Updated 7-18-2024 Connecticut WIC Program Manual WIC 100-18 SECTION: Administration SUBJECT: Procedures for Serving Participants During a Disaster or Public Health Emergency

Federal Regulations: 7 CFR 246.7(o), 7 CFR 246.7(i)(10), 246.26(d) Guide to Coordinating Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Services When Regular Operations Are Disrupted This policy was developed to assist WIC local agencies to meet the needs of WIC participants and applicants during the COVID-19 pandemic and to ensure that there are minimal disruptions to WIC operations that allow eligible participants continue to receive benefits. In addition to providing a historical record, the various procedures outlined in this policy would also apply for future national, state, or local disasters that require modifications to providing WIC services. POLICY During a disaster or public health emergency, WIC regulations allow flexibility in program operations so that WIC State and local agency personnel can contribute to relief efforts by minimizing disruptions to WIC operations and ensuring that eligible, nutritionally at-risk women, infants, and children continue to receive WIC benefits. Disasters and Public Health Emergencies includes Natural Disaster, Human Pandemic, Biological (Bioterrorism). Natural disasters take different forms, such as hurricanes, floods, wildfires, etc. A natural disaster has the potential to disrupt WIC operations and cause the relocation of WIC participants. WIC-eligible foods at WIC retail vendors can be disrupted and may need to be addressed. Pandemics are a global outbreak of new (novel) viruses that can infect people easily and spread from person to person in an efficient and sustained way. During a pandemic, a key public health intervention to slow the spread of the disease may be social distancing. Workplaces, schools, and daycare centers may close for extended periods, leaving many working parents to care for their children at home. Social distancing restrictions may prevent WIC State agencies from certifying applicants for WIC at application/issuance sites or at local WIC clinics in their usual manner. In addition, staff may face an increased workload as State, local, and clinic employees and their families may be impacted by the pandemic and unable to work.

Bioterrorism is the intentional release or dissemination of biological agents. These agents can be in the form of bacteria, viruses, or toxins, and may be in a naturally occurring or a human- modified form.

Updated 7-18-2024 Guidance for local agencies Local agencies may extend the certification period for infants and children, up to 30 days, to accommodate difficulty in scheduling appointments. WIC Services can be conducted remotely, either in the WIC clinic with appropriate physical distancing and safety precautions in place, or via WIC staff teleworking. The expectation is that all remote WIC appointments (phone or virtual platform) are conducted like in-person office appointments. A complete nutrition assessment and nutrition education counseling should occur and documented appropriately in CT-WIC. For any appointment types (HGB, SPFORM, PROOF, HT. & WT, OST) where documentation is required, efforts should be made to obtain the information, via, the health care provider, electronic medical record (EMR), patient portal, email, facsimile, etc. Local agency must have a dedicated email address and/or local agency provided cell phone number for participants and providers to send information and direct inquires. Local agencies should designate a staff person to retrieve email and voicemail messages and triage accordingly. Voicemails and emails should be responded to within 24 hours and by next business day when messages are received over the weekend or on a holiday. Participants should be instructed to provide relevant information prior to their designated appointment time, however if the information is not available at the appointment time, staff should use the existing methods i.e., Self-declaration and short certification to proceed with the appointment, like an in-person appointment. State agency Notification and Messaging If local agencies are required to close due to a disaster or public health emergency, notify the State Agency immediately. State agency staff will aid in generating a text message to participants, notifying them of the closure. Adaptations to Certification and Recertification Procedures Documentation of Eligibility: Proof of Identity, Residency, and Income If enrollment in Medicaid/HUSKY A, C, D has been verified, this can be used to document proof of residency, income, and identity. For participants who are not enrolled/receiving Medicaid/HUSKY A, C or D, review the list of acceptable documentation for identity, income and residency and have the participant forward that information into the WIC office using these acceptable options; mail, pictures of documents emailed or texted, or drop off at the WIC office. Exceptions for Physical Presence The Connecticut WIC Program began operating under a physical presence waiver for COVID-19, in March 2020, therefore all participants were exempt for the physical presence requirement for the duration of the waiver. The Public Health Emergency (PHE) which was extended several times during the COVID-19 pandemic authorized a physical presence waiver for WIC Services.

Updated 7-18-2024 All active WIC waivers issued under the Families First Coronavirus Response Act are now set to expire on August 9, 2023 (90 days following the PHE that ended on May 11, 2023). “Persons with a serious illness that may be exacerbated by coming into the WIC office may be exempt from physical presence (this would also apply if applicants/family members are under a voluntary quarantine)”. The medical conditions (MC) waiver code should be used to document the above exemption. Refer to WIC Policy 200-02: Physical Presence Requirement for more information. Staff can use all the waiver codes as they apply, but if someone reported they are sick with COVID-19 (or a family member) MC is an appropriate code. MC can also be used for future pandemic related illnesses or other medical conditions that would under normal circumstances exempt a person from coming into the office in person. If a participant or family member is not sick and is scheduled for a certification or recertification, and the other Physical Presence codes do not apply, Natural Disaster (ND) should be used. In the event of a future national, state, or local disaster, local agencies requesting an approval of its disaster plan may use the appropriate physical presence waiver code for the approved period of the national, state, or local disaster with appropriate documentation. Connecticut WIC has opted into the nationwide waivers for Physical Presence and Remote Benefit Issuance using the authority granted to USDA by the American Rescue Plan Act (ARPA): WIC Flexibilities to Support Outreach, Innovation, and Modernization Efforts through ARPA Nationwide Waivers – Supporting Remote WIC Operations. This waiver will allow the continuation of physical presence exemption with the conditions outlined in WIC 200-35. See details in Eligibility Documentation under ARPA Waiver policy 200-35. Rights and Responsibilities Participants must continue to be apprised of their Rights and Responsibilities during a disaster. Staff must read the Rights and Responsibilities form (R&R) to the participant, in their language or with an interpreter. Once the participant has had the Rights and Responsibilities form read to them, ask for verbal confirmation that they agree to the information. If the participant agrees to the Rights and Responsibilities, staff must sign or print “disaster – COVID-19” (and the staffs’ initials) or whatever the State Agency designates as the appropriate signature based on the circumstance in the participant’s CT-WIC record. Ask the participant if they have access, by phone or on a computer, to the Connecticut WIC website, if so direct them to the website to read the Rights and Responsibilities form in the “How to Apply” section. The Rights and Responsibilities form is available in English and Spanish. https://portal.ct.gov/DPH/WIC/How-To-Apply

Updated 7-18-2024 If the participant does not have access to the Connecticut WIC website, offer the option of emailing the R &R form, and as a last option, the R & R form must be mailed to participants who cannot access the WIC website or receive the R & R form by email.

CT-WIC Adaptations for anthropometric measurements and hematological data during the COVID-19 pandemic. Documenting Anthropometric Measurements and Hematological Data in the Anthropometrics and Bloodwork grid (The following guidance has since been updated as we transitioned through the pandemic, but is retained here for historical/ documentation purposes)

Staff must be diligent about obtaining current anthropometric/hematological data from the provider, the information should be documented in CT-WIC when available. Staff should make every effort to contact medical providers to collect anthropometric and/or hematological information.

The “?” should be checked and disaster selected from the “? Reason” dropdown when the anthropometric data is unavailable/outdated.

Staff should also select the correct option in the “By Whom” drop down. It is not appropriate to select “WIC CPA” while services are being provided remotely. In most instances “Other” would be the most appropriate option when current data is not available.

Request that participant send completed certification form to the office. If a certification form is not available; determine the date of the last physical/doctor’s appointment, if within the last 60 days, contact the HCP for the information, utilize the available electronic medical record (EMR) data, or ask the participant to send an electronic copy of information available on their patient portal. If the participant has not been seen by their HCP in the last 60 days, determine if there is more recent information available, than what is in CT-WIC, use the most recent information. For example, the anthropometric data in CT-WIC is from September 2019, but the participant reports that they were seen in December 2019 and has that information available, use the December 2019 information, but enter today’s date, check the “?” in Lab screen on the Anthropometric grid and select “disaster” from the “?” Reasons drop down. However, if after checking with the participant and the HCP it is determined that no recent anthropometric data is available, add another row and enter the anthropometric data from September 2019 and use today’s date, check the “?” in Lab screen on the Anthropometric grid and select “disaster” from the “?” Reasons drop down.

Updated 7-18-2024

If using this option, please note that the CT-WIC assigned risk(s) may not be valid (for example short stature), and in such circumstances, a legitimate risk must be assigned by the CPA. In cases where valid anthropometric data was not used at (re)certification, staff must enter an Alert into CT-WIC and updated/valid data must be obtained at the mid-certification appointment. Anthropometrics deferred at mid-certification must be collected at the next recertification. Staff must schedule in-person follow-up appointments when the local agencies reopen for pregnant and breastfeeding women, infants, and children whose growth is a concern so that anthropometrics can be obtained. Staff should use a specific “disaster” code in CT-WIC to tag records that contain questionable anthropometrics and reports will be generated to identify participants that need to have height/weight collected at the next visit. Bloodwork – if bloodwork is not available, WIC regulations allow the blood test to be deferred for up to 90 days for persons with a documented nutritional risk. Select “disaster” from the drop down as the reason for exemption. Staff should enter an Alert to obtain the blood results after the 90 days exemption period. After the exemption period, bloodwork must be collected and entered into the participant’s CT-WIC record. Pronto may be used to collect bloodwork when agencies re-open for in-person appointments if bloodwork from the HCP is not available.

See ARPA Waiver Opt-In Policy 200-35 – Eligibility Determination and Documentation under ARPA waivers for current guidance and expectations for Documentation of Anthropometric measurements and Hematological data.

Nutrition Education notes should capture the assessment and counseling and include documentation that the disaster protocol was followed. Mid-Certification assessments should be completed. If the weight and height measurements are not available, the Anthropometric data grid may be bypassed using the procedure outlined above.

Updated 7-18-2024 Perinatal Mood and Anxiety Disorder (PMAD) Screening If a participant is due for a PMAD screen per protocol, verbally ask if they have had a screening in the last 7 days. If they report they haven’t had a screening, verbally administer the 3- question Edinburgh Perinatal Depression Screen (EPDS) screen. Note that since these 3 questions are the “anxiety” subset, the participant may screen positive. Provide on-line resources and/or referrals as needed. https://www.postpartum.net/ Connecticut Specific information: https://psichapters.com/ct/ Maintaining Program Integrity During a Disaster or Public Health Emergency Applicant/Participant Authorization Form The Participant Authorization form is how we obtain the participant’s consent to contact their healthcare provider. It is important that staff are diligent in complying with this federal requirement. During a Disaster or Public Health Emergency it is important that WIC staff communicate with healthcare providers.

Considering the continuing need for remote services, we are further clarifying that it is mandatory for staff to complete the Participant Authorization form as they did prior to the pandemic during in person services and complete the following steps: • Complete the Participant Authorization form on behalf of the participant (including the name(s), healthcare provider/providers). • Obtain verbal consent from the participant • Print COVID-19 where the participant’s signature is required, date it and include staff initials • Scan/upload into CT-WIC.

In cases where staff are unable to scan/upload the Participant Authorization form (due to issues with the scan/upload feature while working from home), staff must: • Complete the first 3 steps above • Enter an Alert in CT-WIC that the information was obtained and • Save completed electronic or paper form in a confidential file.

Please note: Whenever it is feasible for the participant to complete and email the completed Participant Authorization form, staff should request that they do so. It is permissible for the participant to type their name in place of a signature. In the future, we will explore options for obtaining a digital signature.

Other required documents Local agencies should ask participants about the best way to provide the required documents (Participant Rights and Responsibilities, Family Benefits List (FBL), and Notice of Participant Action (NOPA) Forms, such as, email, mail, text, or pick up in person. eWIC cards

Updated 7-18-2024 For new WIC certification appointments, participants should be offered the option to pick up the eWIC card and other pertinent WIC orientation information in-person. For participants with transportation issues or concerns with going to the WIC office the eWIC card along with other pertinent WIC orientation information can be mailed. Staff should inform the participant of the possible delay in receiving the card and using their benefits if they select this option. For security purposes, send the activation information separately from the eWIC card. FNS Guidance for mailing the eWIC card: • Do not use window envelopes. • Do not identify the name of the WIC clinic or use the words “WIC Program” on the envelope. You may consider using your host agency’s envelopes. Confidentiality Discard any confidential documents that you received that the WIC Program normally would not scan/retain in the participant’s CT-WIC record, i.e., paystubs, driver’s license, social security card. Documents should be destroyed in accordance with the local agency process for destruction of confidential and/or electronic documents. Additional information is contained below regarding securing confidential information while teleworking.

Formula Changes In the event a formula change is required for WIC issued formula, and the participant is unable to come to the WIC office, staff should: • Obtain the completed WIC Medical Documentation Form either from the participant or from the health care provider. • Determine how much of the previously issued formula was purchased and the number of unopened cans remaining for the current month. Staff should take this information into account when voiding and reissuing the current month’s benefits for the newly prescribed formula. • Staff should instruct the participant to bring the unopened cans of the previously issued formula to their next in-person WIC appointment or participants should be offered the option to drop off the formula to the WIC office at a mutually agreed upon time. This can take place after the food package change has occurred. This information must be clearly documented in CT-WIC Alerts.

Medical Documentation Forms Medical Documentation is required for the issuance of special formula and/or medical foods outlined in WIC Policy 400-10 and 400-11. If a participant is unable to provide a WIC Medical Documentation form and the local agency staff is unsuccessful in their attempts to contact the Health Care Provider, one month of benefits may be provided if there is an existing Medical Documentation form on file for the

Updated 7-18-2024 same special formula. The participant should be encouraged to continue trying to contact their Health Care Provider to get the documentation before the next WIC appointment. For participants requiring a new prescription (no Medical Documentation form on file), at minimum, a verbal authorization from the Health Care Provider is required, before benefits can be issued for one month. The HCP should be asked to send the Medical Documentation form to the WIC office at the earliest opportune time. Fillable WIC Certification and Medical Documentation Forms are available at Medical Providers (ct.gov)

Staff Telework Guidance for Serving WIC Participants Separation of Duties When teleworking/working from home, two staff are required to conduct the certification and recertification of a participant. Local Agencies continue to be responsible for the security of state issued WIC equipment whether the equipment is in the WIC clinic, at a satellite location, outreach event, in transit or at a staff person’s home. Equipment includes laptops, signature pads, and printers. Before staff can take state issued WIC equipment home, the Local Agency Coordinator must have staff sign off on the equipment they are taking home. Local agencies must have telework procedures that detail how they will conduct WIC services from home to maintain program integrity, i.e., separation of duties and the continuity of appointments, when both individuals are not in the same location. Local agencies are required to complete and return to the State Agency, the Providing WIC Services while Teleworking Checklist, indicating how they intend to ensure separation of duties, address Limited English Proficiency (LEP) and eWIC card distribution while working from home. Teleworking with Confidential Information, Protected Health Information (PHI), and Personally Identifiable Information (PII): Keep your work physically secure • Do not run errands or leave your car unattended with your laptop or files containing confidential information, PHI, or PII inside • Keep your laptop in a secure, locked location when unattended

Unless approved by your supervisor, do not create or use confidential information, PHI, or PII in paper form • Do not print records containing confidential information, PHI, or PII • Do not remove paper records containing confidential information, PHI, or PII from offices • Do not include identifying information in handwritten notes

Updated 7-18-2024

If it is necessary to handle confidential information, PHI, or PII in paper form: • Your supervisor must approve the use of paper documents containing confidential information, PHI, or PII in your home • All paper copies of confidential information, PHI, or PII must be kept in a secure locking container when not in use • Do not shred documents contain confidential information, PHI, or PII at home locations. Those documents must be returned to office for shredding

Make sure your family and household members do not have access to and cannot read confidential information, PHI, or PII. • Password-lock your computer when unattended • Avoid conducting business on the phone within earshot of family members • Arrange monitors and computer screens so they are not visible to other family members

Ensure that appropriate technological safeguards are in place i.e. Virtual Private Network (VPN) • Use only password-protected wireless connections that are not shared with anyone outside your household • Do not share your VPN password or On-demand token with others

Securing eWIC cards The Program Coordinator or designee is responsible for securing and distributing eWIC cards to WIC participants at cost to the local agency. Cards may be mailed to the participants as outlined above. Maintaining Breastfeeding Support During a Disaster Breastfeeding support is critical during disasters. Local agencies must continue to provide appropriate breastfeeding assessment, education, support, and documentation as part of WIC Nutrition Services. Use of virtual platforms may assist both local agency peer counselors and Designated Breastfeeding Experts to assess breastfeeding issues and develop appropriate plans and solutions. Local agencies must ensure the continuation of provision of WIC breast pumps (manual and personal electric) to assist participants in meeting their feeding goals. Include processes for safe distribution (social distancing, sanitation, use of personal protective equipment (PPE) education, and pick-up of breast pumps in the local agency disaster plan. Local agency Breastfeeding Coordinators must maintain contact with community support providers and hospitals to ensure continuity of care and to make partners aware of changes or disruptions of WIC services and to understand any impacts participants may face during their hospital stay (delivery) or follow-up community support after discharge.

Updated 7-18-2024 Coordination and Communication During a Disaster Local agencies must refer to the State Agency Internal Operating Procedures Plan for additional details regarding coordination and communication during a disaster. Continuation of Benefits Local agencies are expected to serve all participants during a disaster by conducting: • Remote certification of new participants and recertification of existing participants. • Physical presence exemption, if needed • Issuance of verification of certification (VOC) to applicants that must evacuate (due to an anticipated disaster) and evacuees returning to their home state. See WIC Policy 200-20 Transfer of Verification of Certification for additional details. The DPH WIC webpage will contain instructions for participants and other state agencies on how to obtain a VOC and will be updated as necessary during a disaster. Benefit Issuance and Redemption During a Disaster, food instruments (i.e. EBT cards) will be issued in accordance with the procedures outlined above in the eWIC cards section of this policy. eWIC card replacement must comply with WIC Policy 400-08 eWIC Card Replacement and replacement of destroyed supplemental food(s) in accordance with WIC Policy 400-06 Benefit Reissuance: Food Prescription Changes and Voiding. Special Populations The State Nutrition Coordinator is the designated emergency contact person to address the needs of participants with qualifying conditions receiving Food Package III. Local agencies should refer to WIC Policy 200-27: Special Population Participants for details on how to support participants in rural areas and tribal populations. Details on how to support medically fragile participants (i.e participants with documented qualifying medical conditions receiving Food Package III is contained above under Medical Documentation Forms. Food Package Adjustments Local agency staff can tailor food packages in CT-WIC, if food package adjustments (that do not require waivers) are required when the maximum food benefit cannot be offered to participants. The State agency will notify local agencies if additional food package substitutions are required based on availability of approved food items and/or approved food package waivers. In the event of a food shortage, information will be posted on the DPH webpage and participants will be notified by text message.