VIII. Certification September 2021 8.011 - 1 8.011 Certification Risk Determination & Considerations CFR § 246.7(e)(1) and (g) Nutritional Risk and Certification Periods; CFR § 246.2 Definitions

This policy provides considerations and reminders for each category of applicable WIC participants. Please see the DC WIC Program Certification Map for a full description of each step in the certification process, including rationale for each of the requirements.

I. Road to Certification Step Description Part of the: Notes & Greeting Begins the applicant’s appointment Intake & Eligibility Screening Intake / Eligibility Collecting, determining, and documenting eligibility based on category, residency, and income A, B, C, & E Anthropometric, Biochemical, Clinical, and Environmental data gathering Health & Nutrition Assessment D Diet/nutrition data gathering

Nutrition Education & Goal Setting Providing participant centered nutrition education based on the Health and Nutrition Assessment VENA / Participant Centered Counseling Summarize / New Appt Closing out the Assessment and planning for the next visit Food Package Assigning, tailoring, and issuing the food package; Discussing where and how to use WIC benefits Food Benefits Delivery TGIF Documenting in the participant’s HANDS record

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VIII. Certification September 2021 8.011 - 2 II. Pregnant women (PG1/PG2) Intake & Eligibility Screening i. A pregnant woman does not have to prove she is pregnant. If the LA has good reason to suspect the applicant of fraud or abuse, or if the applicant has a history or fraud or abuse, the LA may refuse service to the applicant. ii. A pregnant woman’s household is assessed by increasing it by the number of expected infants (unless the applicant has religious or cultural objections which preclude this). iii. Pregnant applicants under the age of 18 years must be assessed for income eligibility using income information from their parent(s), guardian(s), or other household members that provide financial support to the applicant, if possible. Health & Nutrition Assessment iv. Anthropometric and biochemical assessments shall reflect the applicant’s current participant status (i.e., pregnant women should have height, weight, and hgb assessed while pregnant) v. Evaluate maternal weight status using the prenatal weight grid (see the DC WIC Anthropometrics Manual, or Table 1., below) a. Weight status assessment and weight gain recommendations for pregnant teenagers will be based on the IOM’s nutrition during pregnancy Body Mass Index (BMI) categories vi. Income-eligible pregnant women are presumed to be at nutritional risk and can be certified immediately to receive program benefits for 60 days if the initial certification does not include a health & nutrition assessment. However, the health & nutrition assessment must be performed within 60 days and include anthropometric and hematological data vii. A pregnant woman shall be considered at risk if she meets at least one risk code criterion described in Policy 8.007 – Determining Nutrition Risk. If no risk is found after a complete assessment has been performed (including risk #427 - Inappropriate Nutrition Practices for Women), risk #401 - Failure to Meet Dietary Guidelines for Americans, must be assigned. Participant Centered Counseling viii. Offer an appointment and/or class with a breastfeeding peer counselor ix. Consider the applicant’s due date when scheduling their next appointment(s) Food Benefits x. Women pregnant with multiples and Pregnant women who are also breastfeeding an infant from a previous pregnancy receive the “fully breastfeeding” food package.

Table 1. Prenatal Weight Gain Grid Pre-pregnancy BMI : Underweight (BMI <18) Normal Weight (BMI 18-25) Overweight (BMI 25-30) Obese (BMI >30) A woman pregnant with one baby should gain: 28-40 lb 25-35 lb 15-25 lb 11-20 lb A woman pregnant with twins should gain: 50-62 lb 37-54 lb 31-50 lb 25-42 lb Source: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-weight-gain.htm

VIII. Certification September 2021 8.011 - 3 III. Breastfeeding Women (EN, PN, PN+) Intake & Eligibility Screening No special notes Health & Nutrition Assessment i. Anthropometric and hematological data submitted by a health care provider may be used to establish nutritional risk but must be taken during the postpartum period and within 60 days of the certification date. ii. A breastfeeding woman may be determined to be at nutritional risk if her breastfed infant has been determined to be at nutritional risk. Select the highest priority level for which a mother or infant is qualified for the mother-infant dyad. iii. If no risk is found after a complete assessment has been performed (including for risk #427 - Inappropriate Nutrition Practices for Women), risk #401 - Failure to Meet Dietary Guidelines for Americans, must be assigned. iv. A breastfeeding assessment shall be performed before the issuance of Food Benefits at every visit. The results of the assessment shall be used to provide individualized breastfeeding support and to determine the appropriate food package. v. Review breastfeeding notes, as well, and refer participants to BPCs as needed Food Benefits vi. Breastfeeding women are eligible for the “fully breastfeeding” food package or the “partially breastfeeding” food package depending on the number of daily breast milk feedings provided to the infant.

IV. Postpartum Women (P) Intake & Eligibility Screening i. A woman who would have been eligible for the Program during her pregnancy who has had an abortion, spontaneous (miscarriage) or therapeutic, can also apply for Food Benefits. She is eligible for a total of six (6) months of food benefits from the date the pregnancy ended. Health & Nutrition Assessment ii. Anthropometric and hematological data submitted by a health care provider may be used to establish nutritional risk but must be taken following termination of pregnancy and within 60 days of the certification date. iii. A postpartum woman shall be considered at nutritional risk if she meets at least one risk criterion described in Policy 8.007- Determining Nutrition Risk. If no risk is found after a complete assessment has been performed (including for risk #427 - Inappropriate Nutrition Practices for Women), risk #401 - Failure to Meet Dietary Guidelines for Americans, must be assigned. Food Package No special notes

VIII. Certification September 2021 8.011 - 4 V. Infants (IEN, IPN, IPN+, IFF) Intake & Eligibility Screening i. Infants < 6 months of age shall be certified until their first birthday. Infants 6 to 12 months of age are certified for a 6-month interval. ii. Hospitalized infants cannot receive WIC benefits until discharged. Health & Nutrition Assessment iv. Anthropometric data submitted by a health care provider may be used to establish nutritional risk, but must be taken within 60 days of the certification date. v. All infants > 9 months of age and older shall have a hematological screening performed between 9-12 months of age if not previously conducted. Results may be obtained from a referral source. This hematological screening does not have to occur within 90 days of the certification date. vi. If an infant does not receive hematological screening during the infant certification period, the screening performed for the first child certification may be used to satisfy the requirement but must be performed by the age of 15 months. When this substitution is used, the screening data cannot be counted for the child certification period. vii. A breastfed infant can be certified based on the mother’s health & nutrition assessment. Staff should assign a breastfeeding mother and her infant to the highest priority level for which either is qualified. viii. An infant < 6 months of age may be determined to be at nutritional risk if the infant’s mother was a WIC participant during pregnancy or if medical records document that the woman was at nutritional risk during pregnancy due to detrimental or abnormal nutritional conditions detectable by biochemical or anthropometric measurements or other documented nutritionally related medical conditions. ix. An infant shall be considered at-risk if they meet at least one of the risk codes described in Policy 8.007 Determining Nutrition Risk. If no risk can be identified following a complete assessment (including for risk #411 - Inappropriate Nutrition Practices for Infants), risk #428 - Dietary Risk Associated with Complementary Feeding Practices, must be assigned for infants 4-12 months old. The CPA/CPPA must identify which Complimentary Feeding Practices are of concern in the participant’s HANDS record. Food Benefits x. Infants may receive standard infant formula tailored to their level of breastfeeding. For more information on breastfeeding assessment, see policy 9.006 xi. All special formulas require a prescription – see policy 9.009 xii. Powder formula should be issued unless the infant or caregiver meets conditions listed in policy 9.009; when RTU formula is issued, the reason must be documented in HANDS. xiii. At 6 months of age, infants may begin to receive infant food fruits, vegetables, and cereal; infants who are fully breastfed may also receive infant food meats. xiv. Infants 9-11 months of age receive CVB dollars in lieu of ½ the benefit of infant food fruits and vegetables ($4 CVB for infants fed formula, $8 CVB for fully breastfed infants) Medical Updates Medical updates shall be scheduled ~ 6 months following the initial certification for an infant who was certified at < 6 months of age. Income and eligibility do not need to be assessed at this appointment, but a complete health & nutrition should be performed. If the infant is determined to be high-risk by a CPPA during this appointment, a follow-up by a CPA is necessary.

VIII. Certification September 2021 8.011 - 5 VI. Children (C1 – C4) Intake & Eligibility Screening i. For children who reside with someone other than their biological parent, see Policy 8.006 for information about income eligibility. The child may either be counted as a household of one (1) or be included in the household of the guardian (legal or temporary). ii. Children enrolled in Free and Reduced Meal programs, such as the National School Lunch Program, are considered adjunctively eligible. Health & Nutrition Assessment iii. Anthropometric and hematological data submitted by a health care provider may be used to establish nutritional risk, but must be taken within 60 days of the certification date. iv. Staff shall evaluate the growth grids available in HANDS during the health assessment v. A child shall be considered at nutritional risk if they meet at least one risk criterion described in Policy 8.007 Determining Nutritional Risk. vi. If no risk is found after a complete assessment, to include for risk #411 - Inappropriate Nutrition Practices for Infants and #425 - Inappropriate Nutrition Practices for Children, then one of the following risk codes must be assigned: a. Risk #428 - Dietary Risk Associated with Complementary Feeding Practices (age 1-2), or b. Risk #401 - Failure to Meet Dietary Guidelines for Americans (ages 2-5)

Food Benefits Delivery vii. Children 12-24 months: a. Receive whole milk and yogurt unless contraindicated by a CPA’s assessment b. May receive peanut butter – staff should discuss the signs of peanut allergy with caregivers viii. Children 2-5 years: a. Receive low-fat milk (1% or skim) and yogurt unless the CPA assessment indicates the need for 2% milk (no Rx needed) or whole milk (Rx from medical provider is needed)