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PENNSYLVANIA DEPARTMENT OF HEALTH
Policy and Procedure Number: 1.04 WIC State Agency
Effective Date: November 6, 2017
POLICY AND PROCEDURE MANUAL
1. GENERAL ADMINISTRATION.
1.04 Local Agency Monitoring.
Page 1 of 6
A. POLICY:
PA WIC requires State and Local Agency internal review procedures to monitor and evaluate grantee operation of the WIC Program.
B. PROCEDURE:
1. Local Agency Internal Clinic Monitoring
a. The local agency (LA) shall conduct a formal internal review at least annually. b. On-site reviews shall be conducted at a minimum of 20 percent of the LA’s clinic sites, or a minimum of one clinic, whichever is greater.
c. LAs may use the State Agency (SA) Program Review tools for their internal reviews or develop their own form provided it contains the same criteria. d. The LA shall designate a person or team responsible for coordinating the review and to follow-up when corrective actions are needed to bring operations into compliance. e. Staff interviews shall be conducted regarding the general operation of the Program and to obtain specific details and clarification on day-to-day operations. f. Records, files and reports shall be reviewed to ensure that proper documentation is in place as required by Program regulations and policies and to confirm that proper procedures are being consistently followed. g. Staff shall be observed during their daily activities, including observation of the certification process, nutrition education, and staff interaction with participants and applicants. h. Clinics are selected on a rotating basis in order for all clinics to be reviewed equally unless there are known problem areas in a specific clinic. i. The following components of clinic operations shall be reviewed for compliance with federal regulations, state policies, and where applicable, terms of agreement with sub-contractors:
(1) Anthropometric measurements (2) Hematological testing (3) Food delivery system (4) Food instrument accountability (5) Food package tailoring (6) Nutrition Education (7) Customer Service (8) Clinic flow (9) Clinic facilities (10) Waiting lists (if applicable) (11) Participation levels/assignments (12) Hardware/software security (13) Management Information System (MIS) data security (14) Confidentiality issues (15) Separation of duties (16) Disaster recovery plans (17) Review of staff nutrition education and breastfeeding promotion/support techniques (18) Review of aspects of nutrition education and breastfeeding services that are required by federal regulations and state policies (19) Review of physical layout and environment of the clinic and its impact on nutrition education and breastfeeding promotion activities
PENNSYLVANIA DEPARTMENT OF HEALTH
Policy and Procedure Number: 1.04 WIC State Agency
Effective Date: November 6, 2017
POLICY AND PROCEDURE MANUAL
1. GENERAL ADMINISTRATION.
1.04 Local Agency Monitoring.
Page 2 of 6
(20) Review of available nutrition education and breastfeeding materials and their ethnic and cultural appropriateness
j. Records in the main administrative office or at clinic sites shall be reviewed for accuracy and complete documentation. At a minimum, the following records and files should be reviewed:
(1) Civil Rights File (electronic or hard copy) (2) Exposure Control Plan (electronic or hard copy) (3) WIC Federal Regulations (electronic or hard copy) (4) 20 active participant files (5) Five terminated participant files (6) Five ineligible applicant files (7) Food instrument registers (8) Retail store files (9) Fair hearing files (10) Waiting lists (participants and retail stores) (11) Staff in-service (12) Competent Professional Authorities approval letters (13) New employee orientation records (14) Outreach activities (15) Review of participant files and review of documentation of nutrition education breastfeeding contacts (16) Review of the local agency nutrition education and breastfeeding plans and the degree to which objectives have been met
k. Document any areas found out of compliance with Program policies or operating inefficiently or ineffectively. l. The review must be conducted before June 30th so results can be taken into consideration when developing the outreach, nutrition and breastfeeding annual plans for the upcoming fiscal year. m. Staff shall analyze the results of the internal review and prepare and implement a plan for follow-up and corrective action. Staff shall consider the findings of the internal review when developing nutrition education breastfeeding objectives for the upcoming year. n. Establish a timeframe for follow-up review to discuss deficiencies with clinic staff and develop a corrective action plan. o. All documentation shall be kept on file by the LA and be made readily available for review by the SA and/or the U.S. Department of Agriculture for a period of four years.
2. Clinic No Show Monitoring
a. The LA shall monitor and review the quarterly No Show reports provided on the MIS. LA shall maintain a no show rate of 20% or less. Any LA with a no show rate above 20% is required to identify the reason for the high rate and to plan corrective action if applicable. b. The SA has elected to impact the number of applicants/participants who fail to receive food instruments (FIs) through statewide implementation of a reminder system. The LA shall notify all applicants/participants of upcoming appointments. c. The LA shall contact applicants/participants who miss their scheduled appointment by telephone or postcard within five days of their missed appointment to allow rescheduling prior to the "last use date" of their current Fls or within 25 days of their initial appointment, whichever is less.
PENNSYLVANIA DEPARTMENT OF HEALTH
Policy and Procedure Number: 1.04 WIC State Agency
Effective Date: November 6, 2017
POLICY AND PROCEDURE MANUAL
1. GENERAL ADMINISTRATION.
1.04 Local Agency Monitoring.
Page 3 of 6
d. Staff shall obtain permission to leave messages by entering the date in the "Release for Message Date" field on the address tab and entering the phone number in the "primary phone" field. This record will become part of the e l e c t r o n i c file that is sent to the LA to provide appointment reminders. e. The MIS will generate a quarterly no show report identifying the number of participants in one month who were eligible for Fls, the number of participants who failed to receive Fls labeled as "no shows" and the percentage of no shows for each LA’s clinic. f. The No Show report will be available in January, April, July and October on the MIS Reports tab under LA Monitoring/Statistics. g. The SA will monitor the LA clinic rates and will contact the LA CEO and LA WIC Director if corrective a c t i o n is warranted.
3. State Agency Monitoring
a. The SA shall conduct reviews of each LA at least once every other year except for the fiscal review which will be conducted every year. The SA shall designate one or more reviews for each LA and if applicable, specify which clinic(s) are to be reviewed and assign the month the review is to be conducted. b. The SA shall send written notification to each LA indicating the type(s) and tentative month of review by August 15 of the prior fiscal year. c. A numbered memo will be sent prior to the start of the federal fiscal year which include the specific information evaluated by the SA. d. Approximately thirty days before the review, the SA shall contact the LA to establish a date to conduct the review. e. The LA shall ensure that all information listed in the written notification of its scheduled review is available on the day the review begins. All appropriate WIC staff is to be available to be interviewed and to provide any assistance required to expedite the process. f. Reviewer(s) shall conduct an exit conference onsite or by telephone with the LA WIC Director, CEO or other appropriate staff when the onsite portion of the review is completed to discuss the preliminary findings. The LA is encouraged to identify any issues or concerns. g. Within 30 calendar days of receipt of all of the information required to complete the review, the SA shall prepare a report and letter summarizing the review and request a corrective action plan (CAP) if required. Clinic Administration and Clinic Nutrition Services will send a full report and letter. Fiscal and Retail Store reviews will send a letter.
(1) The LA shall submit a requested CAP in writing to the SA within 30 calendar days of receiving the request for the CAP. (2) The SA shall review the LA’s CAP and notify the LA staff in writing of approval or disapproval of the plan within 15 calendar days of receipt. (3) The SA shall follow-up on the LA’s CAP at the next scheduled review or as necessary.
h. The four types of on-site reviews are as follows and will be conducted every two years for each LA except for the fiscal review which will be conducted every year:
(1) Clinic Administration (2) Clinic Nutrition Services (3) Fiscal (annually) (4) Retail Store
PENNSYLVANIA DEPARTMENT OF HEALTH
Policy and Procedure Number: 1.04 WIC State Agency
Effective Date: November 6, 2017
POLICY AND PROCEDURE MANUAL
1. GENERAL ADMINISTRATION.
1.04 Local Agency Monitoring.
Page 4 of 6
e. Clinic Administration review shall include but is not limited to the following areas:
(1) General Administration
(a) Facility (b) Security (c) Equipment security (d) Software, data, and FI security (e) Security/safety (f) Emergency preparedness
(2) Civil Rights (3) Voter Registration (4) Certification/Eligibility
(a) Income (b) Identification/residency (c) Certification procedure (d) Processing standards (e) Report completion standards (f) Terminated and ineligible (g) Participant rights and responsibilities/WIC Program rules (h) Orientation to WIC (i) VOC cards/letters
(5) Food Delivery System
(a) Proxy authorization (b) Food Instruments
(6) Nutrition Education
(a) Nutrition education contacts (b) Substance abuse education
(7) Referrals (8) Immunization screening (9) The review shall consist of:
(a) Staff interviews (b) Participant surveys (c) Observation of clinic operations (d) Observation of the security of MIS equipment, software, and data (e) An examination of records, files, and computer generated reports
f. Clinic Nutrition Services review shall include but is not limited to the following areas:
(1) Certification/Eligibility
PENNSYLVANIA DEPARTMENT OF HEALTH
Policy and Procedure Number: 1.04 WIC State Agency
Effective Date: November 6, 2017
POLICY AND PROCEDURE MANUAL
1. GENERAL ADMINISTRATION.
1.04 Local Agency Monitoring.
Page 5 of 6
(a) Nutritional Risk/Certification Procedure (b) Dietary Assessment (c) Anthropometrics Equipment & Training Procedures (d) Hematological Equipment & Training Procedures
(2) Nutrition Education
(a) High Risk Participants (b) Nutrition Education Contacts (c) Breastfeeding Promotion & Support
(3) Referrals
(4) Food Supplements
(a) Food Package Tailoring (b) Formula Authorization Form (c) Formula Exchanges
(5) Follow up on corrective action from the previous program review (6) The review shall consist of:
(a) Staff interviews (b) Observation of clinic operations (c) Examination of records, files, and computer generated reports
g. The Fiscal review shall include but is not limited to the following areas:
(1) Cash receipts including record of payment for the invoice(s) reviewed. (2) Invoicing documentation including:
(a) Review of the internal invoice process (b) Review of expenses for cost allowability (c) Review of payroll expense and time records (d) Signed copies of leases and rental agreements for all locations (e) Most recent CPA audit (f) Copies of subcontracts, if applicable
(3) Follow up on correction action from the previous program review (4) The review shall consist of:
(a) Staff interviews (b) Examination of records and files
h. The Retail Store review shall include but is not limited to the following areas:
(1) General administration (2) Authorization of new retail stores
PENNSYLVANIA DEPARTMENT OF HEALTH
Policy and Procedure Number: 1.04 WIC State Agency
Effective Date: November 6, 2017
POLICY AND PROCEDURE MANUAL
1. GENERAL ADMINISTRATION.
1.04 Local Agency Monitoring.
Page 6 of 6
(3) Retail store file review
(a) Authorization/reauthorization (b) SA notification letter (c) WIC retail store application (d) Selection criteria form (e) Minimum Inventory & Price form (f) Determination of participant access or inadequate participant access
(4) Monitoring review 5% routine, inventory audit, and WIC transaction review
(a) Monitoring Review Form (b) Minimum Inventory & Price form (c) Determination of participant access or inadequate participant access (d) Store in compliance notification letter (e) Formal warning letter (f) PA WIC Transaction Review Report form for WIC Retail Stores (g) Formula Inventory Audit monitoring form
(5) Training (6) Compliance Buys (7) Complaints (8) Records Management (9) Vendor Reissue FI research (10) Observation of retail monitoring (11) WIC Retail Store Monitoring Review form (12) Observation of Retail Store monitoring procedure (13) WIC approved food availability/Minimum Inventory & Price form (14) Notification letter
Reference(s): 1. WIC Regulations: 7 CFR Part 246.1l(d) (2). 2. WIC Regulations: 7 CFR Part 246.19(b).
(Federal Register, Vol. 59, No.148, March 3l,1994) 3. WIC Regulation: 7 CFR Part 246.20. 4. OMB Circular A-133 5. M.D. 325.9 6. State Agency Program Review Tools
Policy and Procedure Status: 1. This P&P supersedes P&P Number 1.08, dated March 26, 2004. 2. This P&P supersedes P&P Number 1.18, dated March 27, 2009. 3. This P&P supersedes P&P Number 1.24, dated March 10, 2008. 4. This P&P supersedes P&P Number 5.04, dated February 9, 2012.