215.1 Policy 215 Local Program Monitoring and Review April 5, 2019 (Revised) POLICY The state WIC program will conduct onsite monitoring reviews of each local WIC program at least every two years to assure program operations are carried out in compliance with federal and state requirements. As part of the biennial review process, the state agency shall monitor all programmatic areas as defined by federal policy, including program management, certification, nutrition education, breastfeeding promotion and support, program integrity, and fiscal management. If applicable, the Farm Direct Nutrition Program (FDNP) and/or the Breastfeeding Peer Counselor Program (BFPC) biennial reviews will be performed at the same time as the WIC program review. Between biennial reviews, WIC programs will establish self-evaluation procedures to review their own operations and those of associated clinics and/or contractors. PURPOSE To monitor compliance with federal and state regulations for program operations according to state policies. To assist local programs in assuring consistency and effectiveness of service delivery to participants. RELEVANT REGULATIONS 7CFR §246.19(b)(1-6)—Management evaluation and monitoring reviews 7 CFR §246.11 ¶(c)(5)—Monitor local agency activities 7 CFR §246.11 ¶ (d)—Local agency responsibilities

7 CFR §246.11 ¶ (e)—Participant contacts OREGON WIC PPM REFERENCES

 440 – Staff Training Requirements  716—Breastfeeding Peer Counseling: State and Local Program Responsibilities  660—Competent Professional Authority: Requirements  661—Competent Professional Authority: Appropriate Counseling for Risk Levels  810— Nutrition-Focused Education and Counseling  820— Quarterly Nutrition Education Contacts  830— Nutrition Counseling and Services for High-Risk Participants  840—Documentation for Nutrition-Focused Education and Counseling  1100—Farm Direct Nutrition Program: Local Program Responsibilities

Local Program Monitoring and Review, Continued 215.2 DEFINITIONS Assigned Nutrition Consultant (ANC): Registered Dietitian/Nutritionist (RDN) who works for the state WIC program and is assigned to a specific local agency to provide support and technical assistance to help ensure program compliance with state policies and federal regulations and help with program quality improvement. WIC Compliance Reviewer (WCR): Registered Dietitian/Nutritionist (RDN) who works for the state WIC program and conducts biennial reviews to check for compliance with state policies and federal regulations. WIC Compliance Reviewers rotate through different local agencies and never act as the reviewer for their assigned counties. BACKGROUND Federal regulation requires the state WIC program to review local WIC programs at least biennially. A State reviewer, usually a state WIC Nutrition Consultant, performs an onsite review of local WIC programs every two years. This review is coordinated with the Oregon Health Authority (OHA), Public Health Division triennial review whenever possible. Because the OHA triennial review is done every three years, the state WIC program often needs to schedule WIC reviews independently to meet the biennial monitoring requirement. If applicable, the Farm Direct Nutrition Program (FDNP) and/or the Breastfeeding Peer Counselor Program (BFPC) biennial reviews will be performed at the same time as the WIC program review. (Refer to ⧫716—Breastfeeding Peer Counseling: State and Local Program Responsibilities and ⧫1100—Farm Direct Nutrition Program: Local Program Responsibilities for more information on the BFPC and FDNP reviews). PROCEDURE Review tools 1.0 Current copies of all WIC, FDNP and BFPC review tools are available on the Oregon WIC Web site at: https://www.oregon.gov/oha/ph/HealthyPeopleFamilies/wic/Pages/wic- coordinator.aspx Review criteria 2.0 WIC Compliance Reviewers (WCR) use a standard set of criteria when conducting reviews. Compliance 2.1. WIC, FDNP, and BFPC programs are reviewed for compliance with USDA regulations, state policies, and Oregon Administrative Rules (OARS) as well as performance requirements from the current State of Oregon Financial Assistance Contract for the WIC program. 2.2. Program areas covered during the review include: program management, certification, nutrition education, breastfeeding promotion and support, program integrity, and fiscal management. Fiscal review 2.3. OHA Financial Services staff review local program fiscal operations in conjunction with the WIC program review.

Local Program Monitoring and Review, Continued 215.3 2.3.1. For more information on the fiscal review, refer to the WIC program section of your current contract with the state of Oregon, OHA, Public Health Division. Before review 3.0 Before the onsite review, the state WIC Compliance Reviewer (WRC) and/or support staff shall: 3.1. Send pre-visit checklist and WIC Personnel Summary form to the local agency two months prior to the review. 3.1.1. The local agency will return pre-visit checklist and required documents to the State 30 days before the review. 3.2. Conduct a review of electronic client records 3.3. Review additional Management Information System (MIS) reports as applicable. 3.4. Review past Biennial Review Reports, WIC Review Tools, and compliance issues. 3.5. Review MIS records/reports and local agency documents sent to the state office as requested in the pre-visit checklist to ensure compliance with policies by evaluating the following: 3.5.1. Adherence to State standards for staff qualifications – Personnel Summary Sheet (see ⧫ 660—Competent Professional Authority: Requirements). 3.5.2. Documentation in MIS that staff are appropriately trained for their position and assigned duties (see ⧫ 440 – Staff Training Requirements). 3.5.3. Adherence to state agency policies for quarterly nutrition education contacts (see ⧫810—Nutrition-Focused Education and Counseling, ⧫820—Quarterly Nutrition Education Contacts and ⧫830—Nutrition Counseling and Services for High-Risk Participants). 3.5.4. Planning for and provision of appropriate follow-up services such as rechecking hemoglobin/anthropometric measurements or seeing the RDN for high-risk nutrition-focused counseling (See ⧫661— Competent Professional Authority: Appropriate Counseling for Risk Levels). 3.5.5. Adherence to state agency documentation requirements (see ⧫840— Documentation for Nutrition-Focused Education and Counseling). 3.5.6. Local policies contain all required components and are written in accordance with state requirements. During review 4.0 During the onsite review, the WCR shall:

Local Program Monitoring and Review, Continued 215.4 4.1. At a minimum, observe WIC daily clinic operations at 20% of all sites providing WIC services. The main clinic site will be visited at every biennial review, with all locations that provide WIC services being reviewed at least once over the course of 3 review cycles. 4.2. Meet with the WIC coordinator to review requested on-site materials and MIS reports and submitted pre-visit documents that were evaluated prior to the onsite visit. 4.3. Review nutrition education session guides for all group classes offered. 4.3.1. If nutrition education is provided by non-WIC programs, the WCR shall review the written agreement (MOA/MOU) and the course outlines for those groups. 4.4. Review quarterly time studies for individual employees. 4.5. Use the Observation Tool to observe staff providing WIC nutrition education. 4.6. Observe staff providing WIC services and evaluate the following factors: 4.6.1. Environmental elements such as privacy, space, and a productive atmosphere for learning. 4.6.2. Appropriate anthropometric and biochemical measurement techniques. 4.6.3. Appropriate use of participant centered services. 4.6.4. Accuracy and appropriateness of programmatic and nutrition information provided. 4.6.5. Appropriate referrals for health, social, or educational services. 4.7. Complete the WIC Review Tool to assess processes, procedures, and physical clinic environment for adherence to state policy and federal regulations. 4.8. Discuss topics and concerns relevant to completing the WIC review with participants, WIC staff, the program’s business manager and local health department administrators. Exit interview 5.0 The WCR will schedule an exit interview to discuss the review findings and recommendations with all who wish to attend, including local WIC program staff, nursing supervisors and administrators. The reviewer will leave a draft copy of the completed WIC Review Tool with local program staff. Written report 6.0 The WIC review team will work to email the final Biennial Review Report and finalized WIC Review Tool to the local agency within 30 days of the final exit interview. A hard copy will also be sent to the program’s administrator through the mail. The Biennial Review Report will identify program strengths, recommendations, and compliance findings. For agencies subject to triennial reviews, the most recent WIC Biennial Review Report will also be included in the Triennial Review Report.

Local Program Monitoring and Review, Continued 215.5 Corrective action plan (CAP) 7.0 If compliance findings are identified during the review, the local agency must submit a corrective action plan (CAP). The Corrective Action Plan Development Tool will be mailed to the administrator and emailed to the WIC Coordinator to assist them in writing their CAP. 30-day requirement 7.1. The corrective action plan (CAP), including action steps, how evidence of completion/compliance will be demonstrated, and implementation time frames must be submitted to the state WIC office within 30 days of receipt of the Biennial Review Report. 8.0 The WCR will either accept the CAP as is, return the CAP as approved with modifications, or work with the local agency to finalize the CAP if it was returned incomplete. 9.0 Once the CAP has been approved, the local agency is responsible for notifying the agency’s Assigned Nutrition Consultant (ANC) as compliance issues are resolved and sending supporting documentation if needed. Resolution of Findings 10.0 Per CFR §246.19(b)(4), state WIC staff must continue to monitor the local agency’s implementation of the CAP until all compliance findings have been resolved. 10.1. It is recommended that all compliance findings be resolved by six months after the date of receipt of the local agency’s CAP. Ongoing Evaluation 11.0 Local WIC programs must establish self-evaluation management systems to review their own program operations and those of associated clinics or contractors. The intent of this self-evaluation is to evaluate program operations for compliance with federal and state requirements. At a minimum, self-evaluations must be completed every other year. A review of the most recent compliance findings can help guide the self-evaluation. The self-evaluation must include the following components: • program management, • financial management, • certification, • nutrition education, • breastfeeding promotion, and • program integrity 11.1. Documentation of the local agency’s self-evaluations must be kept on file for three years and must be available for review by state WIC staff during biennial WIC reviews. 11.2. Local agencies are encouraged to use the relevant MIS reports and the state- developed WIC Review Tools. The most current review tools are posted on the Oregon WIC website.

Local Program Monitoring and Review, Continued 215.6 11.3. WIC coordinators and/or Training Supervisors are to complete observations of counseling sessions to review staff skills and competency in nutrition assessment and implementation of participant centered services (see ⧫ 440 – Staff Training Requirements). 11.4. The Assigned Nutrition Consultants (ANC) for each agency will offer to provide a technical assistance and support visit between biennial reviews. During these visits, the ANC can help with the self-evaluation and quality improvement efforts, share best practices, and assist with various other agency needs as determined by the ANC and WIC Coordinator.

RESOURCES 1. WIC Nutrition Services Standards, US Department of Agriculture, Food and Nutrition Service, August 2013. 2. Oregon WIC Program, Participant Centered Education (PCE) online course: https://www.oregon.gov/OHA/PH/HEALTHYPEOPLEFAMILIES/WIC/Pages/modules.as px 3. Oregon WIC Program, Providing Participant Centered Groups paper module: https://www.oregon.gov/OHA/PH/HEALTHYPEOPLEFAMILIES/WIC/Pages/modules.as px 4. Oregon WIC Nutrition Education Guidance: http://public.health.oregon.gov/HealthyPeopleFamilies/wic/Documents/nutr-ed/2010-ne- guidance.pdf 5. Review Tools: https://www.oregon.gov/OHA/PH/HEALTHYPEOPLEFAMILIES/WIC/Pages/wic- coordinator.aspx

POLICY HISTORY Date * Revised, Reviewed, Released 10/31/2008 Revised 2/8/2012 Revised 1/7/2013 Released 4/5/19 Released

The date located at the top of the policy is the date of the most recent release. Policies are to be implemented on release date and will become compliance findings 6 months from the release date. *Released: Significant changes made to policy. Release notes can be found in the corresponding document on the Policy and Procedure Manual page. Reviewed: The writer looked at this policy to make sure it was still accurate. Formatting changes may have occurred. Revised: Minor edits or formatting has occurred without need for release. USDA has accepted a policy and watermark is reviewed. Date of Origin: Date policy was initially released If you need this in large print or an alternate format, please call 971-673-0040. This institution is an equal opportunity provider.