willfully and

egregiously non-compliant; or has been placed on financial hold.

Systemic Finding

A finding for which the contributing factors are inherent to the routine operation

of the CE or site and are likely to occur again in the same review cycle if

operational processes are not changed.

USDA Foods Foods donated by USDA to CEs to provide additional support to certain federal

nutrition programs (formerly called commodities).

Review Cycle

CEs participating in NSLP or SBP must be reviewed at least once during the established three-

year cycle. New CEs entering the program at any point during a three-year cycle must be

reviewed during that three-year cycle.

The current three-year cycle is July 1, 2013, through June 30, 2016.


Review Timeline

Even though TDA has the discretion to review any CE at any given time, TDA will implement

the following schedule in setting up administrative reviews in most cases:

Review Timeline Chart

June, SY Prior

to Review TDA selects CEs for AR for the following SY.

July, SY of

Review

TDA notifies CEs selected for AR.

TDA notifies the CEs to be reviewed of the date of the review.

TDA begins offsite review process.

8 to 12 weeks

prior to onsite

review

TDA begins the offsite review process which includes an initial call and

ongoing communication with the offsite monitor.

CE provides requested documentation.

CE completes web-based assessments in TX-UNPS.

TDA provides technical assistance as appropriate.

2 to 4 weeks

prior to the

review

TDA reviews documentation that is submitted.

TDA reviews information submitted in web-based questionnaires in TX-UNPS.

TDA calls the CE to establish the onsite process and to request any additional

documentation.

CE provides month of review benefit issuance list and list of verified students.2

CE provides applications for the selected sample.3

CE provides meal counts for month of review.

CE provides the completed Accuclaim/Daily Record for month of review.

CE provides requested week of food production records, menus, and menu

worksheets.

TDA works with CE to establish onsite schedule.


Day of review

TDA conducts onsite review.

TDA requests documentation as appropriate.


Final day of

review

TDA holds exit review conference.

TDA provides a summary of AR results.


4 to 6 weeks

after review if

there is a CAD

TDA sends CE request for CAD.

ESC provides technical assistance if appropriate.

CE completes and submits the CAD (and second CAD if appropriate).

Summer after

onsite AR TDA conducts onsite summer program AR if appropriate.4

2 If the AR is conducted early in the school year, the CE may be asked to provide verification documentation from

the previous school year. 3 While the CE’s submission of applications for the selected sample is listed as action during the 2 to 4 weeks prior to

the review, TDA may move this action to the 8 to 12 weeks prior to the review if warranted. 4 TDA has the option to conduct an SSO review the summer before the onsite review.


Review Period

The review period is the most recent month with at least 10 operating days for which a claim for

reimbursement has been submitted. The latest claim information can be found in the Texas

Unified Nutrition Programs System (TX-UNPS).

Special Situation, Review Scheduled Early in the School Year. If the review occurs early in

the school year and the CE has not filed a claim for the current school year, TDA may

designate the month of review as the last claim in the previous school year. In this case,

TDA would review the previous school year’s eligibility determinations, benefit issuance

documents, and procedures for updating eligibility.

Number of Sites to Be Reviewed

When selecting sites for review, TDA must use USDA’s required procedures and criteria. TDA

will make this calculation; however, the following table provides information on how many

sites will be selected for review.

Number of Sites Selected for Onsite Review Chart

Number

of Schools 1 to 5 6 to 10 11 to 20 21 to 40 41 to 60 61 to 80 81 to 100 101 or more

Minimum

Number 1 2 3 4 6 8 10

12 + (5 % of the

number of sites

> 100)5

Once the number of sites to be reviewed has been determined, TDA will select review sites

based on at least one of the following sets of criteria:

Site Selection Required Criteria

Site meeting one or both of these criteria must be selected:

All sites with a free average daily participation (ADP) of 100 or more.

All sites with a free participation factor of 100 percent or more (except Residential

Child Care Institutions [RCCIs] without day students)

USDA Additional Site Selection Criteria

If additional schools are needed to reach the minimum number, sites meeting one or more of the

following criteria may be selected:

Elementary sites with a free ADP of 100 or more and percent free participation of 97

percent or more

Combination schools with a free ADP of 100 or more and a percent free participation

of 87 percent or more

Secondary schools with a free ADP of 100 or more and a percent free participation of

77 percent or more

5 Fractions must be rounded upward to the nearest whole number.


Other Program Criteria. TDA must also review other school nutrition programs that the CE

operates. TDA will use the following criteria for this purpose:

1. SBP at 50% of the selected schools

If all of the schools selected for review are selected based on Site Selection

Required Criteria and none of the schools operates SBP, TDA will select an

additional school that does operate SBP. In this case, TDA will only review SBP at

this additional school. TDA may also select an additional site to conduct the SBP

review even though one or more of the selected sites operates SBP.

If the schools selected for review include schools selected based on USDA

Additional Site Selection Criteria and/or TDA Additional Site Selection Criteria,

TDA may substitute a school that operates breakfast for a school chosen because

of the additional criteria. In this case, TDA will review both SBP and NSLP.

2. One school operating an afterschool program if any selected school operates the

ASCP or At Risk CACFP

3. At least one SSO site if the CE operates SSO

SSO reviews are typically conducted in the summer following the AR, but TDA

has the option to conduct this review the summer before the AR.

4. The appropriate number of FFVP sites as determined by applying the selection

formula (Number of Schools Selected for Onsite Review Chart) to the number of selected

schools only—not all the schools in the CE.

For Example: The CE has 27 sites, so 4 sites are selected. The CE operates FFVP; therefore at least

one (1) site must be selected for a FFVP review.

USDA/TDA Additional Site Selection Criteria

If additional sites are still needed to reach the minimum number after the USDA criteria are applied,

sites meeting one or more of the following criteria may be selected:

Low participation schools

High participation schools

Schools that have less than 100 free ADP but greater than 100 percent free

participation

Food service director recommendation

Findings from onsite visits or the claims review process

Any school in which the daily meal counts appear questionable

Identical or very similar claiming patterns (e.g., identical breakfast/lunch meal

counts for each day of the week)


Large changes in the free meal counts (e.g., a significant increase/decrease in the

amount of free meals reported without reason)

Schools with a new manager

Manager or school never reviewed by TDA

New or unusual accountability system

Proportional mix of the different counting systems employed by the CE

Schools with a significant number of Office of Inspector General Hotline and/or

parent complaints

Schools with alternate points of service

Schools with a mix of age/grade groups (e.g., K-12 schools)

Schools participating in Fresh Fruit and Vegetable Program (FFVP), Afterschool Care

Program (ASCP), Seamless Summer Option (SSO), Special Milk Program (SMP), and

At Risk Child and Adult Care Food Program (At Risk CACFP)

Offsite Review Processes

Eight to twelve weeks prior to the onsite review, TDA will begin to guide the CE through a series

of actions that include submitting documentation to TDA and completing web-based

assessments. Both of these tasks are completed in TX-UNPS. CEs will also be expected to provide

information or complete actions for the offsite process in a specified timeframe as described in AR

notifications and phone calls with TDA staff members assigned to the CE’s AR.

Assessments. During the offsite review process, TDA will ask or direct CEs to answer

questions for three assessments: Meal Compliance Risk Assessment Tool, Dietary Specifications

Assessment Tool, and Resource Management Risk Indicator Tool that are located in TX-UNPS.

High Risk School. During the offsite review, the assessment process is intentionally designed

to identify one school site that has the highest score. This school site is designated as the site

with the highest risk for noncompliance. This designation does not mean the school is out of

compliance. There will be a school identified as high risk for every AR.

Although a nutrient analysis may be conducted based on the high risk identification, the

determination about whether to conduct this analysis is not determined until after the onsite

review process has been completed.


CEs will answer questions and provide documentation on the following topics in the offsite review:

Certification and benefit issuance

Verification

Meal counting and claiming

Meal components and quantities

Dietary specifications and nutritional analysis

Resource management

Local wellness policy

Other federal programs (ASCP, FFVP, SSO, SMP, and At Risk CACFP)

TDA strongly recommends that school nutrition directors reach out to the CE’s technology staff

to ensure that the CE is able to access information, complete web-based assessments, and

upload documents in TX-UNPS as early as possible in the AR process.

Onsite Review Processes

The onsite review process also allows TDA staff to validate information collected during the

offsite assessment, to observe school nutrition program operations at the selected sites, and

evaluate the CE’s compliance with program requirements. The onsite review includes a formal

entrance conference, observation of meal preparation and service, additional questions on

specified topics, additional documentation review, and an exit conference.

Assessments. During the offsite review process, TDA will ask the CE additional questions

as appropriate from the following assessments: Onsite Assessment Tool and Dietary

Specifications Assessment Tool, and Resource Management Risk Indicator Tool.

(NOTE: Some or all of the questions for these assessments may be asked during the offsite process.)

CEs will answer questions and provide documentation on the following topics in the onsite

review in addition to any requests related to validating information provided for the offsite

assessment and documentation submissions:

Offer versus serve

Civil rights

CE onsite monitoring

Competitive food services

Water

Food safety

Reporting and recordkeeping

Other federal programs (ASCP, FFVP, SSO, SMP, and At Risk CACFP)


Records and Documentation Needed for an AR

Section 3, Records Retention provides a detailed list of documentation CEs are required to retain

for the AR as well as other records retention information. TDA recommends that CEs review

this section periodically to make sure needed documentation is being retained as well as prior

to an AR.

The Resources to Assist in Preparing Documentation Chart provides information on which

Administrator’s Reference Manual (ARM) sections provide additional information on records to

retain specifically for the categories listed.

Resources to Assist in Preparing Documentation Chart

Record Retention

Categories ARM Section for this Topic.

Benefit issuance,

household applications,

direct certification, and

categorically eligible

without application

Section 4, Determining Eligibility

Section 5, Special Provision Options

Section 10, Afterschool Meal Programs

Section 12, Seamless Summer Option (SSO)

Section 26, Residential Child Care Institutions

Section 27, Special Milk Program

Communication and

outreach





Competitive foods Section 20, Competitive Food Nutrition Standards

Counting and claiming



Section 7, Counting and Claiming



Section 26, Residential Child Care Institutions


Financial and accounting

Section 7, Counting and Claiming

Section 14, Financial Information Concerning School Nutrition Funds

Section 15, Meal Pricing

Section 16, Ethics

Section 17, Procurement

Section 19, Other Operational Issues

Section 21, USDA Foods

Section 22, Food Service Management Companies

Meal production and

service

Section 2C, Certification for Performance-Based Reimbursement

Section 8, Breakfast


Resources to Assist in Preparing Documentation Chart

Record Retention

Categories ARM Section for this Topic.

Section 9, Lunch



Section 24, Child Nutrition (CN) Labeling and Product Documentation


Program agreement and

application(s)

Section 2, Application and Agreement

Section 16, Ethics

General Issues, Program

Operation

Section 15, Meal Pricing

Section 16, Ethics

Section 19, Other Operational Issues

Section 21, USDA Foods

Corrective Action Documents (CAD)

Findings or errors noted during the review will be addressed at the exit conference and on the

corrective action documents (CAD). CEs are expected to provide an adequate CAD that

demonstrates that the CE has taken action to resolve all findings according to the timeline and

directions that TDA provides at the exit conference. CEs will upload CAD responses into TX-

UNPS. If a CE does not provide an adequate response, TDA may place a financial hold on all

future claims until the CE provides an adequate CAD in response to AR findings.

Independent or Second Review of Household Applications. A CE that has an error rate of

9% or more based on TDA’s review of household applications must complete an

independent or second review of applications in the school year after the AR. TDA will

notify any CE that must implement an independent review process after the AR has been

completed. The CE will be required to conduct an independent or second review of

household applications each year until the CE has an error rate of less than 5%. See the

Administrator’s Reference Manual, Section 4, Determining Eligibility for additional information

on this process.

Follow-up or Second Follow-up Review

TDA may conduct a targeted follow-up review to verify corrective action for findings from any

review. Before TDA conducts a Second Follow-up Review, the CE must provide an adequate

response to all previous CADs and must request the Second Follow-up Review.

TDA strongly recommends that CEs seek assistance from their regional education service center

nutrition specialist for any actions or issues related to a Follow-up or Second Follow-up Review.


Information Box 1

Records Retention

Public and charter schools are

required to keep documentation

related to school nutrition

programs for 5 years.

Private schools, other nonprofit

organizations, and residential child

care institutions (RCCIs) are

required to keep documentation

for 3 years.

Records Retention

CEs must retain documentation related to the AR. If a case

occurs where records used or needed for the AR process exceed

the number of years required for documents to be retained, the

CE must retain all AR related-records until the appropriate

number of years have passed from the date the AR was closed.

CEs have the option to maintain records on paper or

electronically. All documentation or records must be kept on

file for a minimum of five years for public and charter schools

or three years for private schools, nonprofit organizations, and

residential child care institutions after the end of the fiscal year

to which they pertain.

Compliance

Fiscal Action TDA will take fiscal action as described by USDA in its AR guidance. The regulations require

fiscal action for Critical Areas of Review and provide a framework to allow TDA to take fiscal

action or withhold payments for program noncompliance in the General Areas of Review.6 This

includes, but is not limited to, the following:7

Fiscal action may result if an overclaim is noted during the review. 8

Fiscal action may be taken when there are repeated findings across reviews of any type.

Fiscal action may include the suspension of the performance-based reimbursement for

meal pattern noncompliance.

TDA has an option to disregard any overclaim of $600 or less per program each fiscal year.

6 Fiscal action is authorized or required by 7 CFR Parts 210, 2015, or 220, as applicable. 7 See the Administrator’s Reference Manual, Section 7, Counting and Claiming for additional information on this topic. 8 An overclaim is the portion of a CE’s claim for reimbursement that exceeds the federal financial assistance that is

properly payable.


Appeals

An appeals procedure is provided when fiscal action is taken or funds are place on financial

hold. A CE can appeal fiscal action resulting from the denial of all or part of a claim for

reimbursement or withholding of payments established by an AR. Findings cannot be appealed.

The Appeals Timeframe Chart provides a summary of the appeals actions and timelines.9

Appeals Timeframe Summary Chart

CE submits written request for an

appeal—postmarked within 15 calendar

days of receipt of notice of fiscal action or

withholding of funds notice.

TDA and CE informed of the

Administrative Review Official’s

(ARO’s) decision on appeal of fiscal

action or withholding of funds—within

60 calendar days of the date of receipt of the

CE’s request for an appeal.

TDA acknowledges receipt request for

appeal—within 10 calendar days of

receipt of appeal request.

TDA and CE are given notice of the

date of the appeal hearing—at least 10

calendar days before hearing.

TDA Termination of an Contracting Entity (CE) from Participating in School

Nutrition Programs According to federal regulations, TDA will evaluate whether the degree of noncompliance by a

CE warrants program termination when a CE demonstrates long-term or systemic

noncompliance.

9 The requirements for an appeal is set out in Title 4, Part 2, Chapter 1, Subchapter P, Divisions 3, 4, 5, or 6, as applicable of

the Texas Administrative Code.

Section 23, Administrative Review - squaremeals · Texas Department of Agriculture—October 17,...

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