WITH HELPING HANDS SERVING NUTRITIOUS MEALS

RE: Finding 2023-001 – Significant Deficiency – Compliance with Daily Meal Count Records not Being Accurately Completed Response The meal count on 7/14/23 and 7/21/23 for King Parkway Mobile Home was incorrect as the server just wrote down the number of meals served and did not circle the numbers as instructed. This was just a careless error on the server’s part and further training on point of service was needed. The other error on the meal count records was the server indicated 20 meals were served but forgot to circle the very first number on the sheet, therefore there were only 19 numbers circled for the claim. The staff member that was adding the meal count consolidation form perhaps looked at the delivery ticket and not the meal count form to record the number of meals. This too is something that has been addressed and more training was needed. To ensure the Meal Count does not have any errors the Policy & Procedures have been updated as follows: POLICY: Daily Meal Count and Attendance Record (Updated Feb 24) As per TDA Guidelines, a CE must record meal counts and attendance on a daily basis. A CE must record meal counts at the point of service where their staff observe that an eligible child receives a creditable meal. A meal is creditable when a child receives all required components in the correct quantities at the approved mealtime. Daily Meal Count and Attendance Records must be completed at the point of service. POLICY: Meal Service Consolidation (Updated Feb 2024) As per TDA Guidelines each meal must be reported individually. SFSP sites may claim breakfast and supper served to children on week days, weekends, and holidays during a school's summer session. PROCEDURE: “With Helping Hands” (WHH) staff will report each meal separately on the daily meal count form and on a monthly meal consolidation form. The following conditions also apply to the meal service schedule: • The duration of a meal service must not exceed 1 ½ hours for breakfast and 2 hours for supper; • Any meals served outside of the approved meal times will not be claimed or they will be disallowed. • All meals will be recorded at the point of service by the Site Supervisor. • Each site will have their weekly totals and monthly totals reported on the monthly meal consolidation form. • Meal Count Forms will be turned in weekly from the Site Supervisor to the office for processing the claim submission. The office staff and Executive Director will review all documentation prior to claim submission. • Meal Count Consolidation Form will be completed and checked by two staff members’, including the Executive Director. • If the meal count sheet does not match the delivery ticket or any item is missing from the meal count sheet form the meal will be disallowed and further training will be done immediately with the site supervisor and/or staff at that location. • A claim will only be submitted for the meals that are supported by all complete and required documentation.

RE: Finding 2023-002 – Significant Deficiency – Compliance with Accurate Records of Meal Preparation and Ordering Response During the TDA audit, the CE provided meal production records as supporting documentation for meal preparation. Although the meal production record shows the number of meals prepared, the quantity prepared is insufficient for the number of participants the sites anticipate serving per the Food Buying Guide. The meal Production record dated 07/07/2023, shows that the central kitchen prepared 40 lunches for a site. Per the meal production record, the kitchen used 2 #10 cans of sliced peaches to prepare 40 meals, which is not enough to ensure that 40 participants received the correct quantity. Meal Production Records are prepared daily and presented to the kitchen staff in preparation for the meal service. All calculations are done using the food-buying guide on www.squaremeals.org. It was brought to our attention that there were a few calculations that were off on the meal production sheet at the time of the Review. The circumstances that caused this error was simply wrong human calculations that needed to be reviewed by additional staff to ensure the errors were corrected. We pride ourselves in knowing our kids we serve receive quality meals and enough meals are prepared to ensure all children receive the proper quantities. A. To ensure any calculation error does not occur the following steps, process and procedures were updated and implemented effective December 2023 after receiving additional training from Region IV ESC when three staff members attended Meal Production Records training—4 hours. B. Training certificates for the three staff members that attended Meal Production Records training were provided to TDA. Although the training was for CACFP, the process and results are the same for SFSP. This was the most recent training provided and we attended it in order to make the appropriate changes necessary for our program. POLICY: Daily Meal Production (Updated Nov 2023) “With Helping Hands” (WHH) must ensure that its central kitchen and sponsored facilities prepare a meal production record for each meal service each day. The center/facility (ies) must record the food items used, and quantities on a daily basis on H1530, Daily Meal Production Record, or H1530-A. PROCEDURE: All SFSP Program meals prepared by WHH will follow the TDA standard/established guidelines for proper meal pattern servings. Form H1530, Daily Meal Production Record will be completed prior to meal preparation as follows for reimbursement under the SFSP Program. 1) All areas of the form (listed below) need to be completed in entirety: a) Name of contractor b) Name of facility (only required for multiple facilities or if the facility name differs from contractor) c) Agreement number (this is the same as the TX number) d) Dates covered e) Day of meal service f) Food components g) Menu(s) h) Food items used i) Quantity used j) CN Labels used k) Special Diets l) USDA Recipe Numbers m) Whole grains n) Planned participation program meals o) Planned participation non-program meals 2) Meal Calculations are completed by the office staff using the food-buying guide via www.squaremeals.org. These calculations will be verified and checked at random within the month from Administrative Staff to ensure the accuracy of the calculations. 3) The Administrative Staff will check Meal Productions at the end of each week to ensure accuracy and completion. 4) Meal production records must be completed by office and kitchen staff on a daily basis and submitted to the Administrative Staff by the 5th of every month for processing the claim. 5) If there are any findings such as: a. Missing components b. Unallowable food items c. Not enough food prepared d. Uncompleted or Missing Completely e. Wrong Calculations Staff will be given corrective action and review of policy and procedures will be enforced by the Executive Director. 6) If more findings occur, Production Record training will be conducted on-site or via web. 7) Meal Production Training will be taken annually by the Region IV ESC Center annual training INSPO or other training options offered by the ESC and/or TDA SFSP Training Sessions.

RE: Finding 2023-003 - Significant Deficiency – Compliance with Resource Management Response On 7/7/23 the office of site King Parkway notified us that the server was not present due to being absent/vacation and another staff member was filling in for the server while they were gone. We immediately sent over an administrative staff member to train the site “sub” server to ensure the meal service could continue for the kids. There was a TDA representative there doing an unannounced visit at the time. We later found out that the original server of record for King Parkway had Covid and that is why he was absent so abruptly. With this information just given to us only a few minutes before the actual serve time we feel that, we tried to do the best we could by sending over someone to train at the meal service. We understand the ideal situation would be to train this person before the meal service, however there was not enough time to do so. It was brought to our attention that specific day that the site sub, had also been stepping in to help the staff on record to serve on occasions. This information was not given to us until 7/7/23 when the administrative staff was on-site training the site sub. Since this time, the site sub in question has been properly trained and is now the site server of record. The following procedures were updated and put into place effective August 2023. • The Policy & Procedure now includes a new policy for substitutes notification to sponsors when there will be a sub. • Copies of Training Certificate after administrative staff complete training in full on 7/10/2023. POLICY: SFSP Training (Updated Feb 2024) “With Helping Hands” (WHH), its staff and new facility staff who perform key SFSP activities must participate in or receive training in the following areas and subtopics: • Program Meal Pattern o Child meal pattern o Serving sizes for age groups o Creditable foods o Meal service styles o Accommodating special needs diets o Menu planning • Meal Counts o Daily o Weekly o Monthly • Claims Submission o Due date o Late claims o Amended claims • Claims Review Procedures o Review elements o Adverse Action o Appeal rights • Recordkeeping Requirements o Daily, weekly, monthly forms o Child Nutrition Program Application o Annual enrollment information o Meal production records o Attendance records o Financial Records o Record retention o Purchase vended meals • Reimbursement System o Administrative fee o Payment schedule • Civil Rights • Site Substitutes • Site Closures PROCEDURE: (Updated Feb 2024) 1. TDA may require “With Helping Hands” Management to attend additional training during the program year. The TDA will notify WHH when [mandatory] training is scheduled for Executive Directors/Management. 2. WHH Executive Director(s) train all new sites on SFSP during the New Site Pre-Approval Visit. 3. Site Supervisors are responsible for training their site staff prior to performing any SFSP activities. WHH provides all training documents and offers training and technical assistance to all sites and their staff as needed or requested. If found during Monitoring Review that any staff performing SFSP activities has not completed the annual SFSP training or needs further training based on findings, Monitor will conduct training on site. 4. WHH Management will ensure training of all employees will be provided annually on the SFSP program as noted in the policy statement above. Annual training topics will be discussed but will be tailored to each individual specific to their job responsibilities. 5. Civil rights training is a self-paced training curriculum provided online by TDA. It can be accessed from the TDA website at www.squaremeals.org (instructions are included in training packet). All individuals who have SFSP responsibilities must complete this training annually. Office Tech/Clerical Staff ensure that Civil Rights has been completed by comparing Time Distributions to Civil Rights documentation monthly. If it is found during a Monitoring Review that a staff performing key SFSP activities has not completed Civil Rights Training, site supervisors will be notified and staff will be removed from duties until training is complete. 6. WHH Management will ensure training of all employees that serve or handle food will be trained properly and receive training prior to the start of any meal service in which they are participating in. This training can be done on-line or in person provided by the sponsor before the server begins any meal service. Administrative Staff will monitor all sites to ensure the server of record are properly trained and the ones providing services at the approved meal service. 7. Site Supervisors will notify the Site Manager or Sponsor if they can not be present for meal service, if anyone else will be responsible to serve the meal, and only allow the site substitute to serve the meal if they have completed training prior to serving the meal. If a trained substitute can not be present for the meal service then the meal service will be cancelled for the day. Site Supervisor must notify the Sponsor immediately. 8. Signed receipt of training will be kept on file by WHH management in a training folder and maintained for 4 years.

RE: Finding 2023-004 - Significant Deficiency – Compliance with monitoring response When completing the Monitor Review Reports there are times that the staff completing the documents is busy reviewing, teaching, re-directing the site server while being present at the facility to make use for extra training while present. This does not mean that the records should not be taken care of to the standards set forth by TDA. We just sometimes find ourselves in the moment trying to make each site better while we are there monitoring and the records on the monitoring report are missing a few items to complete. The reviewer needs to make sure that the documents of record, Monitor Review is filled out to its entirety at the end of the service time and by the end of the each month when records are turned in and give proper documentation for TDA standards and guidelines. There are times when the records of the Monitor Reviews need to be completed back at the office to ensure the five day reconciliation and meal production records are accurate. At this time the entire Monitor Review packet should be reviewed to ensure it is complete and accurate before turning it into the document binder. See the following step-by-step policy and procedure that is in place effective today Feb. 1, 2024 as these policies were reviewed with staff responsible for these duties. POLICY: Monitor Requirements (Updated Feb 2024) • Being the eyes and ears • Providing valuable feedback about how the sites are operating • Visiting sites on a regular basis and observing the entire meal service • Provide technical assistance to sites and serving staff while present for Monitor Review PROCEDURE: Monitor Review Requirements The monitoring review requirements for facilities participating in the SFSP are as follows: • The Executive Director will conduct a pre-operational visit to every potential site; • The next monitor visit will occur within the first week of operation at each site; and • The minimum number of required visits is 1 within the first 4 weeks of operation, and • A minimum number of required visits is 1 each additional 4 weeks of operation. • If possible due to site approved meal times, he same meal type will not be monitored during each review. • Monitor Review personnel will wear a badge for easy identification. • The Monitor will be present before the meal service begins and stay until the meal service is over. • Sites with findings during the monitor review will be documented and training will be conducted on site. Serious deficiency findings, a monitor review will be conducted within 4 weeks to ensure site is in compliance. If no corrective action is performed, TDA will be notified. • All sites are required to allow access to WHH staff with proper identification and to provide all requested documents that support the Monitor Review. If any site does not comply, the meals will be disallowed for that day and another Monitor Review will be scheduled. • All staff that are responsible for completing Monitor Review’s will attend Monitor Training annually provided by the Executive Director. This training will be given to discuss the importance of the monitor procedures, effective monitor technical assistance given, records completion, findings, training, follow up reviews, serious deficiencies, and procedures set forth by TDA. • All trained monitors will complete the sections of the Monitor Review Documents at the time of the meal service being observed and finish completing the record with the proper documentation back at the office for the Monitor Review Binder. • Each month the trained Monitors will turn in the Monitor Review Documents to the Executive Director for review of completion, status of each site, findings listed, technical assistance given, and for accuracy of the Monitor Review Document. If errors are noted on the Monitor Review Document the Executive Director and Monitor will correct them together to discuss the errors. This will completed at the end of each month before claim submission. The annual monitoring review requirements are based upon the individual facility’s start date in the SFSP.