Colorado WIC Program Policies and Procedures

Section 10: Monitoring and Audits Revised: 01.01.2023

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Local Agency Monitoring Visits

Policy: The State WIC Office will conduct onsite monitoring reviews of at least 20% of a Local Agency’s clinics every other year to assure program operations are carried out in compliance with federal and state requirements.

Local WIC agencies will establish self-evaluation procedures to review their own operations and those of associated clinics and/or contractors at least every other year by the completion of the Colorado WIC Program Administrative Monitoring Form.

Regulation: 7 CFR 246.19(b)(1-6)

Procedure/Additional Guidance

Monitoring Visits: The process used to evaluate all aspects of the local agency WIC Program including program management, nutrition education, participant services, civil rights compliance, accountability, retailer participation, and food delivery. USDA regulations require the State agency to establish an ongoing management evaluation system which includes monitoring of local agency operations, the review of local agency financial and participation reports, the development of corrective action plans to resolve Program deficiencies, the monitoring of the implementation of corrective action plans, and on-site visits. The State agency may conduct additional on-site reviews as the State agency determines to be necessary.

Site Visits: A site visit is an informal meeting between State and local agency staff at the local agency. State Office budget permitting, each local agency, and representative clinics within that agency, receives a site visit during the year the local agency is not being formally monitored. The purpose of a site visit is to:  Review unresolved problems or concerns from previous monitoring.  Train local agency staff.  Provide appropriate assistance to ensure continued compliance with Federal and State program requirements.  Accomplish administration planning.  Prepare local staff for future State initiatives.  Assist with local agency nutrition education planning.  Answer questions from local agency staff.

Local Agency Self-Monitoring: The process by which the local agency examines and evaluates its WIC Program operations prior to the monitoring visit in order to identify strengths and problems. The Colorado WIC Program Administrative Monitoring Form is the basis for local agency self-monitoring as well as use of the other monitoring forms throughout the year.

Monitoring Forms  Colorado WIC Program Administrative Monitoring Form (AMF)  Colorado WIC Program Clinic Observation form  WIC Participant Record Review form  Education Contact/Referrals Review form  Pump/Signature Capture/PAF Review form  Colorado WIC Program Local Agency Monitoring and Site Visit Action Plan  Local Agency Breastfeeding Peer Counselor (BF PC) Program Summary Form

Forms are available on the Colorado WIC website.

Monitoring Visit Activities: The entire clinic staff is encouraged to participate in the monitoring experience including the visit itself and the pre- and post-monitoring activities. During the in-depth monitoring, all aspects of program operation are thoroughly reviewed.

Colorado WIC Program Policies and Procedures

Section 10: Monitoring and Audits Revised: 01.01.2023

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For new agencies, in operation six months or less by the end of the current fiscal year, the first in-depth monitoring occurs the following fiscal year. Both agencies are responsible for the following procedures:

Pre-Visit Monitoring Procedures  The State Office Nutrition Consultant (NC) notifies the Local Agency WIC Director/Manager (Director/Manager) approximately 30 days in advance to establish the date(s) for monitoring.  NC confirms the date(s) in writing and sends/emails it along with the Colorado WIC Program Administrative Monitoring Form (AMF) to the Director/Manager.  Director/Manager completes the AMF.  Once completed, the Director/Manager retains a copy of the AMF and emails a copy to NC who reviews the AMF prior to the monitoring visit.  NC will review and evaluate participant records at the State Office prior to the on-site visit. The number reviewed is based on participant caseload. Potential categories for review include: o An infant. o A child. o A pregnant woman. o A breastfeeding woman. o A non-breastfeeding, postpartum woman. o A participant who has terminated from the Program. o A participant identified as high risk. o An infant or child receiving a special formula.

On-site Monitoring Procedures  On the day(s) of monitoring, the appropriate local agency WIC staff members and Director/Manager join NC in an entrance meeting to discuss the process and significance of monitoring. NC observes the clinic in operation, sits with staff during appointments, reviews participant records, administrative files, and other pertinent documentation. At least one local agency staff member should be available to answer questions that arise.  NC observes the following types of clinic operations: o Participant certification process o Initial explanation of WIC o Anthropometric and hematologic measurement techniques and equipment o Health and nutrition assessment o Food benefit issuance o Nutrition counseling of low and high-risk participants o Referrals to other health or social service programs o Clinic facilities

 Local agency staff and the NC review the following administrative and participant service procedures: o Food delivery and vendor relations. o Documentation of nutrition services. o Staff and participant nutrition education. o Quality and continuity of nutrition services to participants. o Food package issuance and tailoring. o Administrative procedures, including clinic accessibility hours and staffing pattern. o Program outreach and referrals. o Civil Rights complaints. o Breast Pump Loan Program. o Staff training requirements.

Colorado WIC Program Policies and Procedures Section 10: Monitoring and Audits Revised: 1/01/2023

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 Appropriate local agency staff, the Director/Manager and the NC participate in a closing meeting where results of the monitoring visit and subsequent recommendations are shared. Agency strengths and problems identified during the monitoring process are discussed and, where appropriate, a plan, including timeframe, is developed for the resolution of problems.

Post-Visit Monitoring Procedures  Within 30 days after the monitoring visit, NC sends the final monitoring report to Director/Manager. The report includes the Local Agency Monitoring and Site Visit Action Plan, Monitoring Visit Cover Letter, the final AMF, and the Clinic Observation Forms, Participant Record Review, Education Contact/Referrals Review and Pump/Signature Capture/PAF Review forms completed during the visit.  Within 30 days after receiving the final monitoring report, the Director/Manager completes the agency response section of the Local Agency Monitoring and Site Visit Action Plan and emails/faxes it to NC. NC reviews the local agency's response and follows up as appropriate. This either includes a second visit or a follow-up telephone call to the Director/Manager within ninety (90) days to 6 months of monitoring visit.