School Meal Programs: Changes to Federal Agencies' Procedures Could Reduce Risk of School Children Consuming Recalled Food
Published: 2009-08-20T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Over the past few years, several food recalls, such as for beef and peanut products, have affected schools. It is especially important that recalls affecting schools be carried out efficiently and effectively because young children have a higher risk of complications from food-borne illnesses. GAO was asked to determine how federal agencies (1) notified states and schools about food recalls, (2) advised states and schools about disposal and reimbursement of recalled food, and (3) ensured that recalls were being carried out effectively. To do this, GAO reviewed and analyzed relevant documents and interviewed federal and state officials, as well as officials from 23 school districts that had experience with at least one of four recent cases involving the safety of food in the school lunch program.
section_title: What GAO Found
paragraphs: Despite its efforts, the U.S. Department of Agriculture's (USDA) Food and Nutrition Service (FNS), which oversees federal school meals programs, did not always ensure that states and schools received timely and complete notification about suspect food products provided to schools through the federal commodity program. The federal commodity program provides food to schools at no cost to the schools, and accounts for 15 to 20 percent of food served in school meals. During 3 recent recalls, FNS notified states, but in only one case did it inform schools to hold and not serve suspect foods prior to an official recall of commodity products. When a videotape aired by the media showed inhumane treatment of cattle at a plant that provided beef to the commodity program, FNS told states to have schools stop serving the company's beef weeks before the official recall of commodity beef was announced. However, when the U.S. Department of Health and Human Services' (HHS) Food and Drug Administration (FDA) recalled suspect peanut products and canned vegetables in two other cases, FNS did not inform states and schools to hold and not serve the companies' commodity products until the recalls were expanded to include the companies' commodity products--weeks later. FNS's initial notification to states regarding recalls did not provide complete information on the full range of products affected. Instead, states and schools continued to receive information on multiple other recalled products over time. It sometimes took states and schools a week or more to determine what additional products were subject to a recall, during which time they unknowingly served affected products. FNS provided instructions for disposal and reimbursement of recalled products to states who, in turn, provided instructions to schools but, nonetheless, some schools experienced problems. Some schools reported to GAO problems in finding landfills that would accept large quantities of recalled products. Some schools also reported that reimbursement instructions were not clear, reimbursement was delayed for months, and that all of their expenses related to the recalls were not reimbursed. Although both USDA's Food Safety Inspection Service (FSIS) and the FDA procedures direct them to conduct recall quality checks, neither included thousands of schools that had received recalled USDA-commodities products for the beef and peanut recalls because they thought FNS conducted these checks. As a result, they were unable to ensure that the recalls were being carried out effectively by schools. FNS officials said that they did not conduct any kind of systematic quality checks of schools receiving recalled commodities, because they relied on FSIS and FDA to conduct such checks. FDA did include schools in its canned vegetable recall audit checks, and some may have received recalled-commodity canned vegetables. However, because FDA does not systematically sample for schools or analyze results of the quality checks for the group, the agency cannot be assured that the recall was carried out effectively in schools.

section_title: Letter
paragraphs: In early 2009, the Peanut Corporation of America (PCA) and more than 375  companies that received or used its products recalled almost 4,000 types  of peanut-containing foods for possible Salmonella contamination. A year  before, in early 2008, the U.S. Department of Agriculture (USDA)  announced the largest food recall in its history when the  Westland/Hallmark Meat Packing Company recalled more than 143 million  pounds of beef sold over a two-year period. Prior to the recalls, USDA had  purchased both peanut products and beef for school meal programs and  distributed them as a federally-provided commodity to states to serve in  school meals or snacks. Schools also purchased recalled beef and possibly  peanut products commercially. While there were no reported illnesses  among schoolchildren or the public from consuming recalled beef, almost  700 people were sickened from consuming peanut products, of which one- third were school-aged children between the ages of 5 and 18. The  magnitude of these two recalls, and the likelihood that schoolchildren  consumed these recalled products, raises overall concerns about the  safety of foods served in schools and the welfare of schoolchildren.
USDA’s Food Safety and Inspection Service (FSIS) and the U.S.  Department of Health and Human Services’ (HHS) Food and Drug  Administration (FDA) are responsible for establishing regulations to  ensure the safety of the nation’s food supply, while USDA’s Food and  Nutrition Service (FNS) also works to help ensure the safety of food  served in public schools through the federally-supported school meal  programs. FSIS is responsible for the safety of meat, poultry, and  processed egg products; while FDA is responsible for the safety of  virtually all other food products, including grains, nuts, and produce.  These regulatory agencies can request that companies voluntarily recall  food products that are suspected to be unsafe, adulterated, or mislabeled.  Schools are affected by recalled products, when they have received the  product as a commodity from USDA or purchased the product  commercially on their own. Commodities are foods procured by USDA  and provided to states at no charge for schools to serve in school meal  programs. School meal programs include the National School Lunch  Program, which in addition to providing lunches, provides after school  snacks; the School Breakfast Program; and Special Milk Program.  Commodities generally account for 15 to 20 percent of the food served in  school meals. The remaining 80 to 85 percent of food served in schools is  procured on the commercial market by the schools themselves. While  foods schools purchase are only subject to recalls announced by FSIS and  FDA, the commodities are also subject to actions announced by FNS for  safety and quality reasons. For example, FNS can issue an “administrative  hold” on commodities based on the recommendation of FSIS or FDA and  in conjunction with the responsible USDA procurement agency,  prohibiting schools from using a particular product, pending further  investigation, if concerns are raised about its quality and safety. FNS  works with state agencies who, in turn, work with local school food  authorities in their states to administer the school meal programs and to  keep schools informed of food holds and recalls.
Ongoing congressional interest in the safety of the nation’s food supply  has led to numerous requests for GAO reports and testimonies. For  example, in 2004, we reported on USDA and FDA recall programs and  procedures to protect consumers from unsafe food and recommended that  the agencies better track and manage food recalls, achieve more prompt  and complete recalls, and determine if additional ways are needed to alert  consumers about recalled food. In 2007, we added federal oversight of  food safety to our high-risk list because of persistent and longstanding  problems related to having 15 agencies collectively administer at least 30  food safety-related laws. We have reported that this fragmented federal  structure has caused inconsistent oversight, ineffective coordination, and  inefficient use of resources. Recent recalls affecting federally subsidized  school meal programs are of particular concern because children are more  susceptible to developing complications from food-borne illnesses.
In response to your request that we review the effectiveness of recalls of  food products used in school food programs, this report addresses the  following questions:  1.  How do federal agencies notify states and schools about food recalls  involving schools, and what actions did state and school food  administrators take in response to recent recall notifications?  2.  How do federal agencies advise states and schools about disposal of  and reimbursement for recalled products, and what were state and  school food administrators’ experiences with the disposal and  reimbursement process? 3.  How did federal agencies assess the effectiveness of recent recalls, and  to what extent do these assessments ensure that recalls are being  carried out effectively in schools?
To address these questions, we reviewed recent holds and recalls of  products from four companies: 1) the 2009 Peanut Corporation of America  peanut products recalls; 2) the January and February 2008  Westland/Hallmark beef holds and recall; 3) a series of recalls from  December 2007 through February 2008 of canned vegetables by the New  Era Canning Company; and 4) a December 2007 administrative hold on  Glacier Sales Inc. potato rounds. These events were selected to include  recalls that took place over the last two years and include examples of  recalls announced by both FDA and FSIS, as well as administrative holds  initiated by FNS. To determine the role of federal agencies in carrying out  food holds and recalls involving schools, we reviewed relevant regulations,  policies, and guidance related to food holds and recalls, and interviewed  officials from USDA, including FSIS, FNS, and the commodity  procurement agencies, including the Agriculture Marketing Service and  the Farm Service Agency; as well as FDA, the U.S. Department of  Education, and the Centers for Disease Control and Prevention (CDC).  Through interviews with federal officials and reviews of documentation  they provided on recent holds and recalls from the four companies, we  determined how the federal agencies carried out their role of notifying  states and schools of suspect products. This included determining how  they provided identifying product information and disposal instructions,  and how they ensured that recalls were carried out effectively, as well how  they reimbursed states and schools for selected recalls of commodity  foods. To understand the experiences of states and school districts during  food holds and recalls, we conducted site visits to state agencies and to  school districts that state officials identified in California, Indiana,  Pennsylvania, Texas, and Virginia. We also conducted site visits to school  districts in Michigan and New Jersey that were identified in federal  documents as being affected by recalls. After the peanut recall was  announced, we added Minnesota and Idaho to our selected states and  interviewed state and school food administrators from those states about  the peanut product recalls. In total, we reviewed documentation and  interviewed officials from 23 school districts, representing hundreds of  schools subject to commodity and commercial recalls; however, this  information cannot be generalized to all schools. We selected states and  school districts primarily for their experiences with one or more of the  four food holds and recalls that are the focus of this report; but, also to  ensure variation in geographic dispersion of states, school district size,  and quantity of recalled products. In two states, we also interviewed  distributors of food products to schools. To analyze how federal agencies  assessed the effectiveness of recent recalls, we reviewed documentation  on federal agencies’ oversight and assessment of recent recalls and  interviewed federal officials. We also interviewed officials from the  national and state-level School Nutrition Association, the American  Commodity Distribution Association, and the Center for Science in the  Public Interest to obtain their views on food safety in schools. Further, we  coordinated our review of how the Westland/Hallmark recall affected  schools with the USDA Inspector General’s broader evaluation of FSIS  management controls over pre-slaughter activity, published in November  2008; ongoing evaluations of the FSIS effectiveness checks for the  Westland/Hallmark recall; and USDA purchase specifications for ground  beef used in federal food programs, such as school meal programs.
We conducted this performance audit from May 2008 to August 2009, in  accordance with generally accepted government auditing standards. Those  standards require that we plan and perform the audit to obtain sufficient,  appropriate evidence to provide a reasonable basis for our findings and  conclusions, based on our audit objectives. We believe that the evidence  obtained provides a reasonable basis for our findings and conclusions  based on our audit objectives.
subsections: section_title: Background
subsections: section_title: Schools Receive Food Through a Complex Distribution Network
paragraphs: The distribution of food, including processing of food into different  products, can be extensive and complex, with school districts receiving  products from various sources. Once a food is produced by a particular  company, it can travel to distributors, retailers, and/or processors before  reaching schools. Sometimes large school food authorities can receive  food directly from the originating company, but it is more typical for the  food to travel through these middlemen. This complex distribution path  can make it difficult to track food from beginning to end, a problem which  arises during food recalls when distributors, processors, and retailers must  determine and inform states and school districts which products were  produced with recalled foods and which were not. Because this  identification process does not occur all at once, FNS, states, and school  districts sometimes learn about affected products over time (see Fig. 1).
One component of the food distribution system that adds to the  complexity of tracking individual ingredients is processing, whereby  companies turn a food into one or more new foods. For example,  according to USDA, Westland/Hallmark sent much of the commodity  ground beef that it produced directly to processors and, sometimes,  distributors. Distributors sent the beef to school districts, while further  processors used the ground beef to create products schools can more  readily use, such as meatballs and hamburger patties. Processors then sent  these products to school districts, either directly or through distributors.
section_title: Federally Subsidized School Meal Programs
paragraphs: Federally subsidized school meal programs, such as the National School  Lunch Program, are administered by USDA’s Food and Nutrition Service  (FNS), but several other USDA agencies are involved in procuring foods  for the programs. FNS works with states to administer the school meal  programs through local school food authorities. FNS subsidizes the school  meal programs through donated commodities and cash payments. USDA’s  Agricultural Marketing Service (AMS) purchases commodities such as  beef, poultry, fish, egg products, fruits, and vegetables, while the Farm  Service Agency (FSA) purchases commodities such as grains, peanut  products, dairy products, and oils for the school meal programs and other  commodity distribution programs. FNS officials estimate that almost 50  percent of these commodities are further processed. In some instances,  USDA contracts directly with processors, while in other instances, states  and school districts contract with processors and USDA diverts  commodities to processors on the schools’ behalf to make specific foods,  such as sending commodity beef to a processor to be turned into beef for  tacos. Schools also use federal cash subsidies and their own operating  monies to procure food and processed food products commercially, not  involving USDA agencies.
section_title: Food Recall and Hold Procedures
paragraphs: Food holds and recalls to protect consumers are governed by various  laws, regulations, and policies. There are a series of events that typically  precede a food hold or recall. Federal agencies—FSIS, FDA, or CDC—can  become aware of a problem when a company identifies a problem and  independently announces a recall, through inspections, product testing, or  an outbreak of a suspected food-borne illness. CDC works with state  health departments to identify the specific food or product involved. Once  the product and its source are identified, either FSIS or FDA—whichever  has jurisdiction over the product—works with the affected company to  conduct a food recall. Neither FSIS nor FDA has “mandatory recall  authority”—the ability to force a company to recall a product. However,  both FSIS and FDA can request that a company recall a product and, in  most cases, the company complies. Either FSIS or FDA then classifies the  recall from Class I to Class III:    Class I: A recall of food that poses a reasonable probability of causing  serious, adverse health consequences or death. The PCA peanut product  recalls were designated Class I because of the presence of Salmonella; the  New Era canned vegetables recall was Class I because of the potential for  botulism contamination.
Class II: A recall of food that poses a remote probability of adverse health  consequences. The Westland/Hallmark beef recall was designated as Class  II because of a remote probability of adverse health consequences due to  proper inspection procedures not being followed at the meat processing  plant.
Class III: A recall of food that will not cause adverse health consequences,  but does not meet product specifications. For example, a product that  might contain the presence of an undeclared, otherwise safe substance,  such as excess water.
When a USDA commodity product is identified in a recall, FSIS or FDA  contacts FNS. FNS then works with AMS or FSA to obtain more  information on the affected commodity products. FNS then contacts the  state agencies to whom it provided the product. The state agencies then  notify school districts, who then notify the responsible persons at  individual schools. Under USDA procedures, FNS is directed to notify  states within 24 hours of learning of a recall, and then the states are  expected to notify schools within 24 hours of receiving a recall notice  from FNS. This process is used only when USDA commodities are  involved, which account for 15 percent to 20 percent of the products used  in school meals (see Fig. 2).
If a state agency has FNS divert bulk commodity products on its behalf to  a processor and the commodity is subsequently recalled, the appropriate  procurement agency notifies the processor to which the commodity had  been diverted. FNS does not alert the states as to which processors were  affected. If a state or school food authority procures food commercially,  which accounts for 80 percent to 85 percent of products used in school  meals, neither FNS, FSIS, nor FDA is responsible for notifying states and  schools; the school food administrator is typically notified directly by a  distributor, wholesaler, or whoever sold the school district the food. Once  schools are notified, recalls can expand if investigations reveal problems  with products, in addition to those initially recalled. For example, FDA or  FSIS may discover that problems at a particular manufacturing plant are  more longstanding than initially thought. In these instances, the recalling  firm could issue additional recalls for other products or time periods. As a  result, schools could end up serving affected products between the first  and subsequent recalls.
In this report, we address holds and recalls by four companies which  affected schools.
subsections: section_title: PCA Peanut Product Recall
paragraphs: From January 2009 through March 2009, PCA issued a recall—and  expanded the recall on three separate occasions—for products it supplied.  The companies that received or used its products also issued recalls,  covering almost 4,000 types and brands of peanut-containing products.  Recalls were initiated after CDC, FDA, and state investigations of illnesses  suspected of being food-borne revealed Salmonella in peanut butter  manufactured by PCA. Salmonella is an organism that can cause severe  illness, particularly in the elderly, young children, and others with  weakened immune systems. Since peanuts are under its purview, FDA  posted PCA’s recall notices and monitored the recall as it developed.  Schools in four states—Arkansas, California, Idaho, and Minnesota— received recalled commodity peanut products through the school meal  programs that had not been further processed. In addition, commodity  peanut butter was shipped to a further processor, which then distributed  effected processed products to other states.
section_title: Westland/Hallmark Beef Holds and Recall
paragraphs: In January 2008, an animal protection organization released an undercover  video of persons trying to force non-ambulatory cows to stand and walk  at the Westland/Hallmark meat processing plant in Chino, California.  Because of the mistreatment of the cattle, on January 30, 2008, FNS issued  a 10-day hold on all commodity ground beef produced by  Westland/Hallmark since October 1, 2006. On February 8, 2008, FNS  extended the hold for 10 additional days. On February 17, FSIS announced  a recall by Westland/Hallmark, designated as a Class II recall, of more than  143 million pounds of beef produced over a two-year period from February  1, 2006, to February 2, 2008, because proper inspection procedures were  not followed when cows that had become non-ambulatory were not  reinspected before they were slaughtered. There were no problems found  during FSIS testing of meat that was delivered for school meal programs,  but concerns remained among Congress and others because non- ambulatory cows may pose an increased risk of bovine spongiform  encephalopathy, also known as mad cow disease, linked to a rare but fatal  degenerative brain disease in humans.
FNS estimated that over 7,000 school districts in 46 states and the District  of Columbia were involved in the recall of commodity beef products. FNS  also estimated that approximately 50 million pounds of suspect  Westland/Hallmark commodity ground beef was provided to schools, of  which approximately 30 million pounds were served prior to the recall and  about 20 million pounds destroyed as a result of the recall. FSIS and FNS  were not aware of any schoolchildren or any other persons getting sick  from eating the recalled beef.
section_title: New Era Canned Vegetables Recall
paragraphs: The New Era Canning Company issued a recall in December 2007 and  expanded this recall on three subsequent occasions in early 2008, covering  numerous types of New Era canned vegetables. These products had been  distributed nationwide as part of the USDA commodity program and were  sold commercially under 10 different brand names over a five-year period.  These products were recalled because the vegetables had not been  adequately heated during the canning process and could have contained a  bacterial toxin which causes botulism, a potentially life-threatening illness.  According to FDA and FNS officials, there were no reported illnesses  attributed to recalled products and FDA reported that no toxins were  found in product testing. The multiple recalls were the result of FDA, the  Michigan Department of Agriculture, and New Era identifying additional  products and time periods that could be affected.
FNS officials reported that schools in 37 states received New Era products  through the USDA commodity program. Schools received 516,432 cases of  the recalled canned beans, but had only 13,931 cases remaining at the time  of the recall. It is unknown how many cases states and school districts  purchased commercially.
section_title: Glacier Sales Potato Rounds Hold
paragraphs: On December 3, 2007, FNS issued an administrative hold on Glacier Sales  potato rounds because of texture, taste, and odor issues. FNS officials said  that Glacier Sales subsequently withdrew the product and worked with  school districts to arrange reimbursement and/or replacement. FNS  reported that 5 states had schools that were affected and that 6,480 cases  of the product were involved during the hold, though additional states  were affected once the company issued a withdrawal notice. Subsequent  testing of the potato rounds found no health or safety problems.
section_title: Despite Its Efforts, FNS Did Not Always Ensure that States and Schools Received Timely and Complete Information about Potentially Dangerous Commodity Products in Three Companies’ Recalls
paragraphs: As a result of a number of factors, FNS did not always ensure in our three  recall cases that states and schools received timely and complete  notification about suspect food products provided to schools through the  federal commodity program. First, USDA has procedures that explicitly  allow FSIS to provide FNS with immediate notification of investigations  that could involve commodity products, which could allow FNS to issue a  precautionary hold on the suspect product, but FDA and FNS do not have  similar formal protocols. Second, in two recent recalls we reviewed, FNS  followed the lead of the FDA, and removed foods from school meals when  they were officially recalled, but did not work with FDA and the USDA  procurement agencies to place a hold on the products when it first became  aware of food safety issues at facilities that supplied commodities. Third,  in its recall notices, FNS did not provide complete and accurate available  information that would be needed by schools to identify all affected  products in their inventory, particularly for processed products. In  addition, states did not always provide schools with timely and complete  information. FNS tried several mechanisms to provide information directly  to schools; however, these did not work as intended either for content or  timeliness. As a result, in some cases, schools served affected products in  school meals. FNS is aware of these factors, and is taking a number of  steps to improve its processes.
subsections: section_title: FSIS Has Procedures that Allow it To Provide FNS Early Notification of Investigations involving Commodity Products; however, FDA Does Not, Which Could Limit FNS’s Response
paragraphs: When FSIS learns a food within its regulatory jurisdiction—such as meat  or poultry products—may be adulterated or mislabeled, USDA procedures  allow for immediate notification of FNS. FSIS alerts FNS and the  procurement agency, such as AMS, that there is a potential recall. In  consultation with others, FNS determines whether to put a temporary hold  on the product. If FNS decides to issue a hold, it notifies states and  schools so they can remove the commodity products from school menus,  pending additional testing and data collection. FSIS convenes a committee  which, when commodities are involved, includes representatives of FNS  and other agencies.
In the case of the Westland/Hallmark beef recall, FNS placed a hold on  commodity beef products from the California plant prior to the publicly  announced recall; however, in this case, the hold did not result from  communication with FSIS. Instead, FNS officials said that following the  media coverage of inhumane practices at the plant, they consulted with  AMS and initiated a hold on January 30, 2008, for beef products produced  at the Westland/Hallmark plant. However, rather than placing a hold on all  products produced at the plant; the hold only covered products produced  after October 1, 2006. FSIS officials said that they did not have an ongoing  investigation at the time, but that a USDA investigation was started soon  after. According to FNS officials, they were subsequently included in FSIS  recall discussions, and on February 17, FSIS announced the recall. The  recall covered a longer time frame than the FNS hold—including all beef  produced after February 1, 2006—as a result, some schools could have  served recalled beef produced between February 1, 2006, and October 1,  2006, during the FNS hold, even though this beef was later recalled.
Although FNS works to help ensure the safety of USDA commodities that  may be served in schools, FNS stated that it is not responsible for taking  food safety actions for products commercially procured by schools. This  distinction led to confusion and potential risk of consuming affected  products when schools purchased Westland/Hallmark beef commercially  during the FNS hold on Westland/Hallmark commodity beef. For example,  a school district in California told us that during the FNS hold, some of its  processors believed that Westland/Hallmark commercial products were  safe, claiming that only Westland/Hallmark commodity beef was affected.  School district administrators said they explained to the processors that  they did not want to receive any Westland/Hallmark product, and  commercial products were subsequently included in the FSIS recall,  suggesting the school district, had it believed the processors, would have  served the suspect meat to school children.
Unlike FSIS procedures, FDA procedures do not specifically provide for  immediate notification of FNS when FDA investigations include  commodity products, although agency officials stated that they  communicate frequently. FDA is responsible for the safety of virtually all  food products, except for meats, poultry, and processed egg products.  FDA procedures require FDA notify USDA agencies, including FNS, “of  recalls of FDA-regulated products that have been distributed to any USDA  agency that may have involvement with the school lunch program.”  However, the procedures do not give any indication that FNS can be  included in the recall deliberations, as they are when an FSIS food is  concerned. According to FDA officials, FNS was included in discussions  and email correspondence during the investigation of the Salmonella  outbreak that was traced to peanut products, but FDA did not provide us  with information about notifications provided to FNS during the  investigation of the New Era plant. According to FNS and FDA officials,  they are working together with AMS and FSA officials on developing a  memorandum of understanding that will provide for specific notification  to FNS, AMS, and FSA during FDA investigations that may involve  commodities intended for school meal programs. However, the agencies  have not established a time frame for completing the memorandum of  understanding.
section_title: FNS Waited to Take Action on Commodity Products until New Era and PCA Issued Recall Notices Affecting Commodity Products Instead of Using Available Information to Initiate Administrative Holds after Initial Recalls
paragraphs: FNS and USDA procurement agencies determined whether commodity  products were involved after receiving FDA announcements of recalls of  New Era and PCA products. For the initial PCA recall on January 13, 2009,  FNS officials said that the FSA, which procures food for USDA commodity  programs, checked for commodity peanut butter purchases for school  meal programs from PCA’s Blakely, Georgia plant, and found that there  were none within the time period identified in the notice, so FNS did not  notify states to take any precaution with commodity peanut products.  Subsequently, after two FDA announcements of recall expansions, on  January 23, 2009, FNS posted to its Web site a statement that none of its  commodities were affected by the PCA recall. Five days later, on January  28, 2009, following additional inspection and review at the Blakely plant,  FDA announced another PCA recall notice, which expanded the  manufacturing dates and products subject to recall. Upon learning of the  January 28 expanded recall, FNS worked with FSA to determine if  commodities were affected. FNS informed the affected states of the  recalled commodity products the following evening. Similarly, after the  first New Era recall announcement in December 2007, FNS officials said  that AMS checked for commodity canned bean purchases from New Era  and found that it had purchased other products from New Era, but not  those that were part of the recall, so FNS did not notify states to take  precautions with New Era commodity products. In January 2008, New Era  expanded its recall to include additional products. FNS worked again with  AMS which, this time, determined that commodity products were affected.  The following day, FNS informed affected states of the recall.
FNS did not issue administrative product holds after it was notified about  initial recalls of New Era and PCA products. In both the PCA and New Era  situations, the initial recalls did not include commodity products; but in  both cases, commodity products were eventually recalled because the  recall was expanded either to include products manufactured over a  longer time period or to include more products manufactured at the same  plant. USDA hold and recall guidance does not indicate what factors and  criteria FNS should consider when determining whether to institute an  administrative hold. FNS, in consultation with the responsible  procurement agency, could have placed a hold on all commodity products  produced by these companies when it became aware of a potential food  safety issue, regardless of when the products were produced, particularly  given the serious health risks of botulism and Salmonella potentially  posed by the recalled products. Instead, FNS relied strictly on the recall  notices and only notified schools about the potential hazards of  commodity products after the firms had expanded their recalls to  specifically include products purchased through the commodity program.
Because FNS did not immediately place a hold on all PCA peanut products  and New Era canned vegetable products at the time of the initial recall,  children may have possibly consumed these products through the school  meals programs—products that were later included in the expanded  recalls. According to the CDC, of the 691 individuals sickened, 226 were  school-aged children, of which 46 were hospitalized due to consuming  Salmonella-contaminated peanut products. CDC does not have  information on how many of the children may have consumed the  products in school.
section_title: FNS Notifications to States about the Westland/Hallmark Recall Did Not Always Provide Complete Information, Particularly on Processed Products
paragraphs: In the Westland/Hallmark case, FNS officials said that they notified states  on the same day they learned of the recall affecting commodity products,  but FNS’s initial recall communication did not provide states with  complete and accurate information that was needed by schools to identify  all affected products on their shelves. The initial recall communication  issued by FNS informed states that the products that had been subject to  hold were now being recalled, but did not inform states which specific  processed Westland/Hallmark beef commodity products, such as sloppy  joe mix, frozen beef patties, and other items offered by FNS to states to  order for school meal programs, were also subject to the recall. It was not  until February 26, 2008—almost four weeks after the original hold was  issued—that FNS notified states that these further-processed products  contained recalled beef. The longer recalled products remain unidentified,  the greater the risk that these products could be inadvertently consumed.
FNS also did not provide states and schools with information to identify  the processors of products containing Westland/Hallmark beef in  instances where commodity beef ordered by states in bulk from FNS was  provided directly to processors. In addition to allowing states to order  processed commodity products from USDA, the Department also allows  states to have FNS bulk commodities, such as beef, diverted directly to  processors of the state’s choosing for further processing. During the  Westland/Hallmark hold, FNS notified further processors, providing them  information that allowed them to identify affected beef products. FNS also  advised states in its recall instructions to contact their processors to  determine if their state or schools had received further processed food  containing recalled beef. USDA’s procedures do not specify how and when  processors are to inform states and schools of recalled products and, as in  the Westland/Hallmark recall, FNS officials said that they did not oversee  this notification to ensure that further processors promptly inform states  and schools. Moreover, although FNS knew which further processors  received affected Westland/Hallmark beef, it did not provide the names of  these further processors to states and schools, because FNS considers it  the responsibility of the processor to contact consignees, in this case  states and schools. As a result, states and schools had to wait for further  processors to identify and inform them of affected products. Some school  food administrators told us that they received information from further  processors for some products weeks after the initial Westland/Hallmark  holds announcements, during which time affected products were served in  some school meals.
Moreover, in its initial administrative hold notice, FNS did not alert states  that further processors often commingle beef from multiple sources to  create end products, which means that states and schools could receive  affected end products, even if the bulk beef they diverted to further  processors came from a plant other than Westland/Hallmark. After the  Westland/Hallmark administrative hold was announced, identifying the  affected beef, officials in one state said they assumed all its further  processed beef products were not affected, because it had not had FNS  divert Westland/Hallmark beef to processors on its behalf. However,  almost three weeks after the hold announcement, the state said it learned  from FNS that beef processors often commingle commodity beef and  realized some of its further processed products were made, in part, with  affected beef from other states. Due to the confusion, schools in the state  had likely been serving products in school meals for several weeks which  should have been put on hold. FNS officials told us that they are in the  process of rewriting the USDA recall procedures and it will address  processors and further processed products; however, FNS officials said  that they have not established a time frame for completion.
section_title: States Did Not Always Provide Timely and Consistent Information to School Districts on Holds and Recalls, but Some School Districts Took the Initiative to Hold Products as They Waited for More Information
paragraphs: Although USDA procedures direct states to notify affected schools within  24 hours of receiving a recall notice from FNS, states did not always  forward the information within this time frame and schools sometimes  received critical information days later. FNS announced its administrative  hold on Westland/Hallmark beef on January 30, 2008, but in one state, a  school official told us that she did not hear about the hold from the state’s  technical assistance office until five days later, on February 4, 2008.  Similarly, after the Sunday, February 17, 2008, USDA announcement of the  Westland/Hallmark beef recall, officials in four of the five states we  interviewed said they did not notify schools until after the Monday  holiday, on Tuesday, February 19, Wednesday, February 20, or Thursday,  February 21. Officials in one state in which schools were open on the  Monday federal holiday said that they were unable to provide information  schools requested, because the FNS regional office was closed for the  holiday. For the New Era recall of canned vegetables, officials in another  school district told us they found out about the January 18, 2008, recall  when FDA investigators showed up at the school five days later, on  January 23, 2008, to check their compliance with recall procedures; FDA  investigators and school officials did not find any affected product  remaining in inventory. Later that same day, school district officials said  they received an email from the state informing them they had received a  truckload of affected canned green and garbanzo beans several years  before. State officials said they did not initially forward information about  the recall because they assumed that the product was so old it was likely  consumed.
After receiving information about the Westland/Hallmark hold from FNS,  indicating that further processors were responsible for notifying states of  further processed products containing Westland/Hallmark beef, states  gave different instructions to school districts on what to do about the hold,  resulting in different responses. For example, at the beginning of the beef  hold, one state said that it instructed its school districts to place all  processed beef products on hold until processors had time to figure out  which items were affected and which were not. As a result, this state’s  schools had all affected beef on hold. On the other hand, according to a  school district in a different state, the state did not instruct its school  districts to place all beef products on hold and state officials did not  initially realize that some processed products could also be affected. A few  days after the initial hold announcement, state officials determined  processed products from one processor could be affected and sent school  districts an email informing them that many additional processed items  were subject to the hold. As a result, a school district in this state told us  that its schools may have served affected products in the interim.
Some school districts took the initiative to hold suspect products, pending  final notification about all products affected by the recalls. In the case of  Westland/Hallmark, some schools told us that media and parent inquiries  about the safety of the meat served in schools prompted them to remove  all beef from their school lunch menus after the initial recall. One school  district in California, in an abundance of caution, did not serve beef for the  remainder of the school year. Because they stopped serving any beef  products after the recall announcement, these school districts did not risk  serving products, including processed products, that were later identified  as the recall unfolded and expanded.
section_title: FNS Has Used Supplemental Notification Strategies, but Most Have Not Resulted in More Timely Notification to States and Schools
paragraphs: Supplemental notification methods provide the potential for FNS to  communicate recall information directly to schools in a more timely  manner than under the standard notification procedures. The standard  USDA procedures allow FNS 24 hours after learning of a recall involving  commodities to notify states, and then allow an additional 24 hours for  states to notify schools. Under this standard notification process, schools  might not learn of a recall until 48 hours after it was announced by FSIS or  FDA, during which time, schools could unknowingly serve affected  products. Although FNS could explore ways to reduce the standard  notification time frames, supplemental notification methods providing  information directly to schools, such as through email and Web site  postings, could potentially provide schools with more timely information.
Because of the breadth of the recall, FNS officials said that they used the  U.S. Department of Education’s crisis communication email system to  send email alerts directly to all schools about the Westland/Hallmark beef  recall; but, this additional notification did not seem to improve  communication to schools. FNS officials said this was the first time that  they had used Education’s crisis system to ensure schools received prompt  notification. However, this communication was not sent until February 22,  2008, more than 3 weeks after FNS had placed the commodity beef on  hold and 5 days after the recall was publicly announced.
FNS also employed its own newly-developed commodity alert system to  notify school districts directly about the PCA peanut product recall, but  the system did not appear to improve the content or timeliness of  communications to schools. FNS’ Commodity Alert System was designed  to email “instant notices” on food safety issues to registered subscribers.  According to FNS, the system was first used January 30, 2009, to  communicate that the PCA peanut product recall included commodity  products. However, the email was not sent until 2 days after FDA publicly  announced an expanded recall of products containing suspect peanuts.  More importantly, the email to subscribers did not identify the affected  commodity products by name or the states or schools receiving them, but  simply stated that “a limited number of  products were identified  as being purchased by USDA.” FNS said it did not include information on  products or states affected because alert emails could not exceed 300  characters of text. FNS subsequently assessed how many of those who  signed up for the service successfully received the January 30, 2009, email  alert and found that 37 percent of those who completed the initial  registration and who could have expected email alerts on important food  safety problems did not receive the email due to problems with their  registrations. FNS stated they would take steps to improve the  registration process. In a subsequent alert, sent on March 17, 2009,  regarding expanded PCA recalls of commodity peanut butter, FNS stated  that two recall notices had been issued 20 days and 14 days earlier  because USDA purchased peanut butter associated with the PCA  Plainview, Texas plant.
FNS has also used its Web site to communicate food safety information to  states and schools, but recent postings have not been timely or complete.  FNS’ food safety Web site notes, “Here you will find information on food  safety and security related to the assistance programs administered by  FNS, as well as links to FNS’ food safety partners,” and includes  information under a heading, “Current Initiatives and Resources.”  However, we found only a single posting for the New Era canned  vegetables recall and it addressed only the initial New Era recall and the  first recall expansion, not the second and third recall expansions that  involved commodities. According to the Web site, “No USDA-purchased  commodities are involved at this time.” The Web site did not inform states,  schools, parents, and the public that two subsequent New Era recalls did  include USDA-purchased commodities. For the PCA recall, FNS posted a  statement on January 30, 2009, 2 days after FDA publicly announced an  expansion of the recall, to say that a limited number of recalled products  were identified as USDA purchases. However, the announcement did not  say whether schools were affected, which states were affected, or what  products were affected. Another USDA statement posted to the FNS Web  site on March 6, 2009, explained that 10 days earlier, FNS had learned that  commodity peanut butter purchased from Sunland Inc., and distributed to  schools was made from peanuts roasted at PCA.
section_title: FNS Provided Disposal and Reimbursement Instructions to States, but State and School Administrators Reported Challenges in Disposing of Products and Obtaining Reimbursement
subsections: section_title: FNS Provided Disposal Instructions, but Not All Schools Followed Disposal Procedures and Some School Districts Reported Challenges in the Disposal of Recalled Beef
paragraphs: FNS provides disposal instructions to states that are specific to each  recall; these instructions are then tailored by each state to meet state or  local public health procedures. For example, for the Westland/Hallmark  beef recall, FNS guidance instructed states and school food authorities  with 50 cases or less to destroy the product on site, and render it unfit for  human consumption by following guidance from state or local health  authorities. If states or school food authorities had more than 50 cases,  FNS guidance said to take the product to a landfill, have it incinerated, or  send it for inedible rendering. States often revised the FNS notice before  sending it on to school districts by changing the listed contacts or  including additional disposal instructions specific to the state. For  example, one state allowed its school districts to follow alternate methods  of disposal suggested by local health departments.
Although all school districts we interviewed that had recalled products in  their inventories reported disposing of them, at least two school districts  did not follow all instructions provided by FNS and state officials. For  example, a school district official in one state told us her staff destroyed  recalled New Era canned beans that had been opened by pouring the  contents down the garbage disposal. FNS and FDA’s notices said not to  open cans and the FNS notice said further, that if cans were already open,  not to put the contents in a garbage disposal because of the risk of  exposure to the toxin that causes botulism. Another district worked with  its distributor, who was storing Westland/Hallmark recalled beef products,  to divide the district’s recalled beef among its schools so the district did  not exceed 50 cases at any one location. School district officials said this  allowed them to dispose of the products on site, rather than make special  arrangements with a landfill, as specified in FNS destruction instructions  for school districts with more than 50 cases of recalled products.
In some instances, the destruction and disposal of recalled product was  delayed as school food administrators searched for a means of disposal,  increasing the risk that these products could be inadvertently consumed.  Five of the 15 school districts we interviewed that had affected  Westland/Hallmark products in-stock reported challenges in disposing of  affected beef products in landfills. For example, an official from one  district found that the district’s trash pickup company would not take  15,000 pounds of affected beef because they did not accept food. There  was no local landfill, and a neighboring town’s landfill also refused to take  the beef. The food service director told us neither the state nor the city  health department was able to help locate a disposal site. Finally, at the  suggestion of someone in another state, the food service director arranged  disposal at a landfill in another town, but the director had to arrange for  delivery of the 15,000 pounds of meat to the landfill. The raw beef was  buried, in accordance with state instructions. A school district in another  state told us the city landfill would not accept raw beef; so after making  inquiries, the food service director learned he could send the beef to a  rendering company, which turns food into other products. For a fee, the  rendering company collected the district’s 400 cases of raw beef from the  district warehouse. However, the rendering company required that all beef  be removed from its packaging, so the food service director and his staff  spent a few hours opening 400 cases and separating meat from its  wrapping. Figure 3 shows a large quantity of beef from one school district  at a transfer station, prior to being transported to a landfill for disposal.
Schools that had smaller quantities of recalled beef typically did not report  difficulties in disposing of recalled products. FNS destruction instructions  allowed school districts with smaller quantities to dispose of the suspect  foods in their regular trash such as by opening packages, dousing the food  with bleach, and double-bagging it to prevent consumption before placing  it in the trash receptacle.
School districts also reported that disposal of commercially purchased  foods was simpler as the processor or distributor typically collected and  disposed the recalled products. Officials at some of the school districts we  interviewed told us it was their distributor or processor who informed  them of commercial recalls, and then collected any affected product  and/or stopped delivery. For example, one school district reported that its  distributor collected and disposed of commercially purchased  Westland/Hallmark beef.
section_title: Some State and School Officials Said They Were Not Reimbursed for All Costs Incurred in Disposal and Found the Process Difficult
paragraphs: Some school officials told us they were not reimbursed for all costs  incurred due to recalls. USDA guidance defines which expenses are  reimbursable and which are not. Reimbursable expenses include some  transportation, as well as storage, destruction, and processing costs.  Schools and school districts are not reimbursed for administrative and  personnel costs, including overtime paid to deal with a hold or recall, or  for other foods purchased to replace recalled products.
However USDA guidance did not specifically address whether states can  be reimbursed for commodities that have been processed with recalled  ingredients, leading to inconsistencies in reimbursement in the  Westland/Hallmark recall. After the Westland/Hallmark recall schools  were either reimbursed for the recalled beef or received a replacement.  However, officials in one state told us its schools were not reimbursed for  the cost of other commodities that had also been used in recalled  processed beef products, such as commodity tomatoes used to make  spaghetti meat sauce. In contrast, a school district in Texas was  reimbursed for commodity cheese it had sent to a further processor, along  with commodity beef to make burritos and taco snacks. FNS officials told  us that it reimbursed states for all commodity products, such as tomatoes  and cheese, used in further processed products that were subject to  recall.
Reimbursement and replacement for recalled commodity products varied  by recall. For the Westland/Hallmark recall, school districts provided  documentation on the quantity of recalled beef destroyed to the states, and  the states served as the intermediary for FNS reimbursement and  replacement. For disposal costs related to New Era recalled products, FNS  officials said they reimbursed states for their disposal costs, who then  reimbursed schools. Most school districts did not receive reimbursement  or replacement of New Era products because in eight of the nine states  that had recalled product, the quantities destroyed were so small, states  did not request product replacement or reimbursement. FNS officials said  that only one state had a significant amount of the recalled products and  that this state requested reimbursement which FNS provided.
Some school officials informed us that they found the overall  reimbursement process confusing, and three states reported having to  submit multiple claims. FNS general procedures and those specific to  Westland/Hallmark did not explicitly describe all types of documentation  necessary for reimbursement. One school district in Indiana reported that  it was unclear what information was required for reimbursement and staff  spent a lot of time removing the code stickers and other identifying labels  from recalled products, thinking they would need to submit them to the  state. They later learned the code stickers and labels were not required.  The district submitted a claim, but was later asked by the state to submit  additional documentation on disposal costs such as mileage and labor, so  more staff time was spent assembling this information and resubmitting  the claim.
Some school districts also found the reimbursement process to be lengthy.  USDA procedures direct that reimbursement to states occur within 90  days (3 months) of a recall, and that states, in turn, reimburse school  districts “in a timely manner.” Districts in several states that were  reimbursed for New Era and Westland/Hallmark claims reported that they  did not receive payment until many months after the recalls. In at least one  state, state officials reported that they received reimbursement more than  90 days after the Westland/Hallmark recall. After receiving reimbursement  from FNS, states may also have contributed to delays in providing  reimbursement to schools. For example, food service staff in California  told us their district filed for reimbursement of about $42,000 in March  2008 for Westland/Hallmark beef but had not been reimbursed by their  state as of November 2008, eight months later. California state officials  told us that reimbursement was delayed, in part, because the state could  not disburse payments until the budget was passed, which occurred in late  September.
section_title: Federal Regulators Did Not Systematically Monitor and Assess the Effectiveness of Recalls and Holds in Schools
subsections: section_title: Neither FDA nor FSIS Systematically Monitored the Effectiveness of Recalls for Schools
paragraphs: Although both FSIS and FDA have procedures to systematically conduct  and document quality checks to determine whether recalls are carried out  effectively, the procedures did not ensure these checks were done in  schools affected by recent recalls of USDA commodities. These checks,  called effectiveness checks by FSIS and audit checks by FDA, involve  visiting or contacting a sample of affected consignees—entities that  received a recalled product, such as distributors, hospitals, restaurants,  and schools—and determining whether they were notified of a recall; all  affected product was located; affected product was properly disposed; and  all steps were completed in a timely manner. These checks help ensure  that affected products are removed from the market and are not  consumed. Both FSIS and FDA conduct quality checks of a sample of  consignees, however, procedures differ and neither ensures that a sample  of schools is included. In an overall review of FSIS and FDA food recalls,  we also previously reported that the agencies’ procedures for selecting the  sample of companies to check did not ensure that all segments of a food  distribution chain are included, as well as problems with the timeliness of  the checks.
FDA procedures do not require it to systematically monitor recalls in  schools by explicitly sampling schools for audit checks, grouping  consignees into categories, or reviewing audit checks by consignee  category, such as schools. Nonetheless, many of the FDA audit checks for  the New Era recalls were conducted in schools that may have received the  product as a USDA commodity or procured it commercially. FDA officials  said that although they are not required to do so, in this case, they tried to  give schools preference for selection in the sample if a school was  identifiable from the available information. The FDA district coordinator  told us that of 2,553 completed audit check reports on the New Era recalls,  823 were for schools. The district coordinator was able to identify schools  for whom audit check report forms were completed by the name on the  audit form or because the person who completed the form wrote “school”  under consignee type. “School” is not listed as one of nine consignee types  on the audit check form, which includes “retailer,” “hospital,” and others.  Our review of the audit checks of schools in one of the states we visited  indicated some schools were not properly notified or had not followed  recall instructions. Also, in the remarks section of some of the FDA audit  check forms, the preparer indicated the recall for the school was  “ineffective” or “not effective.” The FDA district coordinator for the New  Era recalls said the completed audit check forms were grouped by  category, including a category for schools, and that any problems that  were identified on the forms were addressed. However, FDA did not have  documentation of any analysis that was done for the schools as a group to  determine whether there were systemic problems, nor did they have  documentation of corrective actions taken.
FDA officials said that they conducted audit checks for the PCA peanut  product recalls, and field staff were instructed to give priority to schools in  making their selections for the audit checks, but only schools that  procured the products commercially were included because the audit  checks specifically excluded schools that received affected peanut  products only through the school meals program. FDA officials said that  they rely on FNS to conducts its own checks of schools that received  affected commodities for school meal programs. FDA instructions for  conducting audit checks for the PCA recalls included special provisions  for selecting schools and other facilities that served vulnerable  populations. However, at the time of our contact with FDA officials, they  did not know if schools had procured affected peanut products  commercially or had been selected for audit checks and did not have an  assessment of audit check activity to date for schools or other consignees.  According to FDA, the analysis of audit checks typically occurs further  into the monitoring phase of the recall, closer to the termination phase of  the recall.
FSIS procedures explicitly allow for grouping those to be contacted for  effectiveness checks in categories such as schools, and selecting  consignees from each category to create its sample. However, after the  Westland/Hallmark recall, FSIS did not create a school category for its  effectiveness checks, even though thousands of schools were affected.  FSIS did ask FNS to provide names of schools and states affected by the  Westland/Hallmark recall of commodity beef and received a list of over  7,000 affected school districts, but FSIS officials did not use this  information to include the schools in its effectiveness checks. FSIS  effectiveness checks for the Westland/Hallmark beef recall did not include  any schools that received the beef through the commodity program. FSIS  estimated there were 9,500 consignees who received recalled  Westland/Hallmark commercial beef, not including schools and others that  had received Westland/Hallmark commodity beef for federally-subsidized  food programs. FSIS officials said they did not know how many of the  9,500 consignees that had procured beef commercially were schools. FSIS  determined its statistical sample would be 200 of the 9,500 consignees,  using systematic sampling with a sampling interval of 47. Our review found  2 names of schools, the name of a preschool, and a school food distributor  included in the sample; both schools that were selected procured the  product commercially.
FSIS officials said they did not specifically include schools receiving  recalled commodity products in their checks for the Westland/Hallmark  recall, and FDA officials said they did not specifically include schools  receiving recalled commodity products in their checks for PCA recalls,  because they said that USDA was responsible for conducting its own  checks of schools receiving commodities.
section_title: FNS Did Not Monitor the Effectiveness of Recalls or its Own Administrative Holds for Commodity Products in Schools
paragraphs: Although FSIS and FDA procedures direct them to monitor the  effectiveness of recalls, they told us that they relied on FNS to conduct  checks of schools affected by recalls of USDA commodity products;  however, FNS does not conduct such effectiveness checks. FNS officials  told us it was not their responsibility to check on the effectiveness of any  of three companies’ recent recalls covered in this review, but that they  relied on their regulatory partners, FSIS and FDA, to conduct these quality  checks. FNS has authority to issue holds on USDA commodity products, in  conjunction with regulatory and procurement agencies, but does not have  procedures in place to conduct a systematic review of schools to  determine whether schools received notice of the hold and followed  instructions to keep the identified products from being served to students.
FNS did not conduct such checks on its hold or hold extensions for  Westland/Hallmark beef or Glacier Sales potato rounds.
section_title: Conclusions
paragraphs: Protecting school children from food-borne illnesses in schools depends  on the efforts of many local, state, and federal entities. Agencies within  USDA and HHS, including FSIS, FNS, and FDA, have critical roles in  identifying food safety issues, disseminating information, providing  guidance, and evaluating the effectiveness of food holds and recalls. While  these agencies have related policies and procedures in place, recent  recalls of products, from raw beef to peanut butter, have highlighted the  importance of revisiting these policies and procedures to ensure they  accomplish what they intend. Nearly 700 people, including over 200  school-aged children, were sickened by Salmonella during a 2009 recall of  Peanut Corporation of America products and ingredients. And while it is  not known to what extent the source of the bacteria in these cases of  illness were from a school snack or meal, federal and state agencies must  ensure schools receive timely notification, adequate information, and clear  instructions on food holds and recalls. Evaluations also must be  conducted to determine the effectiveness of those efforts. School children  are a vulnerable population, in part because they are more likely to suffer  complications from food-borne illnesses, and in part because they may  have less knowledge to make informed choices about the foods they  consume. As such, USDA and HHS should make the policy and procedure  changes necessary to ensure that the food children consume in schools is  unadulterated and safe.
The speed and complexity with which recalls unfold, often leading to  multiple recalls of related products or covering longer manufacturing time  frames, creates challenges for agencies and their efforts to protect  consumers—particularly school children—from potentially harmful foods.  Although FNS, in conjunction with the responsible USDA procurement  agency, can issue an administrative hold on suspect products prior to a  recall—an action taken in the Westland/Hallmark recall—the lack of  criteria and guidance on when to issue a hold may have contributed to a  conservative response to the New Era and PCA recalls, whereby FNS did  not preemptively issue a hold on products that were later recalled. Absent  guidance on when to issue administrative holds, FNS will continue to face  challenges in deciding when to issue administrative holds. The ability to  issue holds provides a valuable tool that allows FNS to act quickly to  protect school children while investigations are ongoing. In addition, FNS  and FDA officials said they are working on a memorandum of  understanding about how the agencies will communicate during FDA food  safety investigations. Such a document could provide FNS with important  information when it considers administrative holds of suspect commodity  products used in school meal programs. But, no time frame has been  established for completing it.
Gaps in the protocols federal agencies follow in communicating with each  other and gaps in states then communicating with schools districts have  led to delays in schools receiving notice of recalls and sufficient  information on what actions to take. These delays were, in some instances,  exacerbated by difficulties in identifying processed foods that contained  recalled ingredients, in part, because federal hold and recall guidance does  not explicitly address the role of processors or distributors. As a result,  some affected commodities were served to school children after holds and  recalls were announced. In addition, insufficient guidance on disposal  procedures for recalled products increased the risk that they could be  inadvertently consumed. FNS officials said they have plans to address the  role of processors and update the hold and recall procedures for USDA  commodities, but have not established a time frame for completing the  revisions. It is important for FNS to make changes to the procedures as  soon as feasible to avoid confusion and delays the next time a major recall  occurs that involves processed products.
Given the current technology for almost instant communication, it seems  federal regulators could disseminate information through states to schools  and directly to schools more quickly than the standard procedures, which  permit up to 48 hours to elapse by the time FNS communicates with states  and states communicate with schools. New strategies for federal  regulators to communicate directly with schools, such as the FNS  Commodity Alert System used for the PCA recalls, are promising but have  yet to deliver timely or complete information. Further, although FSIS and  FDA perform checks of how effectively recalls are carried out, neither  agency systematically monitors or evaluates holds and recalls in schools.  While FDA selected some schools for its New Era recall audit checks, it  did not document its analysis of audit checks conducted at schools, nor  did it track corrective action taken as a result of its audit checks of  schools. Unless FSIS, FDA, and FNS revise their assessment procedures,  these agencies will not be able to determine if additional actions are  necessary to keep school children safe.
We have previously reported that food safety oversight is a complex and  fragmented system requiring major improvements. Yet smaller, immediate  improvements in coordination, notification, and evaluation procedures in  the near term could better equip states and schools to protect their  students from unsafe foods.
section_title: Recommendations for Executive Action
paragraphs: To better ensure the safety of foods provided to children through the  school meal programs, we recommend the Secretary of Agriculture and  the Secretary of HHS take 12 actions to make improvements in three areas  related to recalls affecting schools: interagency coordination; notification  and instructions to states and schools; and monitoring effectiveness.
We recommend the Secretary of Agriculture direct FNS and that the  Secretary of HHS direct FDA to jointly:    establish a time frame for completing a memorandum of understanding on  how FNS and FDA will communicate during FDA investigations and  recalls that may involve USDA commodities for the school meal programs,  which should specifically address how FDA will include FNS in its  prerecall deliberations.
We recommend the Secretary of Agriculture direct FNS to:   develop guidelines, in consultations with AMS and FSA, to be used for  determining whether or not to institute an administrative hold on suspect  commodities for school meal programs;   work with states to explore ways for states to speed notification to  improve the timeliness and completeness of direct communication  between FNS and schools about holds and recalls, such as through the  commodity alert system;  take the lead among USDA agencies to establish a time frame in which it  will improve the USDA commodity hold and recall procedures to address  the role of processors and determine distributors’ involvement with  processed products, which may contain recalled ingredients, to facilitate  providing more timely and complete information to schools;  revise its procedures to provide states with more specific instructions for  schools on how to dispose of recalled commodities and obtain timely  reimbursement; and institute a systematic quality check procedure to ensure that FNS holds on  foods and products used by schools are carried out effectively.
We recommend the Secretary of Agriculture direct FSIS to: revise its procedures to ensure that schools are included in effectiveness  checks.
We recommend the Secretary of HHS direct FDA to:  revise the Recall Audit Check Report form to include a consignee prompt  for schools; revise FDA procedures to ensure schools are included in audit checks,  either by drawing a separate schools-only sample or providing a selection  preference for schools; and revise FDA procedures to ensure analysis of its audit checks is  documented, and any problems with recalls or audit checks affecting  consignees involved with schools identified and acted upon.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to USDA and HHS for review and  comment. USDA stated that it generally agreed with and supported the  recommendations of the report and provided additional information on the  roles and responsibilities of all stakeholders involved in assuring the  safety of food provided by USDA through its nutrition assistance  programs. We have reprinted USDA’s comments in their entirety in  appendix I. HHS stated that it agreed with the recommendations of the  report and that GAO has raised important issues regarding the safety of  foods provided to children through the school meals programs. We have  reprinted HHS’s comments in their entirety in appendix II. Both USDA and  HHS also provided technical corrections to the report which we  incorporated, as appropriate.
As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. We will send copies of this report to the Secretary of  Agriculture, the Secretary of Health and Human Services, the Secretary of  Education, and relevant congressional committees. In addition, this report  will be available at no charge on GAO’s Web site at http://www.gao.gov.
If you or your staffs have any questions about this report, please contact  me at (202) 512-7215 or brownke@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this report. Key contributors to this report are listed in appendix  III.
section_title: Appendix I: Comments from the Department of Agriculture
section_title: Appendix II: Comments from the Department of Health and Human Services
section_title: Appendix III: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: In addition to the contact named above, Kathryn A. Larin, Assistant  Director; Sylvia Arbelaez-Ellis; Susan L. Aschoff; Susannah L. Compton;  Jean L. Cook; Sarah A. Farkas; Alexander G. Galuten; Nisha R. Hazra;   Lise L. Levie; Daniel S. Meyer; and Charles E. Willson made key  contributions to this report.