10.006 - 1 Monitoring and Audits

Revised September 2019 X. Monitoring and Audits – Internal Evaluation

PROCEDURE 10.006 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 30, 2019

I. Authority USDA

II. Reason for the Policy 7 CFR 246.19 (b)(6)

III. Applicability DC WIC Local Agency Staff

IV. Policy Statement The Local Agency shall conduct a thorough evaluation of its operations at least once, every other year and at any time as deemed appropriate. The management evaluation tool entails chart reviews, staff’s competency observations, and Management Information System (MIS) documentation review.

V. Purpose The purpose of Local Agency internal-evaluation is to identify strengths and areas for improvement. This also allows the Local Agency to realize its achievements, identify competent staff and those who need coaching or re-training. The following staff shall be evaluated during internal evaluations:

1. Competent Professional Authorities (CPAs). The Local Agency Director or designate staff shall monitor CPAs for competency in the following areas:

a. Nutritional risk screening using ABCDE guidance b. Care plan (TGIF) notes and SMART goal setting c. Special formula prescriptions and approvals d. Group or class nutrition education e. High nutritional risk management and follow ups f. Design of lesson plans

2. Competent Para-Professional Authorities (CPPAs) and Clerks. Depending on their job description, the Local Agency Director or CPA shall evaluate their competency as it relates to:

a. Participants’ intake (proof of address, income, adjunctive eligibility, pregnancy, etc.)

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Revised September 2019 b. Laboratory works (anthropometric measurement and hematological assessment) c. Rights and responsibilities (R&R) d. Voter registration and immunization record e. Participant’s appointment scheduling f. Food package tailoring g. Check issuance and registers h. TGIF note and SMART goal setting i. Missed appointment contact and rescheduling j. Referrals

3. Breastfeeding Peer Counselors (BPCs). The Local Agency Director, Local Agency Breastfeeding Coordinator, designated CPA, or IBCLC shall assess peer counselors regarding:

a. Breastfeeding promotion and support b. Pregnant women and breastfeeding mothers’ follow-up contact (text messaging, phone calls, emails, etc.) c. Effective counseling and understanding of participant’s needs d. Breast pump issuance and log keeping e. Processing and management of breastfeeding referrals

4. New WIC Employees. The Local Agency Director, CPA or designated staff shall evaluate the competency of all new staff members during the first six (6) months of employment or until they are deemed competent to operate independently. This entails consistently monitoring their work, including direct observation and files reviews.

V. Procedures 1. Local Agencies shall perform internal evaluations every other year, as directed by the State Agency.

2. Local agencies shall use the following tools to prepare for and document staff and program evaluations:

a. 10.004A – Pre-Management Evaluation Questionnaire i. LAs shall use this document as a guide to prepare them for performing the ME, allowing appropriate staff members at the given site/s being evaluated to answer relevant questions, while the LAD will answer other questions (such as those pertaining to Local Agency policies, and financial management).

b. 10.004B – Management Evaluation Workbook This excel workbook has tabs for the following: i. Certification Observations ii. File Reviews

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Revised September 2019 iii. Clinic Environment Reviews iv. Breastfeeding Peer Counselor Reviews v. Secondary Nutrition Education Reviews 3. Local agencies shall submit pre-Management Evaluation questionnaires, Management Evaluation workbooks, and internal evaluation reports with corrective action plans (see 10.004C) by April 15 of the years when no State agency Management Evaluation is occurring or as directed by the State agency. VI. Appendix

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VII. Reference 10.001 Reports and Reporting Procedures 10.004A Pre-Management Evaluation Questionnaire 10.004B Management Evaluation Workbook 10.004C Management Evaluation Report and Corrective Action Plan Template