10.004 - 1 Monitoring and Audits Revised September 2019 X. Monitoring and Audits – State Management Evaluations PROCEDURE 10.004 Implementing Office: Community Health Administration (CHA) Revised September 2019 Approved by: _______________________ LaQuandra S. Nesbitt MD, MPH; Agency Director Review by Legal Counsel: ____________________ Phillip Husband, Esq.; General Counsel Effective Date: September 2019 I. Authority USDA II. Reason for the Policy FED § 246.19 State Agency Responsibilities b (2), (3), (4) and (6). III. Applicability DC WIC State Agency and Local Agency Staff IV. Policy Statement 1. Management Evaluations of Local Agencies shall encompass, but not be limited to, certification, nutrition education, breastfeeding support, civil rights compliance, accountability, financial management systems, and food delivery systems. 2. The State Agency shall conduct management evaluations of each Local Agency at least once every two years, but reserves the right to conduct the management evaluation every year. Such reviews shall include on-site reviews of a minimum of 20 percent of the clinics in each Local Agency or one clinic, whichever is greater. 3. The State Agency shall develop a corrective action process which includes: prompt notification of deficiencies to the Local Agency, timely development of corrective action plans, and monitoring of Local Agency implementation of such plans. 4. The State Agency shall require Local Agencies to establish management evaluation systems to review their operations and those of associated clinics or contractors. 5. The Local Agency must submit a corrective action plan, including implementation time-frames, within 30 days of receipt of a Management Evaluation report. V. Procedures 1. Sixty days before a management evaluation, the Local Agency shall receive written notification from the State Agency that a management evaluation will be conducted. See appendix 10.003A for an example of the pre-management evaluation questionnaire. 2. The Local Agency shall provide documentation and/or access to files as indicated in the written notification.

10.004 - 2 Monitoring and Audits

Revised September 2019 3. The Local Agency shall set aside an appropriate workspace for State Agency staff. 4. The Local Agency Director, or a designated representative, shall participate in an entrance interview with State Agency staff. 5. The Local Agency shall ensure availability of staff for observation of actual service delivery, gathering data, and interviews. 6. The Local Agency Director, or a designated representative, shall participate in the exit interview with WIC State Agency staff. 7. The Local Agency shall receive the management evaluation report from State Agency within 30 days of exit interview. 8. The Local Agency shall submit a corrective action plan within 60 days of receipt of the management evaluation report. 9. Once the Local Agency has submitted their Corrective Action Plan, the State Agency shall review within 30 days.

VI. Appendix

10.004A Pre-Management Evaluation Questionnaire 10.004B Management Evaluation Workbook 10.004C Management Evaluation Report Template with Corrective Action Plan

VII. Reference N/A