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Could Reduce Risk of School Children Consuming Recalled Food' which was 
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Report to Congressional Requesters: 

United States Government Accountability Office: 
GAO: 

August 2009: 

School Meal Programs: 

Changes to Federal Agencies' Procedures Could Reduce Risk of School 
Children Consuming Recalled Food: 

GAO-09-649:  

GAO Highlights: 

Highlights of GAO-09-649, a report to congressional requesters.  

Why GAO Did This Study: 

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.  

What GAO Found: 

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.  

What GAO Recommends: 

GAO recommends that USDA improve FNS notification procedures and 
instructions on carrying out recalls. GAO also recommends specific 
steps that USDA and HHS take to improve monitoring of the effectiveness 
of recalls.  

USDA and HHS agreed with this report’s recommendations.  

View [hyperlink, http://www.gao.gov/products/GAO-09-649] or key 
components. For more information, contact Kay E. Brown at (202) 512-
7215 or BrownKE@gao.gov.  

[End of section]  

Contents: 

Letter: 

Background: 

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: 

FNS Provided Disposal and Reimbursement Instructions to States, but 
State and School Administrators Reported Challenges in Disposing of 
Products and Obtaining Reimbursement: 

Federal Regulators Did Not Systematically Monitor and Assess the 
Effectiveness of Recalls and Holds in Schools: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Comments from the Department of Agriculture: 

Appendix II: Comments from the Department of Health and Human Services: 

Appendix III: GAO Contacts and Staff Acknowledgments: 

Figures: 

Figure 1: Possible Food Distribution Routes from a Company to Schools: 

Figure 2: Simple Diagram of How Schools are Notified of Commodity 
Recalls: 

Figure 3: A School District's Large Quantity of Westland/Hallmark Beef 
Products at a Disposal Transfer Station: 

Abbreviations: 

AMS: Agricultural Marketing Service: 

CDC: Centers for Disease Control and Prevention: 

FDA: Food and Drug Administration: 

FNS: Food and Nutrition Service: 

FSA: Farm Service Agency: 

FSIS: Food Safety and Inspection Service: 

HHS: U.S. Department of Health and Human Services: 

PCA: Peanut Corporation of America: 

USDA: U.S. Department of Agriculture: 

[End of section] 

United States Government Accountability Office:
Washington, DC 20548: 

August 20, 2009: 

Congressional Requesters: 

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.[Footnote 1] 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.[Footnote 
2] 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.[Footnote 3] 

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. 

Background: 

Schools Receive Food Through a Complex Distribution Network: 

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 Figure 1). 

Figure 1: Possible Food Distribution Routes from a Company to Schools: 

[Refer to PDF for image: illustration]  

This illustration depicts possible food distribution routes from a 
company to schools, as follows:  

Company to school district; 
Company to retailer to school district; 
Company to distributor to school district; 
Company to distributor to retailer to school district; 
Company to distributor to another distributor to school district; 
Company to processor to school district; 
Company to processor to another processor to school district; 
Company to processor to retailer to school district; 
Company to processor to distributor to school district; 
Company to processor to another processor to retailer to school 
district; 
Company to processor to another processor to distributor to school 
district.  

Sources: GAO analysis; Art Explosion (images).  

[End of figure] 

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. 

Federally Subsidized School Meal Programs: 

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. 

Food Recall and Hold Procedures: 

Food holds and recalls to protect consumers are governed by various 
laws, regulations, and policies.[Footnote 4] 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.[Footnote 5] Either FSIS or FDA then classifies the recall 
from Class I to Class III:[Footnote 6] 

* 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 Figure 2). 

Figure 2: Simple Diagram of How Schools are Notified of Commodity 
Recalls: 

[Refer to PDF for image: illustration]  

HHS: FDA: releases recall information; 
USDA: FSIS: releases recall information; 
AMS: identifies commodities affected by the recall; 
FSA: identifies commodities affected by the recall;  

FNS: notifies affected states of the recall;  

State agency: notifies schools of recall;  

School district: locates recalled products at district and school 
level.  

Sources: GAO analysis; Art Explosion (images).  

[End of figure] 

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. 

PCA Peanut Product Recall: 

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. 

Westland/Hallmark Beef Holds and Recall: 

In January 2008, an animal protection organization released an 
undercover video of persons trying to force non-ambulatory[Footnote 7] 
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.[Footnote 8] 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. 

New Era Canned Vegetables Recall: 

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. 

Glacier Sales Potato Rounds Hold: 

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. 

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: 

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. 

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: 

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."[Footnote 9] 
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. 

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: 

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.[Footnote 10] 
CDC does not have information on how many of the children may have 
consumed the products in school.[Footnote 11] 

FNS Notifications to States about the Westland/Hallmark Recall Did Not 
Always Provide Complete Information, Particularly on Processed 
Products: 

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.[Footnote 12] 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. 

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: 

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. 

FNS Has Used Supplemental Notification Strategies, but Most Have Not 
Resulted in More Timely Notification to States and Schools: 

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.[Footnote 13] 

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. 
[Footnote 14] 

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.[Footnote 15] 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 
[peanut] 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.[Footnote 16] 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. 
[Footnote 17] 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. 

FNS Provided Disposal and Reimbursement Instructions to States, but 
State and School Administrators Reported Challenges in Disposing of 
Products and Obtaining Reimbursement: 

FNS Provided Disposal Instructions, but Not All Schools Followed 
Disposal Procedures and Some School Districts Reported Challenges in 
the Disposal of Recalled Beef: 

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,[Footnote 18] 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. 

Figure 3: A School District's Large Quantity of Westland/Hallmark Beef 
Products at a Disposal Transfer Station:  

[Refer to PDF for image: photograph]  

Source: Long Beach Unified School District.  

[End of figure]  

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. 

Some State and School Officials Said They Were Not Reimbursed for All 
Costs Incurred in Disposal and Found the Process Difficult: 

Some school officials told us they were not reimbursed for all costs 
incurred due to recalls.[Footnote 19] 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.[Footnote 20] 

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. 

Federal Regulators Did Not Systematically Monitor and Assess the 
Effectiveness of Recalls and Holds in Schools: 

Neither FDA nor FSIS Systematically Monitored the Effectiveness of 
Recalls for Schools: 

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. 
[Footnote 21] 

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. 
[Footnote 22] 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. 

FNS Did Not Monitor the Effectiveness of Recalls or its Own 
Administrative Holds for Commodity Products in Schools: 

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. 

Conclusions: 

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. 

Recommendations for Executive Action: 

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 
schools; 

* 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. 

Agency Comments and Our Evaluation: 

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 [hyperlink, 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.  

Signed by:  

Kay E. Brown: 
Director, Education, Workforce, and Income Security Issues: 

List of Congressional Requesters: 

The Honorable George Miller: 
Chairman: 
Committee on Education and Labor: 
House of Representatives: 

The Honorable Carolyn McCarthy: 
Chairwoman: 
Subcommittee on Healthy Families and Communities: 
Committee on Education and Labor: 
House of Representatives: 

The Honorable Rosa L. DeLauro: 
Chairwoman: 
Subcommittee on Agriculture, Rural Development, Food and Drug 
Administration, and Related Agencies: 
Committee on Appropriations: 
House of Representatives: 

The Honorable Richard J. Durbin: 
United States Senate: 

[End of section] 

Appendix I: Comments from the Department of Agriculture: 

USDA: 
United States Department of Agriculture: 
Office of the Secretary: 
Washington, D.C. 20250:  

July 22, 2009:  

Ms. Kay E. Brown: 
Director: 
Education, Workforce, and Income Security Issues: 
U.S. Government Accountability Office: 
441 G Street, NW: 
Washington, D.C. 20548:  

Dear Ms. Brown:  

We appreciate the opportunity to review the draft report, School Meal 
Programs: Changes to Federal Agencies' Procedures Could Reduce Risk of 
School Children Consuming Recalled Food (GAO-09-649) and to discuss the 
audit with Government Accountability Office (GAO) audit staff on May 1, 
and July 10, 2009. The health and safety of the children we serve in 
the Department of Agriculture (USDA) nutrition assistance programs is 
of the utmost importance to us. While we generally agree with and 
support the recommendations of the report, it is important that the 
report accurately reflect the roles and responsibilities of all 
stakeholders involved in assuring the safety of food provided by USDA 
through its nutrition assistance programs. Specific technical comments 
have been provided to GAO separately. 

As Secretary of Agriculture, I oversee four agencies that each play a 
unique role relative to the food served in schools and oversight of the 
safety of that food. The Food Safety and Inspection Service (FSIS) 
regulates all meat, poultry, and egg products in commerce, including 
those products purchased by schools on the commercial market and those 
products purchased for use by schools through the USDA commodity 
programs, The Food and Drug Administration of the Department of Health 
and Human Services has oversight responsibility for the remainder of 
the food supply. Together, FSIS' regulations and inspections, along 
those of FDA, provide the foundation for the safety of food served in 
schools, including that obtained commercially and that from USDA-
purchased commodity sources. 

Other USDA agencies also play important roles in the process. The 
Agricultural Marketing Service (AMS) purchases USDA commodities, and 
AMS purchase contracts impose additional specification requirements for 
the commodities it purchases for schools. The Farm Service Agency 
(FSA), in addition to AMS, also procures USDA commodities using 
specific contractual requirements. 

The Food and Nutrition Service (FNS) receives orders from State 
agencies for food requested by local school districts, and FNS fills 
those orders using commodity purchases made by both AMS and FSA. FNS 
serves as a conduit for information on any recall action taken by the 
two regulatory agencies, FSIS and FDA, or for administrative hold or 
recall actions requested by either AMS or FSA. FNS relies on the 
regulatory agencies, FSIS and FDA, for food safety assurances. 
Specifically, FNS relies on the regulatory agencies for early warnings 
about recalls that affect USDA-purchased commodities, information about 
recalls as they unfold when USDA commodities are affected, and 
assistance from their field staffs in conducting effectiveness checks 
or audits to assess the completeness of a recall that affects a USDA-
purchased commodity. 

Through the authorities of USDA agencies and FDA, we will continue to 
ensure that food served in schools is healthy and safe. USDA is 
committed to continuous improvement in our food safety responsibilities 
and actions based on best practices and information we learn from 
recall events.  

We have already taken a number of steps to enhance capability regarding 
recalls; these actions include rolling out the web-based notification 
system in 2006, initiating a comprehensive revision of departmental 
hold and recall procedures, and drafting revised technical assistance 
materials on holds and recalls for State agencies and schools. We 
developed an arrangement with the Department of Education to broadcast 
a food safety message of significant public health concern to schools, 
and are working with FDA on a Memorandum of Understanding to allow 
sharing of information during an investigation and prior to an official 
announcement of a recall that affects USDA-purchased commodities. 
Overall, the goal is to streamline communications among departments, 
agencies, and State partners to yield a more effective and integrated 
approach to handling recalls. 

Our comments above, and the technical comments we previously provided 
to and discussed with GAO staff, are consistent with the subject GAO 
report's recommendations to improve and strengthen the food safety 
system for USDA nutrition assistance programs, In conclusion, USDA will 
continue to work internally, and with HHS, to build a system that will 
assure the safety of the food provided and, thus, the health and well-
being of all children that participate in our nutrition assistance 
programs.  

Sincerely,  

Signed by:  

Thomas J. Vilsack: 
Secretary:  

[End of section] 

Appendix II: Comments from the Department of Health and Human Services: 

Department Of Health & Human Services: 
Office Of The Secretary: 
Assistant Secretary for Legislation: 
Washington, DC 20201:  

July 22, 2009:  

Kay E. Brown, Director: 
Education, Workforce and Income Security Issues: 
U.S. Government Accountability Office: 
441 G Street N.W. 
Washington, DC 20548:  

Dear Ms. Brown:  

Enclosed are comments on the U.S. Government Accountability Office's 
(GAO) report entitled: "School Meal Programs: Changes to Federal 
Agencies' Procedures Could Reduce Risk of School Children Consuming 
Recalled Foods" (GAO-09-649). 

The Department appreciates the opportunity to review this report before 
its publication.  

Sincerely,  

Signed by:  

Barbara Pisaro Clark: 
Acting Assistant Secretary for Legislation:  

Attachment:  

[End of letter]  

Department Of Health & Human Services: 
Public Health Service: 
Food and Drug Administration: 
Rockville, MD 20857:  

Date: July 22, 2009:  

To: Acting Assistant Secretary for Legislation:  

From: Principal Deputy Commissioner of Food and Drugs:  

Subject: FDA's General Comments to GAO's Draft Report entitled, School 
Meal Programs: Changes to Federal Agencies' Procedures Could Reduce 
Risk of School Children Consuming Recalled Food (GAO-09-649):  

FDA is providing the attached general comments to the U.S. Government 
Accountability Office's draft report entitled: SCHOOL MEAL PROGRAMS: 
Changes to Federal Agencies' Procedures Could Reduce Risk of School 
Children Consuming Recalled Food (GAO-09-0649).  

FDA appreciates the opportunity to review and comment on this draft 
report before it is published.  

Signed by:  

Joshua M. Sharfstein, M.D. 
Principal Deputy Commissioner of Food and Drugs:  

Attachment:  

FDA's General Comments to the U.S. Government Accountability Office's 
(GAO) Draft Report Entitled, School Meal Programs: Changes to Federal 
Agencies' Procedures Could Reduce Risk of School Children Consuming 
Recalled Food (GAO-09-649):  

The Food and Drug Administration (FDA) appreciates the opportunity to 
review and comment on the Government Accountability Office's (GAO) 
draft report. GAO has raised some important issues regarding the safety 
of foods provided to children through the school meals programs. FDA 
continually strives to advance its public health mission, and this 
includes efforts to improve and strengthen communication among all 
agencies involved to ensure the safety of food products. 

FDA's Specific Comments on GAO Recommendations for Executive Action:  

GAO Recommendation 1:  

We recommend the Secretary of Agriculture direct the Food and Nutrition 
Service (FNS) and that the Secretary of HHS direct the Commissioner of 
the FDA to jointly:  

* Establish a timeframe for completing a memorandum of understanding 
(MOU) on how FNS and FDA will communicate during FDA investigations and 
recalls that may involve USDA-commodities for the school meal programs, 
which could specifically address how FDA will include FNA in its pre-
recall deliberations.  

FDA Response:  

FDA agrees with GAO's recommendation and will continue to work with FNS 
to complete a MOU as soon as possible.  

GAO Recommendation 2:  

We recommend the Secretary of Agriculture direct FNS to:  

* Work with states to explore ways for states to speed notification to 
schools.  

FDA Response:  

FDA will offer its network to FNS to speed notification to schools. FDA 
will continue a close working relationship with FNS and stand ready to 
aid in any way possible within areas under our jurisdiction. 

GAO Recommendation 4:  

We recommend the Secretary of HHS direct the Commissioner of FDA to:  

* Revise the Recall Audit Check form to include consignee prompt for 
schools. 

FDA Response:  

FDA agrees with GAO's recommendation and is currently taking steps to 
implement the revision to the Recall Audit Check form. 

We recommend the Secretary of HHS direct the Commissioner of FDA to:  

* 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. 

FDA concurs that the best approach to protect public health is to 
ensure that special and vulnerable populations including, but not 
limited to, schools are covered as part of a broad recall audit 
approach. Currently, when FDA recall staff review consignee lists and 
decide which firms to include in audit checks, FDA notes and gives 
special consideration to special and vulnerable populations. Per GAO's 
recommendation, FDA will provide additional instruction to recall 
coordinators to continue to give special consideration to schools and 
other vulnerable populations during audit checks. 

We recommend the Secretary of HHS direct the Commissioner of FDA to:  

* Revise FDA procedures to ensure analysis of its audit check is 
documented and any problems with recalls or audit checks affecting 
consignees involved with schools identified and acted upon. 

FDA agrees with GAO that having as much information as early as 
possible regarding the results of a recall would be ideal. However, 
during large-scale, complex recalls, fully compiling and documenting 
recall results is challenging because the FDA recall coordination staff 
involved are overseeing the recall as it unfolds. 

Response to Recommendation 2, bullet 1: 
R/D:GLewis:7/2/09:
Edits:FNS-Marion Hinners:7/8/09: 
Revised:GLewis:7/9/09: 
Cleared:NBeru:7/10/09: 
Edits:CAinsworth:7/13/09: 
Edits/Cleared:BHarden:7/13109: 
Cleared:LTarantino:7/14/09:  

Response to Recommendation 4 bullet 2: 
R/D:JThomas:7/10/09: 
Comments:OE:AZamora:7110/09: 
Cleared:RWagner:7/10/09: 
Edits:CAinsworth:7/13/09: 
Edits/Cleared:BHarden:7/13/09: 
Cleared:LTarantino:7/14/09:  

Comments: Y.Jenkins/C.Grillo/D.Foellemer: 7/15/09: 
Edits: Y. Jenkins: 7/16/09: 
Cleared with Edits: V. Madamba (OCC): 7/20/09: 
Edits based on Teleconference with JM Sharfstein: 07/21/09:  

Responses to Recommendation 1, bullet 1 provided by: ORA: 
Responses to Recommendation 4, bullet 1 provided by: ORA: 
Responses to Recommendation 4, bullet 2 provided by: ORA (blue) and 
CFSAN (black): 
Responses to Recommendation 4, bullet 3 provided by: ORA.  

[End of section]  

Appendix III: GAO Contacts and Staff Acknowledgments: 

GAO Contact: 

Kay E. Brown, (202) 512-7215, or brownke@gao.gov: 

Acknowledgments: 

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. 

[End of section]  

Footnotes:  

[1] GAO, Food Safety: USDA and FDA Need to Better Ensure Prompt and 
Complete Recalls of Potentially Unsafe Food, [hyperlink, 
http://www.gao.gov/products/GAO-05-51] (Washington D.C.: Oct. 6, 2004). 

[2] GAO, High-Risk Series: An Update, [hyperlink, 
http://www.gao.gov/products/GAO-07-310] (Washington, D.C.: January 
2007) and GAO, High-Risk Series: An Update, [hyperlink, 
http://www.gao.gov/products/GAO-09-271] (Washington, D.C.: January 
2009). 

[3] U.S. Department of Agriculture, Office of Inspector General, Audit 
Report: Evaluation of FSIS Management Controls Over Pre-Slaughter 
Activities, 24601-0007-KC, (Washington, D.C., Nov. 2008). 

[4] FDA, Regulatory Procedures Manual, (Washington D.C., Mar. 2009); 
FSIS, Recall of Meat and Poultry Products, Directive 8080.1 Revision 5, 
(Washington D.C., Nov. 2008); USDA, Commodity Hold and Recall Process, 
(Washington D.C., July 2001). The FDA manual provides policy, 
responsibilities and procedures for FDA staff to initiate, review, 
classify, publish, audit and terminate recall actions. The FSIS 
directive provides responsibilities and public notification procedures 
regarding the voluntary recall of FSIS-inspected meat and poultry 
products. FNS officials said they use the USDA procedures for handling 
commodity holds and recalls. This document--developed jointly by FNS, 
FSIS, the Agricultural Marketing Service, and the Farm Service Agency-
-defines federal, state, and local agency roles and obligations. 

[5] Should a company fail to voluntarily recall a product, the FSIS and 
FDA have methods to remove products from commerce, such as product 
seizure. 

[6] FSIS makes a determination of the recall classification at the time 
the recall is announced. FDA does not make a recall classification 
until after further evaluation; however, FDA makes an initial decision 
of how to treat the recall, based on known information about the recall 
at the time. For example, FDA treated the PCA peanut product recall as 
a potential Class I recall before it actually classified the recall 
because of the products' association with Salmonella. 

[7] USDA defines "non-ambulatory" cattle as those that cannot rise from 
a recumbent position or cannot walk. 

[8] The Agricultural Marketing Service contracts with companies like 
Westland/Hallmark to provide commodities for the school meal programs. 
These contracts prohibit the mistreatment of animals; so when AMS 
became aware that Westland/Hallmark was mistreating cows, it suspended 
its contract and worked with FNS to place a hold on Westland/Hallmark 
beef. While FNS issued a hold for a contractual violation, FSIS issued 
a recall because Westland/Hallmark did not follow inspection procedures 
that require a veterinarian to reinspect non-ambulatory cattle before 
slaughter. 

[9] FDA Regulatory Procedures Manual. 

[10] CDC provided data for persons aged 5 through 18 for use as school- 
aged children. 

[11] Data from CDC, as of March 24, 2009.  

[12] USDA guidance provides that FNS notify states within 24 hours of 
learning of a recall involving commodities. 

[13] We have previously reported on the need for USDA and FDA to ensure 
that customers are notified promptly of food recalls and to determine 
if additional approaches are needed to alert customers. GAO-05-51. 

[14] The notification, sent through the Department of Education's 
crisis communication system, went to school administrators and 
principals, not to school food service professionals. 

[15] The commodity alert system was first used for the PCA recall. It 
was not developed until after the Westland/Hallmark recall. 

[16] FNS officials have indicated that they have increased the number 
of allowable characters to 1000. 

[17] These persons may have completed the initial registration and had 
received an email welcoming them to the system, but if they did not 
reply to the email to acknowledge receipt of the confirmation, they 
would not have completed their registration. 

[18] This refers to the New Era, Westland/Hallmark, and PCA recalls. 
Glacier Sales was an administrative hold. 

[19] Federal, state, and sometimes local agencies, as well as the 
recalling company, may play a role in the reimbursement or replacement 
of recalled products, as well as related expenses. 

[20] USDA procedures provide that schools typically receive 
reimbursement and replacement directly from the recalling firm, unless 
the firm goes out of business or delays reimbursement, in which case 
USDA will initiate action to provide reimbursement or replacement.  

[21] [hyperlink, http://www.gao.gov/products/GAO-05-51]. 

[22] FNS collects information on the disposition of recalled product 
through its reimbursement process, but this does not constitute an 
effectiveness check. As previously discussed, effectiveness checks 
confirm for a sample of consignees, such as schools, whether they had 
been notified and carried out the recall properly, including whether 
all affected products had been identified and disposed of properly. 

[End of section]  

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