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Maine Center for Disease Control and Prevention WIC Nutrition Program Effective: October 1, 2012 Policy No. MA-2 Revised: October 1, 2021

Monitoring Authority 7 CFR §246.19(b) 22 MRSA §255 and §1951 10-144 Chapter 286, Section II.B

Policy

1. The State Agency shall be required to conduct a Management Evaluation Review (MER) of each Local WIC Agency once every two (2) years. 2. Local Agency reviews shall be conducted by State Agency staff. 3. Local Agencies shall provide information requested by the State Agency within 30 days of the first request for information. 4. The State Agency shall provide the Local Agency with written documentation of findings on non-compliance with program requirements within sixty (60) days after last MER visit. 5. The Local Agency shall respond with a corrective action plan (CAP), including timeframes for implementation, within sixty (60) days of receipt of the State Agency’s findings. 6. The State Agency shall monitor Local Agency implementation of corrective action plans. 7. The State Agency may conduct additional reviews as necessary. 8. Each Local Agency shall establish internal procedures to monitor operations of all its clinics. 9. The State Agency shall update the audit process as necessary to maintain program integrity.

Procedures

1. The State Agency shall utilize the following protocol when it monitors Local Agencies: 1.1. Advance notification of monitoring visit, sent electronically, 60 days prior to visit. 1.2. The Local Agency MER shall start on the day the first site visit is conducted.

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1.3. Local agency participant file, financial records and administrative documentation reviews and additional site visits to meet the 20% threshold shall be completed within 30 days of the start of the MER, unless unforeseen circumstances arise. 1.4. The State Agency shall provide a final MER report to the Local Agency within sixty (60) days of the last site visit. 1.5. The final MER report shall include the completed Appendix MA-2-A MER Form, a summary letter and notification for appeal procedures. 1.6. The following appeal statement shall be used:

Appeal: Informal Conference and Administrative Hearing

If you are disagree with this Management Evaluation Review(MER) you may request an informal conference in writing within 15 calendar days of the receipt of this MER letter. If a local agency disagrees with the Department’s written informal conference decision, the local agency may request an administrative hearing. The written request for an informal conference and an administrative hearing must be sent to: DHHS, Division of Administrative Hearings 109 Capitol Street Augusta, Maine 04330-0011

1.7. The State Agency shall schedule an exit conference with Local Agency staff prior to submitting the final MER report. 1.8. The exit conference shall include discussion of findings and opportunity for Local Agency staff input. 1.9. The Local Agency must submit a corrective action plan (CAP) within sixty (60) days of receiving the final MER report from the State Agency if the MER has identified noncompliance. 1.10. The State Agency shall include recommendations for corrective action in the final MER report. 1.11. The State Agency shall evaluate the adequacy of the Local Agency’s CAP within thirty (30) days of receipt. 1.12. If the State Agency accepts the Local Agency’s CAP, an acceptance letter shall be sent to finalize the MER. 1.13. If the State Agency does not accept the Local Agency’s CAP, the Local Agency shall submit a revised CAP within thirty (30) days of notification of the non-acceptance for consideration and approval.

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1.14. The State Agency shall verify implementation of the Local Agency’s corrective action plan, including site visit(s) and/or participant file and financial record review(s) in the off-year as necessary. 1.15. All letters and documents pertaining to the MER shall be transmitted electronically. 2. State Agency staff shall utilize the standard MER form (Appendix MA-2-A). 3. The State Agency shall utilize the Local Agency Annual Report (Appendix MA-2-B) as well as PowerBI, Spirit Utilities and SPIRIT reports in the Local Agency MER. 4. The State Agency shall utilize Local Agency review data to: 4.1. Track individual Local Agency performance 4.2. Compare administration costs 4.3. Compare staffing levels among all Local Agencies 5. State Agency staff may visit Local Agencies and clinic sites at any time. 6. State Agency may complete observations with any Local Agency staff including but not limited to Coordinator and counselors. 7. The State Agency shall use a tracking document to summarize Local Agency reviews for each fiscal year. The tracking document shall include the following information for each Local Agency MER: 7.1. Date of initial contact and summary of schedule 7.2. Percent of clinics visited 7.3. Date of completion for each review section 7.4. Date of exit conference 7.5. Date State Agency final MER report sent 7.6. Date Local Agency corrective action plan due 7.7. Date late notice sent, if applicable 7.8. Date Local Agency corrective action plan received 7.9. Date State Agency requests additional CAP information, if needed 7.10. Date additional CAP is due 7.11. Date Local Agency additional corrective action plan received 7.12. Date of Local Agency corrective action plan acceptance 7.13. Date of follow up visit, if applicable