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Section 100

GENERAL INFORMATION

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WIC PROCEDURE MANUAL

WIC is the Special Supplemental Nutrition Program for Women, Infants, and Children. It is a federally funded program carried out according to provisions of the Child Nutrition Act passed by Congress in 1966 and amended in 1978.

WIC is funded through the Food and Nutrition Service (FNS) of the United States Department of Agriculture (USDA). It is administered in the State of Rhode Island by the Department of Health (HEALTH) through various local health centers; Social Service Agencies and hospitals (or "locals") which determines eligibility distribute the food funds and provide nutrition education to participants.

Many pregnant women, infants, and young children are in danger of having poor physical and mental health because they eat poorly and have inadequate health care. WIC is designed to help such pregnant women, infants, and young children by directly improving what they eat and the way they eat. The program provides special supplemental foods, including milk, eggs, juice, cereal, beans and peas, cheese, whole grain bread and tortillas, fruits and vegetables and infant formula and nutrition counseling, to eligible participants who have certain income limitations and show evidence of special nutritional need.

The program provides this extra help during critical times of growth and development in order to prevent the occurrence of health problems and improve the health status of participants.

This WIC Procedure Manual is intended as a reference source for local agencies in the WIC Program. It contains the essential procedures mandated by federal and state authority that apply to local agency operations. It is designed to present the users, in an organized and sequential way, the necessary facts and agency obligations for each step or area of the WIC process. It also includes the various forms and reports required at each step. Additional information about WIC is available to local agencies in WIC regulations, the WIC State Plan, State Operations Manual, and in various informational materials and communications provided by the HEALTH to locals. In unusual circumstances where mandated procedures do not provide adequate guidance, local agencies should call the state agency for instructions.

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RHODE ISLAND DEPARTMENT of HEALTH

WIC PROGRAM

LOCAL AGENCY ADMINISTRATION and LOCAL WIC CLINICS

Local WIC Agency Administration Local WIC Agency Clinics

Mr. David Caprio, Executive Director Children’s Friend and Service 153 Summer Street Providence, RI 02903-4011 (401)331-3285

Ms. Lucia Santiago Food Program Mgr. 550 Hartford Avenue Providence, RI 02909 (401) 721-7920

Children’s Friend 500 Prospect Street Pawtucket, RI 02860 (401) 721-6416

Children’s Friend 621 Dexter Street Central Falls RI 02863 (401) 752-7827

Friendship Center 350 Point Street Providence, RI 02903 (401) 752-7781

Hartford Ave. Center 550 Hartford Avenue Providence, RI 02909 (401) 752-7920

Berkshire Center 99 Berkshire Street Providence, RI 02908 (401) 752-7590

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Ms. Joanne McGunagle, Executive Director Comprehensive Community Action Program, Inc. 311 Doric Avenue Cranston, RI 02920 (401) 467-9610

Ms. Kathy Cooper, WIC Coordinator/Nutritionist Comprehensive Community Action Program, Inc. 311 Doric Avenue Cranston, RI 02920 (401) 946-4650

Comprehensive Community Action Program Inc. 311 Doric Avenue Cranston, RI 02920 (401) 946-4650

Coventry Satellite 191 MacArthur Blvd. Coventry, RI 02816 (401) 828-5335

Jeanne LaChance, Chief Executive Officer Thundermist Health Center 450 Clinton St Woonsocket, RI 02895 (401) 782-0850

Mr. Dennis Horta Coordinator/Nutritionist Thundermist Health Center of Woonsocket WIC Program 450 Clinton Street, 1st floor Woonsocket, RI 02895 (401) 767-4109

450 Clinton Street, 1st floor Woonsocket, RI 02895 (401) 767-4109

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Mr. Dennis Roy, Chief Executive Officer Eastbay Community Action Program 19 Broadway Newport, RI 02840 (401) 437-1000

Ms. Beth Nitkin, WIC Coordinator/Nutritionist Eastbay Community Action Program WIC Program 9 John H. Chafee Blvd. Newport, RI 02840 (401) 619-5970

Eastbay Community Action Program Newport Community Health Center WIC Program 9 John H. Chafee Blvd. Newport, RI 02840 (401) 619-5970

Eastbay Community Action Program WIC Program 1048 Stafford Road Tiverton, RI 02878 (401) 625-1364

Eastbay Community Action Program WIC Program 100 Bullocks Point Avenue Riverside, RI 02915 (401) 437-1007

Bristol WIC Program 115 Franklin Street Bristol, RI 02809 (401) 253-7577

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John Kelly, Chief Executive Officer Casey Ferrera, WIC Director Meagan Sheehy, Coordinator Meeting Street 1000 Eddy Street Providence RI 02905 (401) 533-9100

Meeting Street WIC Program 1000 Eddy Street Providence RI 02905 (401) 533-9100

St. Joseph Health Center 21 Peace Street Providence, RI 02907 (401) 456-4069

Sharon Conard-Wells Executive Director West Elmwood Housing Development Corporation 224 Dexter Street, Providence RI 02907

Ineida Rocha Coordinator/PC 224 Dexter Street Providence RI 02907 (401) 453-3220 x 101

West Elmwood Housing WIC Center 450 Clinton Street, 1st floor Woonsocket, RI 02895 (401) 767-4109

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Rosanna Grillo, Executive Director Jummy Olagundoye, WIC Coordinator Scalabrini Dukevich Center 300 Laurel Hill Avenue Providence, RI 02909 (401)632-4770

Scalabrini Dukcevich Center WIC Program 300 Laurel Hill Avenue Providence, RI 02909 (401) 632-4770

Mr. Joseph R. DeSantis, Executive Director Casey Sardo, WIC Coordinator/Nutritionist Tri-County Economic Opportunity Committee Tri-County Health Center WIC Program 1130 Hartford Avenue Johnston, RI 02919 (401) 519-1933

Tri-County Health Center WIC Program 1130 Hartford Avenue Johnston, RI 02919 (401) 351-2750

North Providence WIC location 33 Maple Avenue North Providence RI (401) 351-2750

Mr. Paul Salera, Executive Director Westbay Community Action, Inc. 224 Buttonwoods Avenue Warwick, RI 02886 (401) 732-4660

Ms. Kelly McHugh, Coordinator Westbay Community Action, Inc 205 Buttonwoods Avenue Warwick, RI 02886 (401) 732-4660

Westbay Community Action, Inc WIC Program 205 Buttonwoods Avenue Warwick, RI 02886 (401) 732-4660

West Warwick WIC 145 Washington Street West Warwick, RI 02893 (401) 826-3230

North Kingstown WIC 650 Ten Rod Road North Kingstown, RI 02852

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Ms Anna Bailey Associate Vice President Clinical Resource Development Women and Infants 101 Dudley Street Providence, RI 02905

Hailey Grant, WIC Coordinator Women & Infants' Hospital WIC Program 2 Dudley Street WPCC Nutrition Services - Suite 565 Providence, RI 02905-2401 (401) 274- 1122Ext. 42776

Women and Infants' Hospital WIC Program 2 Dudley Street WPCC Nutrition Services – Suite 565 Providence, RI 02905-2401 (401) 274-1122 ext. 42768

Alison Croke CEO Terry Reis, WIC Coordinator/Nutritionist Wood River Health Services WIC Program 823 Main Street Hope Valley, RI 02832 (401) 539-2461

Wood River Health Services WIC Program 823 Main Street Hope Valley, RI 02832 (401) 387-9638

Westerly WIC Satellite 93 Tower Street Westerly, RI 02891 (401) 539-2461 X200 Eugene Montero, Ex. Director Gloria Price, Coordinator Mount Hope Neighborhood Associates 199 Camp Street Providence, RI 02906 521-8830

Mount Hope Neighborhood Associates 199 Camp Street Providence, RI 02906 521-8830

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GLOSSARY OF TERMS

Agreement - the written document between the Rhode Island Department of Health WIC Program and a local agency which states the responsibilities and obligations of both parties in order to provide the WIC Program. The period covered by the WIC agreement is the Federal fiscal year.

Alternate Shopper - a person designated in writing by a payee and authorized by the Program to pick up Program food instruments for the payee and to redeem them for food at authorized Program vendors. Also known as Proxy.

Applicant- an individual who makes application for WIC Program benefits.

Breastfed Infants - persons under one year of age who are wholly or partially breastfed by a breastfeeding woman participant.

Breastfeeding Women - women up to one year postpartum who are breastfeeding their infants on the average of at least once a day.

Caretaker - one who has the responsibility for the care of the participant.

Categorical Ineligibility - persons who do not meet the definition of pregnant women, breastfeeding women, postpartum women, or infants or children.

Certification - the use of criteria and procedures to assess and document each applicant's eligibility for the Program.

Children - persons who have had their first birthday but have not yet attained their fifth birthday.

Clinic - a facility where applicants are certified.

Confidential Health Care Information - all information relating to a patient's health care, history, diagnosis, condition, treatment or evaluation.

Competent Professional Authority - an individual on the staff of the local agency authorized to determine nutritional risk and prescribe supplemental foods. The professional qualifications required of competent professional authorities are set forth in Federal Regulations. A competent professional authority is herein considered to be a physician, a nutritionist, a dietician, a registered nurse, a physician's assistant or a state or local medically trained health professional approved by the state agency. Also applies to qualified persons not on the staff of the local agency who are qualified to provide medical/nutritional assessment data.

Days - calendar days except for those time standards which specify working days.

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Disqualification - the act of ending Program participation of a participant, food vendor, or authorized state or local agency, whether as a punitive sanction or for administrative reasons.

Dual Participation - simultaneous participation in the Program in one or more than one WIC clinic, or participation in the Program and in the Commodity Supplemental Food Program (CSFP) during the same period of time.

Family - a group of related or non-related individuals who are living together as one economic unit, except that residents of a homeless facility or an institution shall not all be considered as members of a single family.

FNS - the Food and Nutrition Service of the United States Department of Agriculture.

Fiscal Year - the period of 12 calendar months beginning 1 October of any calendar year and ending 30 September of the following calendar year.

Food Costs - the cost of supplemental foods, determined in accordance with Section 246.l2 (b) (l).

Food Delivery System - the method used by State and local agencies to provide supplemental foods to participants.

Food Package - supplemental foods selected for an individual WIC recipient based on that individual's nutritional need.

Health Services - ongoing, routine pediatric and obstetric care such as infant and child care, and prenatal and postpartum examination.

Homeless Facility - the following types of facilities which provide meal service. A supervised publicly or privately operated shelter (including a welfare hotel, congregate shelter or shelter for victims of domestic violence) designed to provide temporary living accommodations; a facility that provides a temporary residence for individuals intended to be institutionalized; or a public or private place not designed for or normally used as a regular sleeping accommodation for human beings.

Homeless Individual - one who lacks a fixed and regular nighttime residence or whose primary nighttime residence is one of the following (1) A supervised publicly or privately operated shelter (including a welfare hotel, congregate shelter or shelter for victims of domestic violence) designed to provide temporary living accommodations; (2) an institution that provides a temporary residence for individuals intended to be institutionalized; (3) a temporary accommodation in the residence of another individual; or (4) a public or private place not designed for, or ordinarily used as a regular sleeping accommodation for human beings.

In-Kind Contributions - any money, supplies, advertising materials or equipment provided in support of the WIC Program from other sources.

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Income Poverty Guidelines - l85% of the USDA poverty guideline.

Infants - persons under one year of age.

Institution - any residential accommodation which provides meal service, except private residences and homeless facilities.

Local Agency- an agency under contract with the Rhode Island Department of Health to provide WIC Program services.

Management Evaluation - a system of program review used by the State agency and FNS to assess the local agency accomplishment of program objectives and provisions as provided under the Federal Regulations, State and FNS guidelines and instructions, the local agency Nutrition Education Plan, and the written agreement with the State agency.

Migrant Farm Worker - An individual whose principal employment is in agriculture on a seasonal basis, who has been so employed within the last 24 months, and who establishes, for the purposes of such employment, a temporary abode.

Nutrition Education - individual or group educational sessions and the provision of information and educational materials designed to improve health status, achieve positive change in dietary habits, and emphasize relationships between nutrition and health, all in keeping with the individual's personal, cultural, and socioeconomic preferences.

Nutrition Services and Administration Costs (NSA) - those direct and indirect costs, exclusive of food costs, which State and local agencies determine to be necessary to support Program operations. Such costs include, but are not limited to, the cost of Program administration, monitoring, auditing, nutrition education, startup, outreach, certification, and developing and printing food instruments.

Nutritional Risk - (l) Detrimental or abnormal nutritional conditions detectable by biochemical or anthropometric measurements; (2) Other documented nutritionally related medical conditions; (3) Dietary deficiencies that impair or endanger health or (4) Conditions that predispose persons to inadequate nutritional patterns or nutritionally related medical conditions.

Participants - pregnant women, breastfeeding women, postpartum women, infants, and children who are receiving supplemental foods or food instruments under the Program and the breastfed infants of breastfeeding women who are receiving supplemental foods or food instruments under the Program.

Participation - the number of persons who have received supplemental foods or food instruments in the reporting period plus the number of breastfed infants of breastfeeding women who have received supplemental foods or food instruments in the reporting period.

Participant Number - the identification number assigned to a recipient by the WIC local agency.

Payee - the custodial parent or guardian or, if unavailable, the delegated caretaker for an infant or

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child. Authorized to pick up checks and redeem them for food at authorized Program vendors.

Postpartum Women - women up to six months after termination of pregnancy.

Pregnant Women - women determined to have one or more embryos or fetuses in utero.

Priority Group - one of six priority groupings of nutritional risk established by the Federal Regulations which are to be applied by the competent professional when vacancies occur after a local agency has reached its maximum participation level.

Resident - a person making one's home in a place, who can provide evidence of such residence or who is homeless and living in an authorized WIC homeless facility or institution or is homeless and can show evidence of living and sleeping in a place not designed for or normally used as a regular sleeping accommodation for human beings.

HEALTH - Rhode Island Department of Health.

Secretary - Secretary of Agriculture.

State agency - Rhode Island Department of Health.

WIC Check - check issued by the Rhode Island Department of Health WIC Program specifying certain WIC allowed foods which is used by a participant to obtain the specified foods.

WIC Coordinator - a local agency staff member who is responsible for coordinating the ongoing operation and management of the WIC Program; for maintaining an active liaison relationship between the state agency and other appropriate local agency officials and staff; and for communicating state agency directives, policies, procedures, guidance, and other information to all local agency persons who have a need for such information in order to perform their WIC responsibilities.

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G-1 REVISIONS IN PROCEDURE AND STATE OPERATIONS MANUALS Manuals

A. Procedure Manual

B. State Operations Manual

Procedure

A. Each proposed change to WIC procedures shall be reviewed for approval by the Chief, WIC Program.

B. When approved by the Chief and reviewed and approved by the USDA Regional Office, the policy shall be enumerated according to placement in the appropriate manual.

C. Policies - State and Local

(1) Policies concerning the internal management of the State agency shall become effective when approved by the Chief.

(2) Policies directly affecting local agencies shall, whenever possible, have a period for comment by local agencies. This period shall be stipulated when the policy is distributed.

(3) Minor revisions of policy necessary to the efficient operation of the Program and with little or no impact on other entities may be made without a period of comment for the public or local agencies, but with approval from USDA.

(4) Policies which have a significant impact on other entities shall be promulgated for comment and approval in accordance with FR 246.4 (b) and R.I.G.L. 42-35.

D. Policies which constituted State Plan Amendments shall be submitted to USDA for approval and shall become effective as stipulated by the Chief.

E. Once in effect, the new policy shall be considered an integral part of the manual and shall be filed therein.

F. Revisions to the Manuals shall be filed with the Rhode Island Secretary of State.

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G - 2 USE OF WIC NAME AND LOGO PROHIBITED

The United States Department of Agriculture (USDA) and the Rhode Island Department of Health (HEALTH) WIC Program do not permit the use of the WIC name, acronym “WIC”, or the national and Rhode Island WIC logos in connection with a business or a commercial product. Such use may be mistakenly taken as an endorsement of the business, or the product by the agencies. USDA’s and HEALTH’s policy is to avoid endorsements, directly or indirectly, of any commercial business or product. Also note, that the WIC acronym and logo are registered service marks of USDA.

Use of the WIC name and the WIC logos is reserved for official use by Program officials, only. Examples include Program issued identification, public notification and outreach purposes. . Attached are copies of FNS Instruction 800-2, and a recent All States Memo stemming from an unauthorized use by Ross Labs for PediaSure.

 Please inform this office of any commercial use of these identifiers.  Local agencies should also obtain approval from the State WIC office before initiating any public use of these identifiers (see VII, B of the Instruction), or the RI WIC logo.

If you have any questions about the use of the WIC name or logo, contact the Health Department’s Information Line at 401-222-5960.

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SECTION 200

ELIGIBILITY AND ENROLLMENT

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SECTION 200

ELIGIBILITY AND ENROLLMENT

(Goals - II, Operations - 2)

210 - Application and Eligibility Determination

211 GENERAL

The certification forms and the screening criteria used to determine eligibility for certification are uniform statewide. The procedures for certifying a WIC applicant may be found below. Electronic criteria forms (in RI WEBS) are used to determine an applicant's nutritional need for the Program. The USDA WIC Income Poverty Guidelines are used statewide for screening for income eligibility. Guidance in procedures for determining income is provided to local agencies.

Eligibility Requirements

To be eligible to receive available benefits of the WIC Program, a person must be:

A. A resident of the State of Rhode Island.

B. A pregnant, breastfeeding or postpartum woman, an infant, or a child up to his/her fifth birthday.

C. A member of a household with an income of less than l85 percent of the poverty level guideline except as noted under section 212 number 3 (see Income Guidelines - Appendix).

D. All participants meeting income guidelines will be assumed to be at nutritional risk if no other risk is identified.

Application to Local Agency

Application to the WIC Program is made at a local WIC health care service agency. The local agency is responsible for informing applicants of eligibility requirements, accepting applications, determining eligibility or ineligibility, and distributing WIC checks.

A. When a person calls or visits the local agency to apply, local agency personnel will inform the person of the eligibility requirements as stated above. Obviously ineligible applicants (not a resident of Rhode Island; not a pregnant, breastfeeding or postpartum woman, or infant, or child up to his/her fifth birthday; income clearly exceeding l85% of poverty level guideline and not eligible based on participation in another program) should be so informed.

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B. Pregnant Women and Employed Individuals

The local agency must make every reasonable effort to see for certification assessment, any potentially eligible pregnant woman on an expedited basis. Breastfeeding women should be given next priority for appointments followed by infants, children, and non-breastfeeding postpartum women, in that order. The local agency must have evenings or weekends available to schedule appointments for each employed individual seeking to apply for participation in WIC so as to minimize the time the individual must be absent from the work place.

C. When there are no funds available for new participants, potentially qualified applicants' names are placed on the agency's waiting list for the appropriate priority group (see SEC. 2l3 Priority System and WIC Waiting List form) including date of contact, address, telephone number, date placed on waiting list and any priority related screening information. Applicants or their caretakers are to be told about being placed on the waiting list as soon as possible, and never more than 20 days after they apply for Program benefits.

D. Referral of Applicants to other Local Agencies

When a local agency is unable to enroll an applicant for an extended period of time, the local agency should offer the applicant the option of being referred to another local agency where a certification appointment might be more quickly available. Additional assistance should be given to applicants of priorities 1,2,3, and 4 in locating other local agencies, especially applicants with severe nutritional or financial needs. The state agency may be contacted for information regarding local agencies that may have shorter waiting lists or more readily available certification appointments.

The referring agency should confirm with the reviewing agency that space is available for the client. The participant ID number should be given to the receiving agency so that the client's certification data can be electronically requested. Local agencies must provide any waiting list information to the state agency, upon request, in order to foster referrals.

E. Initial Visit

When inquiries are made to the local WIC office, local agency staff is to enter appropriate intake information into the RI Webs for future applicant processing, scheduling purposes, and coordination with other services. The application process for a new applicant (when a funded opening is available), or for the next applicant on the highest priority Waiting List (when funds become newly available) begins when the applicant visits the local agency during clinic office hours. If the certification process is not completed, record the results of the initial visit, showing the reasons why any data was not obtained and the plan for completing the certification. Pregnant women who miss their 1st certification appointment need to be contacted to reschedule.

* F. Certification of Staff of a WIC Local Agency

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The application, reapplication and check issuance procedures for a local agency staff member must be entirely handled by other WIC staff authorized to conduct each activity. The local agency staff member applicant, participant or payee may not conduct any of the application procedures such as demographic information completion, income eligibility, dietary assessment, anthropometric and blood screenings, nutrition risk assessment, nutrition education, or any part of check issuance on or for their own behalf.

To ensure such separation of functions, either of two procedures must be followed:

1. The WIC Coordinator of an agency's employee must perform all CPA functions for the employee and review demographics data and documentation or,

In a large agency, with considerable separation between departments, the agency may request an exception if non WIC staff members do not share supervision and regular contact with the WIC unit staff.

2. An applicant staff member can apply to a different local agency from any agency the applicant is affiliated with in a work/volunteer capacity.

The application for WIC benefits of any agency staff member to his/her own agency must be reported to the WIC coordinator for the agency receiving the application.

G. The application process continues as specified below under Eligibility Determination.

H. The following applicants shall be notified of their eligibility or ineligibility within 10 days of the date of application for available benefits.

1. Pregnant women meeting Priority 1 criteria

2. Breastfeeding women who are breastfeeding a Priority 1 infant

3. Infants under six months of age.

4. Members of migrant farm worker households who soon plan to leave the jurisdiction of the local agency.

Others must be notified within 20 days of such application.

Eligibility Determination

A. Applicants who have been assessed by the local agency as meeting the income, residence and nutritional risk criteria should be issued checks. However, local agency WIC staff may not

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-5- certify themselves for the Program. The staff person responsible for certification of any applicant may not also print checks for that same applicant.

B. Summary of Procedures

The local agency must determine that the applicant meets the categorical, income, residency, and nutritional need criteria. When an applicant does not meet one or more of these criteria, the applicant is deemed to be ineligible, and cannot be certified for WIC benefits. Applicants who do not have documented proof of pregnancy but have met all other eligibility criteria should be issued benefits. Documentation of pregnancy should then be required within 30 days to assure linkage with appropriate prenatal care services. Applicants may not be charged for pregnancy tests.

1. The local agency employee securing information for eligibility interviews the applicant or caretaker of the applicant for the household income and the number of persons in the household (See 212 Determination of Income). This information is entered into the computer (see Appendix). The intended payee should read or be read and sign the Eligibility Agreement. Income will be determined on the basis of the most accurate reflection of current income (weekly, bi-monthly, monthly, yearly). Full instructions for completing certification will follow in Sec. 220.

2. Verification of Address

a. The employee verifies the address of the applicant as a standard part of the certification procedure. To foster accuracy, the preferred verification would be a utility bill or other business mail addressed to the participant. Less desirable sources include street directories, other mail, rent receipts, or other documents initiated by a third party showing the applicant's or parent's name and address. If the applicant is homeless or living in a homeless facility the address of the local agency may be used. A letter from an official of the facility or another disinterested party acceptable to the WIC Program who can verify homelessness should be in the file if it can be obtained with reasonable effort. The CPA's best judgment should be used before denying benefits to obviously destitute people.

b. The state agency may use other means to verify applicant addresses.

i. If a client's address is not documented properly, the State agency will notify the local agency of the deficiency. The local agency should review the participant's record and flag the record. The local agency will contact the participant regarding his/her address and document the contact in the record. The local agency will make a determination by correcting the documentation, documenting a new address or documenting that the address given by the participant is suspected of being fraudulent. The local agency will then notify the State agency within two weeks as to its

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ii. If there is cause to suspect deliberate misrepresentation of an address or telephone number, the local agency shall consult with the state agency liaison to consider possible disqualification from Program benefits. (Participant Violations Sec. 242)

3. Local staff person checks identification of the applicant and the potential authorized representative (authorized representative identification must be verified and documented at each certification). The following are acceptable sources of identification for applicants and authorized representatives in order of preference:

Payee

Child/Infant

Picture ID such as current passport

Birth Certificate

Driver's license

Immunization Record

Work or School ID Card

Foster Care Placement letter

Alien care stub

Doctor’s Form Immunization Record

Hospital Birth Card

Voter Registration Card

Verified Rite Care Card

Social Security Card

Birth Certificate Verified Rite Care Card

4. Information & Rules - the local staff person reviews Information & Rules information on the WIC-5 Eligibility form and the WIC ID folder. The information is explained to or read by the applicant.

5. The local agency employee then proceeds to conduct the nutritional/medical assessment to determine if the applicant is at nutritional risk.

6. When funds are available inform a person that he/she is being certified and issue checks to him/her.

7. Foster Children and Institutionalized Children

a. For the purposes of the WIC Program the foster child shall be considered a one member household.

i. The money the foster family receives for the maintenance of this child shall be considered the gross income of this child. Special payments to the foster family for special needs, such as medical-related expenses, may be disregarded with approval from the State Agency.

ii. The foster parent shall then be named as the authorized representative for the foster child.

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iii. The adopted foster child with state subsidy should be considered to retain his/her foster child status.

b. If there is concern about retaining a child's whereabouts in confidence, the social worker may be named as the authorized representative with the foster parents named as the alternate shopper. This situation should be temporary since the children would not be receiving the benefit of nutrition education.

c. If a child is in the middle of a certification period when becoming a foster child, the benefits shall continue until the end of that certification period, at which time the above income standards will apply.

d. Institutionalized children shall not be considered eligible for WIC except as under Sec.226D.2.

8. An applicant with no proof of identity and/or residency, such as a victim of theft, loss or disaster, a homeless individual, a migrant, or a person holding a VOC card, must sign a statement attesting to his/her identity and residency (WIC - 88). In the situation where such a statement is used as the applicant’s proof of identity and/or residency, the WIC staff must include the statement and a brief notation explaining why the applicant could not produce proof of identity and/or residence.

9. Partial Determinations

The primary responsibility of securing and presenting information and documents needed to establish eligibility is the applicant's or their parent(s), or their guardian(s).

Staff will assist in the obtaining, presenting, and evaluating of required data.

WIC checks must not be issued until all determination procedures are completed, including:

(a) Verification of identification (or statement of self-declaration) (b) Verification of address/residence (or statement of self-declaration) (c) Documentation of income (or statement of self-declaration) (d) Determination of nutritional risk (e) Preliminary determination of available benefits (caseload and any State directed adjustments).

When the applicant encounters difficulty in presenting required eligibility data, then additional assistance, interviews, and appointments should be offered to help them establish their eligibility.

*A verified Rite Care card can be used as proof of ID, residency and income when needed.

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-8- In cases of obvious need, a lack of the documentation or third party statement regarding income status should not be a barrier to providing WIC services. Consult the State Office to discuss alternative documentation or a waiver.

212 DETERMINATION OF INCOME PROCEDURES

1. Each WIC applicant is required to present to the local agency, at the time of eligibility determination, reasonable documentary evidence, or "best available substantiation," of the sources and amounts of income the applicant has declared.. Income worksheets from other departments and programs may be used for documentation of income provided it meets WIC income standards and standards for proof of income. (Contact the State WIC Office for guidance on programs and procedures which meet these requirements.) Applicants referred by these programs should be given a copy of the worksheet to present at the WIC office. If the worksheet is used as income documentation it should be kept with the Eligibility Agreement form and kept on file. The worksheet may be used up to 60 days after its completion date, subject to the WIC Coordinator's discretion. The form should reflect current earnings.

(a) Applicants will be required to have, at the time of eligibility determination, those types of documentation most commonly available for a particular source of income. Adjunctive Eligibility - A verified Rite Care card serves as proof of income for WIC participants. A verbal income is acceptable for those receiving Rite Care.

(b) The State agency may waive the documentation requirement above (a) for

(I) an individual for whom the necessary documentation is not available (for example, farm worker or person who works for cash; or

(ii) an individual, such as a homeless woman or child, for whom the agency determines the requirement above (a) would present an unreasonable barrier to participation.

(c) If income documentation is waived (see i and ii above), the applicant must sign a statement attesting to the self-declared income (WIC-89), and the reason that documentation is unavailable. This should be accompanied by a written statement from a reliable third party that has knowledge of the applicant’s income. Reliable parties might include staff of a social service agency, church or legal society, or employers.

2. Local agencies have latitude and judgmental prerogative in documenting an applicant's source and amount of income. Local agencies may utilize current existing documented income data secured from a participant's eligibility for the agency's health center or clinic, or may choose instead to require that current documentation be secured from the WIC participant at the time of eligibility determination for WIC specifically.

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3. Definition of Income - Income means gross cash or other monetary income received, before deductions for taxes, employees' social security taxes, insurance premiums, bonds, savings, retirement etc. No expenses due to hardship, child support payments or other deductions are allowed.

The full amount and source (place of employment, child support, etc.) of any family income must be recorded, unless specifically excluded, below. Eligibility for certification as a WIC participant is defined as income that does not exceed l 85 percent of the current poverty guidelines as provided by the WIC Program to local agency staff (see Income Guidelines). The WIC Program will implement adjusted WIC income eligibility guidelines concurrently with Medicaid income eligibility guidelines. Exception must be made for individuals with RIte Care/Medicaid, Supplemental Nutrition Assistance Program (SNAP), RI Works or GPA documentation (see 7(a) below). Income should be recorded on the Eligibility Agreement.

4. Excluded Income - Do not count as income.

(a) When determining eligibility for the WIC Program, income or benefits from the following programs are excluded from consideration:

(i)

Reimbursements from the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (Public Law 91-646, Section 216).

(ii)

Any payment to volunteers under Title II (RSVP, foster grandparents, and others) and of the Domestic Volunteer Service Act of l973 (Pub. Law 93-113, Section 404 (g)), as amended. Payments under Title I, Part A, (VISTA) to volunteers shall also be excluded.

(iii) Payment to volunteers under the Small Business Act (SCORE AND ACE)

(iv)

Income derived from certain submarginal land of the United States which is held in trust for certain Indian tribes (Public Law 94-114, Section 6).

(v)

Payments received under the Job Training Partnership Act.

(vi)

Income derived from disposition of funds to the Grand River Band of Ottawa Indians (Public Law 94-540, Section 6).

(vii) The value of assistance to children or their families under the National School Lunch Act, the Child Nutrition Act of l966 and the Food Stamp Act of l977.

(viii) Payments by the Indian Claims Commission to the Confederated Tribes and Bands of the Yakima Indian Nation or the Apache Tribe of the Mescalero Reservation.

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(ix)

Payments to the Passamaquoddy Tribe and the Penobscot Nation or any of their members received pursuant to the Maine Indian Claims Settlement Act of 1980.

(x)

Payments or allowances received pursuant to the Home Energy Assistance Act of l980 (Public Law 96-223, Title III, Section 3l3 (c) (l)).

(xi)

Payments received from the youth employment demonstration programs (Public Law 95-524, Title IV, Part A, Section 446).

(xii) Per capita payments of $2,000 or less to each Indian from judgment awards or trust funds under Public Law 97-458.

(xiii) Payments under the Disaster Relief Act of 1974, as amended by the Disaster Relief and Emergency Assistance Amendments of 1989 (Pub. L. 100-707, sec. 105 (i), 42 U.S.C. sec. 5155 (d)).

(xiv) Payments under the Low-Income Home Energy Assistance Act, as amended (Pub. L. 99-125, sec. 504(C), 42 U.S.C. sec. 8624(f)).

(xv) Effective July 1, 1991, payments received under the Carl D. Perkins Vocational Education Act, as amended by the Carl D. Perkins Vocational and Applied Technology Education Act Amendments of 1990 (Pub. L. 101-392, sec. 501, 20 U.S.C. sec. 2466d).

(xvi) Payments pursuant to the Agent Orange Compensation Exclusion Act (Pub. L. 101-201, sec. 1).

(xvii) Payments received through Wartime Relocation of Civilians under the Civil Liberties Act of 1988 (Pub. L. 989b-4 (f) (2)).

(xviii) Value of any child care payments made under section 402 (g) (1) (E) of the Social Security Act, as amended by the Family Support Act (Pub. L. 100-435, sec. 501, 42 U.S.C. sec. 602 (g) (1) (E)). Value of any child care provided or arranged (or any amount received as payment for such care or reimbursement for costs incurred for such care) under the Child Care and Development Block Grant Act Amendments of 1992 (42 U.S.C. 9858 a et seq.)

(xix) Benefits received through the Farmers Market Coupon Nutrition Project (FMNP) under section 17 (m) (7) (A) of the Child Nutrition Act of 1966, as amended (Pub. L. 100-435, sec. 501, 42 U.S.C. sec. 1786 (m) (7)( (A)).

(xx) Payments received under the Veteran's Educational Act of 1984, as amended (Pub. L. 99-576, sec. 303 (a) (1), 38 U.S.C. sec. 1411 (b)).

(xxi) Value of assistance received under the Child Nutrition Act of 1966 (Pub. L. 89-642, sec. 11 (b), 42 U.S.C. sec. 1780 (b)).

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(xxii) Payments received under the Old Age Assistance Claims Settlement Act, except for per capita shares in excess of $2,000 (Pub. L. 93-500, sec. 8, 25 U.S.C. sec. 2307).

(xxiii) Payments received under the Cranston-Gonzales National Affordable Housing Act, unless the income of the family equals or exceeds 80 percent of the median income of the area (Pub. L. 101-625, sec. 522 (i) (4), 42 U.S.C. sec. 1437f nt).

(xxiv) Payments received under the Housing and Community Development Act of 1987 unless the income of the family increases at any time to not less than 50 percent of the median income of the area (Pub. L. 100-242, sec. 126 (c) (5) (A), 25 U.S.C. sec. 2307).

(xxv) Payments received under the Sac and Fox Indian claims agreement (Pub. L. 94-189, sec. 6).

(xxvi) Payments received under the Judgement Award Authorization Act, as amended (Pub. L. 97-458, sec. 4, 25 U.S.C. sec. 1407 and Pub. L. 98-64, sec. 2 (b), 25 U.S.C. sec. 117b (b)).

(xxvii) Payments received under the Alaska Native Claims Settlement Act Amendments of 1987 (Pub. L. 100-241, sec. 15, 43 U.S.C. sec. 1626 (c)).

(xxviii) Payments for the relocation assistance of members of Navajo and Hopi Tribes (Pub. L. 93-531, sec. 22, 22 U.S.C. sec. 640d-21).

(xxix) Payments to the Turtle Mountain Band of Chippewas, Arizona (Pub. L. 97- 403, sec. 9).

(xxx) Payments to the Blackfeet, Grosventre, and Assiniboine tribes (Montana) and the Papago (Arizona) (Pub. L. 97408, sec. 8 (d)).

(xxxi) Payments to the Assiniboine Tribe of the Fort Belknap Indian community and the Assiniboine Tribe of the Fort Peck Indian Reservation (Montana) (Pub. L. 98-124, sec.5).

(xxxii) Payments to the Red Lake Band of Chippewas (Pub. L. 98-123, sec. 3).

(xxxiii) Payments received under the Saginaw Chippewa Indian Tribe of Michigan Distribution of Judgment Funds Act (Pub. L. 99-346, sec. 6 (b) (2)).

(xxxiv) Payments to the Chippewas of Mississippi (Pub. L. 99-377, sec. 4 (b)).

(xxxv) Payments for the Filipino Veterans Equity Compensation Fund for certain veterans, or surviving spouses of veterans, who served in the military of the government of the Commonwealth of the Philippines during World War II.

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SECTION 211-212

-12- (Pub. L 111-5)

(xxxvi) Payment received in addition to the service member’s basic pay; as a result of the service member’s deployment to or service in an area that has been designated as a combat zone; and not received by the service member prior to his/her deployment to or service in the designated combat zone (Pub L. 111- 80)

(b) The value of inkind benefits and payments, such as meals, clothing, housing, or produce from a garden.

(c) TANF and WIN Classroom Incentive Allowances.

(d) CETA youth programs; training benefits paid to youths only; wages paid to adult staff are not excluded.

(e) Earned income of children under the age of eighteen who are students at least half time.

(f) United States Department of Education administered student grants or loans for undergraduate educational purposes.

(g) That portion of scholarship grants and work-study programs used for tuitions, books, fees, equipment, or transportation for school purposes.

5. Computation of Income

(a) Definition of Family - A household or an economic unit composed of a person or group of related or unrelated persons who usually (although not necessarily) live together, who are not residents of an institution, and whose production of income and consumption of goods or services are related. A child not living in the household but receiving child support is not considered a part of the economic unit. Separate economic unit status for the applicant within a household may only be accepted if a group or an individual meets all the following criteria:

(i) Must pay a minimum of $68.17 per month for room and board for an adult (Board $54, room $14.17) and,

$95.33 per month for a child under age 12 and, $117 per month for a child age 12 or over.

(ii) The applicant's production of income and consumption of goods or services are not related with respect to anyone else in the household.

(iii) The applicant is not a spouse of a member of the household; or is not a child under age 18 under the parental control of, or a financial dependent of, a member of this household. The applicant must also be dependent upon income which is separate from that of others residing in the household (see No.7 (6)).

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-13- (iv) Supplemental foods are purchased separate and apart from others in the household, and consumed only by the participant.

(v) 2010 Census with income screen procedures. Consider the income of the family during the past 12 months and the family’s current rate of income to determine which indicator more accurately reflects the family’s status. In general, the length of employment for Census workers is most likely no more than a few months.

Effect on Family Size of Pregnancy

An applicant pregnant woman who does not meet income eligibility requirements on the basis of her current family size and income shall be reassessed for eligibility based on a family size increased by one, or by the number of expected multiple births with the approval to increase the family size by the applicant.. Note: Proof of multiple births is required following standard procedure.

In situations where the family size has been increased for a pregnant woman, the same increase family size should also be used for any of the categorically eligible family members.

(b) The goal of the computation process is to determine the most accurate and most current reflection of family income. The local agency staff member should first inquire as to the fluctuations in the family income in the current month, in the past year, and the anticipated fluctuations during the forthcoming certification period.

(c) Depending on the pattern of the family's income, the staff member will then determine the family income and record it on the Eligibility Agreement. The source of income documentation would be reflected or determined by the period of income under consideration.

5. Resolving Questionable Income Cases

(a) Circumstances that local agencies should consider questionable-

(i) Income stated is inconsistent with other statements made on the application.

(ii) The income information is inconsistent with any other information given by the applicant to the agency.

(iii) The income information is inconsistent with other information actually received and documented by the agency.

(iv) Where the income declared would appear to be below minimal survival levels.

(v) Where the applicant or family members appear to meet basic eligibility requirements

for financial aid programs but no such income is declared.

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-14- (vi) Where an unemployed family member has worked in the past year and does not report receiving Employment Security Benefits (ESB).

(b) Steps to be taken to resolve questionable cases.

The applicant may withdraw his/her request, provide the documentation needed to resolve the question, or authorize the agency to obtain the documentation.

The primary responsibility of securing and presenting information and documents needed to establish income eligibility is the applicant's or his/her parent or guardian. If needed, however, the local agency should provide assistance in obtaining the required data. In some cases questions can be resolved quickly by the applicant and local agency jointly telephoning an employer or other collateral source. If it is necessary for the agency to contact the resource directly, it is the applicant's responsibility to provide authorization for the agency to do so.

The state agency has available information release forms for documenting a family's income from the following sources:

(i) State Income Tax Division (These forms are given out on a case by case basis. Local agencies should inform the state agency when forms are sent into the Income Tax Division. Forms will be returned to the state agency by the Income Tax Division.)

(ii) Financial Assistance Agencies (Department of Employment Security, Welfare, etc.)

(iii) Generic forms are available for release of miscellaneous information to check sources determined appropriate by local agencies.

(iv) Consult with state agency staff about other possible available documentation.The CPA's best judgement should be used before denying benefits to obviously destitute people.

7. Types of Income/Documentation

Local agencies should consider the following usual sources of income and their most usually available means of documenting the source and amount of that income.

(a) Program eligibility (Adjunctive Eligibility) - Applicants who can document participation in the following programs are considered income eligible for WIC:

SNAP: An individual must be certified as fully eligible to receive SNAP benefits,

RI Works: An individual who currently receives RI Works or is presumptively eligible (pending completion of the eligibility determination process),

A member of a family certified eligible to receive RI Works

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Medicaid (the federally funded portion of the RIte Care Program): An individual certified eligible for Medicaid

A member of a family in which a pregnant woman or an infant is certified eligible for Medicaid

Participation in special programs, such as Title XIX (Medicaid, or Rite Care), RI Works, GPA or SNAP Benefits is automatically considered to be income eligible for WIC. Identification of current beneficiary status must be provided as acceptable documentation of adjunctive eligibility.

For RIte Care recipients, verification of current eligibility must be verified using either the individual’s Social Security Number or RIte Care card number Confirmation on the state website is acceptable. No additional proof of income is needed if they are actively participating in RIte Care.

Adjunctively income eligible WIC participants (and those income eligible under the State option) are afforded a full certification period (at the time of certification).

(b) Wages or Salary - The average weekly, bi-monthly, monthly, or annual wage should be determined. Usually this would mean substantiation of the previous four weeks, or the previous month's wages based on pay stubs. W-2 forms or tax returns may also be used if they reflect current earnings. The average wage might be adjusted then on the basis of anticipated changes (increases, bonuses, payless vacations), or seasonal fluctuations as established by the preceding year pattern. Year to date income figures should be reviewed to determine whether the income was continuous from the beginning of the year and adjusted for the portion of the year to get an annual or monthly figure.

(c) Self-employment - The difference between the amount of gross receipts and amount of operating expenses for producing the income. Either the reported income for the prior year, or the estimated income for the current year based on at least three months of operation may be used. Sources include tax returns and bookkeeping records.

(d) Fees, Tips, Commissions and Net Royalties - Such income may be in addition to either wages, salary, or self-employment income and should be declared. Employers usually provide some statement of the commissions and fees paid. Tax returns may also be used.

(e) Lodger/Boarder - Any income above the cost of maintaining a lodger or boarder is considered as income. Board payment for a foster child, however, is disregarded.

(f) Rental - Net amount after deduction of expenses is considered as income. If the applicant lives in the same dwelling, only the tenant's share of the property expenses would be deducted from the rental income. Total revenue and expenses must be explicitly stated.

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Payments on principle or depreciation are not allowed as an expenses. Expenses for a given property can only be deducted up to the amount of revenue for that property.

(g) Employment Security benefits and Temporary Disability Insurance - Award letters or actual checks that show the amount of income received. Claim book will show if claim filed and status of claim.

i. Strikers - No ESB until after a 6 week penalty plus one week waiting period.

ii. Quit work (without good cause)-No ESB until the person has returned to the job market and worked 4 weeks at $20 or more per week.

iii. Fired for proven misconduct or refused suitable work- No ESB until returned to the job market and worked 4 weeks at $46 per week.

(h) CETA - Wage stubs would show the income received from CETA employment.

(i) Dividends and Interest - Dividends and interest received include those which are allowed to remain in the account, not just those that are withdrawn. If substantial, (affecting eligibility) a tax return, W-3, or other bank statement should be sought.

(j) Social Security - Survivors and Disability Insurance Benefits - Railroad Retirement Benefits - Determine which applicant or family members are the actual beneficiaries. Award letters or actual checks would show the amount being received.

(k) Estates and Trusts - Lawyers' letters or other court notices usually show the amount to be received from an estate, or a trust fund. Also, checks or a statement from the person authorized to disburse funds to the beneficiary.

(l) Veteran Benefits - Benefits may be paid to the veteran or to his/her dependents. In addition, veterans educational benefits may include an amount for living cost which would be counted as income. The educational related portion would not be. Benefit checks and award letters show the amount.

(m) Military Pay--regular or reserve--should also include an additional allotment or allowance for dependents. Checks or stubs show amounts. Cash payment for subsistence, special rations or other special duties should be included. Some payments are made only once a year (like clothing) and should prorated over the whole year. Cash payments for housing should not be included (listed as BAQ or VHA on stub). Gross income should be determined based on available data. For WIC purposes, military personnel serving overseas or assigned to a military base, even though they are not living with their families, should be considered members of the economic unit.

Military personnel who are temporarily absent from their home may have their pay or paystubs sent to their families or they may designate a spouse and/or child allotment, whereby the government sends the family member(s) a check in an amount authorized. The allotment(s) designated for family members may reflect only a portion of the military person's total pay. If the family members are sent a spouse and/or child

Rhode Island WIC Program

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-17- allotment, the applicant for WIC may possess no documentation of the family's total gross income. If documentation is not available allow the applicant to self-declare the family's military income at the time of certification. Certify the applicant for two months. Income documentation must be produced in order to certify for the rest of the full certification period.

In cases where a military person receives a temporary increase in pay due to hazardous or combat duty consider the income of the family during the past 12 months as a more accurate indicator of the family's income status.

In cases where a child or children are in the temporary care of friends or relatives when parents are temporarily absent due to military service consider and choose one of the following three options in determining family composition and income.

One option is to count the absent parents and their children as the economic unit as would have been the case prior to the parents' deployment. Use of this option would be dependent on whether the local agency could reasonably determine, based on available data, the total gross income of that economic unit.

A second option, depending on the circumstances, is to count the children as a separate economic unit. To be considered a separate economic unit, the unit must have its own source of income, e.g., child allotment(s). The local agency must then decide whether the income is adequate to sustain the economic unit. If the child allotments are not considered adequate to consider the children as a separate economic unit, then procedures set forth in option three below would be used.

A third option, when options one or two are not applicable, is to consider the children to be part of the economic unit of the person(s) they are residing with; therefore, family composition and income would be determined on this basis.

These same options would apply if the children and one parent temporarily moved in with friends or relatives.

(n) Workmen's Compensation - Awards letters and checks would show the amount.

(o) Private Insurance - Income may be received from settlements, lump sums, or in the form of periodic payments or annuities. Amount used to pay for medical or correspondence from the insurance company should show amounts awarded. The applicant can request duplicates if the originals are not available.

(p) Pensions - Employment, military, and dependents' pensions or annuities, checks and award notices.

(q) Alimony and Child Support - The person receiving this benefit should have a copy of a court order showing the amount of the support.

Other regular contributions from persons not included in the economic unit.

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SECTION 211-212

-18- (r) Scholarships and Work Studies - The amounts over and above the educational related expenses may be counted as income. Room and board is not education related. (See 4, Excluded Income)

(s) Cash Income Received or Withdrawn - Includes, but is not limited to, amounts received or withdrawn from banks, insurance companies, or any other accounts; to be considered as income for the period of time for its frequency of withdrawal that is once a year, once a month, etc.

(t) Nonrecurring Lump Sum Received - Amounts received as reimbursements for lost assets or for injuries (such as amounts received from insurance companies for loss or damage of real or personal property or payments that are intended for a third party to pay for a specific expense) should not be counted as income for WIC eligibility purposes. Lump sum payments that represent new money intended as income (such as gifts, inheritances, lottery winnings, workman's compensation and severance pay should be considered as "other cash income". Lump sum payment should be treated so as to most accurately reflect the economic situation of the household. Lump sum payment should either be counted as an annual income or be divided by 12 to estimate a monthly income. All other income for the same twelve month period is then added to the lump sum amount to obtain the annual total family income. If this amount exceeds the guidelines, then the applicant would be ineligible until the end of the twelve month period.

8. Income Determination Worksheet (Refer to Items 1 through 9)

The Income Determination Worksheet (Appendix) may be completed by the WIC staff member using the information and documents supplied by the applicant, or obtained with the applicant's permission to help with determining total income. All sources of income should be included. Documents used to substantiate amount and frequency should be described. Report total family income on the Eligibility Agreement form.

9. Changes in Income

Applicants should be informed that any changes in income during the period of their certification which might affect their eligibility must be reported. If the application process indicates the probability of a change during the certification period, this should be noted by the agency and pursued at the appropriate time. If the change results in an excess of income for the balance of the certification period, termination procedures should be instituted.

10. Unemployment Income

When an adult member of the household is unemployed, the household income determination will be based on the rate of income during the period of unemployment, if the loss of income causes the income to be less than the limit for WIC eligibility.

11. Migrant Farm Workers

Migrant farm workers and family members who need to be recertified because their 226 VOC

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-19- cards have expired will be considered to have met the state's income standard, provided that the income of those workers is determined at least once every 12 months. This income procedure does not apply to non-migrant participants whose VOC cards have expired.

12. Difficult Cases

When difficulties in determining, computing, or documenting income are encountered, the first source of help is to refer to the written procedure. If the question cannot be resolved by local personnel, state WIC staff is available for consultation.

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213 NUTRITION ASSESSMENT

A. Assessment Procedures

1. A Competent Professional Authority determines nutritional risk by performing a complete nutritional assessment on a one-on-one basis. Each individual seeking certification or recertification for participation in the program shall be physically present at the clinic site for determination of program eligibility. This applies to all new applicants for their initial certification as well as participants who are presently receiving benefits and who are applying for a subsequent certification. The only exceptions to this policy are:

NB2 = For newborn infants certified as Priority II. Infant must be present at or before the mother’s 6-week postpartum recertification. OHC= An infant or child who was physically present at the initial certification visit and is receiving ongoing health care from a provider other than the local WIC agency (as shown by a completed and signed WIC Medical Form or documentation in a medical record). FTE = An infant or child who has one or more parents who are full-time employees [as shown by proof of income > 35 hours/week MC = Medical condition (see below for allowable exceptions). ND = Natural Disaster (see below for allowable exceptions). Medical Condition (may be self-reported by the participant, parent, or caretaker)

• A medical condition that necessitates the use of medical equipment not easily transportable. • A medical condition that requires confinement to bed rest. • A serious illness or condition: A newly discharged premature infant or an individual with a severe medical condition that would make a trip to the WIC site hazardous or life threatening does not have to be seen. • Infectious disease: An individual with an infectious disease (e.g. measles, tuberculosis, flu, chickenpox, etc.) should not be required to come to the WIC site under any circumstances. • Recuperation from major illness or injury: An individual recuperating from surgery, cancer treatment, burns or another condition that would make a trip to the WIC site hazardous or life threatening does not have to be seen. Natural Disaster

In the event of a flood, hurricane, blizzard or other condition that would make travel to the WIC site hazardous, an individual does not have to be seen at the time of certification.

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Working Parents/Caretakers

The state agency may exempt from the PP requirement an infant or child who was present at his/her initial WIC certification and at a WIC certification or recertification within 1 year of the current date, and who has one or more full-time working primary caretaker(s) whose working status presents a barrier to bringing the infant or child to the WIC clinic.

Instructions for Documentation

All WIC participant categories “I” and “C” must have physical presence documented in their WIC chart to complete a certification. If the child is present, check the “Physically Present” box in the demographics tab. If the child is not present and a waiver code can be applied, still check the “Physically Present” box in the demographics tab and document the appropriate waiver code in the participant’s SOAP note or general note section. If the child is not present and does not meet the above stated waiver criteria, the local WIC agency will decide whether or not to collect any additional information at that time. A “Best Practice” procedure would be to allow the payee to complete the WIC certification paperwork that the child’s PP itself does not affect directly (proof of ID, address, income, and nutrition assessment). The participant should then be asked to return in a timely manner to verify PP, and complete any other required certification information.

2. Referral information from a Competent Professional Authority not on the staff of the local agency may be used in making the determination. If the applicant would incur a cost to obtain data from an outside health care provider, solely to obtain the data for WIC, the local agency should offer to conduct the assessment procedures free of charge. Infants and children cannot be certified on the basis of a medical referral form without being physically present unless a waiver code is deemed appropriate.

3. An exception to the assessment procedure can be made only for Priority II infants. When it is impossible to get anthropometric data or when the parent or guardian cannot bring the infant or medical records to the local agency promptly after birth, the infant may be certified on the basis of the mother's documented status during pregnancy. A follow-up weight check should be done in WIC at the 6 week follow- up appointment.

6. Anthropometric measurements may not be more than 60 days old prior to certification and age- appropriate/category-appropriate blood work results (hemoglobin/hematocrit) must be entered within 90 days of the WIC certification. Lead screening results may not be more than 180 days old. Collected data must be reflective of the category. Should the agency run out of hematological screening tools, the agency is still responsible for obtaining blood work results from the provider in the federally required timeframe. The agency must make contact with the

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-3-

provide either by phone or through the medical documentation form for WIC and place the participant on monthly check issuance until blood work results are obtained

7. The following assessment tools should be considered in determining the individual's nutritional status:

 WIC Medical Information Form (WIC-2A or 2B)  Prenatal Weight Gain Grid  Infant or Child Growth Grids  Client Centered Survey tool for Infants, Children and Women (WIC 3B, 3C, 3D, 3E)

B. The assessment includes all the following areas:

1. An individual history that includes:

(a) A client Centered Survey:

(i) Nutrition assessment (ii) Exploration of food preferences, family mealtime dynamics, nutritional supplements, fads, etc.

(b) Medical history related to nutrition. The history may be obtained through a review of the applicant's medical record or referral information from a competent professional not on staff of the local agency. For example:

(i) Obstetrical history. (ii) Condition of teeth. (iii) Use of drugs or medications.

(c) Socioeconomic factors that affect nutrition.

(i) Resources available for food purchase. (ii) Availability of food storage and cooking facilities. (iii) Educational level of the participant.

Particular attention should be paid to determine whether nutritional patterns are subject to variation over time, such as when personal or family resources, situations, or functioning impact on nutritional patterns.

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2. Anthropometric Measurements - The consistent and accurate use of pregnancy weight gain grids, or growth grids as a recording and evaluation tool for the following measurements is imperative:

(a) For Women and Children 2 years of age or older.

(i) Height (ii) Weight

(b) For Infants and Children up to 2 years of age. The WHO growth standards are now used for this category.

(i) Recumbent length (ii) Weight

(c) Measurements shall be conducted not more than 60 days prior to certification for program participation. Note: pregnant and postpartum women’s measurements must be taken during their pregnancy (pregnant women), or after the termination of their pregnancy (postpartum and breastfeeding women).

(d) When taking measurements: coats, hats, shoes should be removed. Remove infant’s clothes (including jeans w/ belts, bibs w/ pacifiers etc); weigh infant with underclothes only.

Note: All scales, including those that are digital must be calibrated based on manufacturer's schedule and procedures, but at least on a yearly basis. Zero-balance scales on a daily basis and document on form WIC-86. See Appendix for information on Municipal Sealers.

3. Laboratory Analyses: In an effort to ensure participants are receiving ongoing health care, every effort must be made on behalf of the local WIC agency to obtain medical information (anthropometric and hematological test results, medical history, etc.) from the provider. This will ensure cost-savings to the WIC program by preventing unnecessary repeat blood work testing for participants. The local agency should utilize the WIC medical information form (WIC 2A/2B) which is available online through the DOH website or can be delivered to providers by the local agency.

(a) Hematocrit/hemoglobin measurement must be done as follows:

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(i) Pregnant Women: • The data collected must be taken as early as possible during the current pregnancy. • Prenatal women may be certified without receipt of blood work for up to 90 days after the date of WIC certification, but only for patients with at least one nutrition risk factor at the time of their WIC appointment. The date, bloodwork is recorded in the record will be documented in the chart. • For pregnant women, use the blood work cutoff that corresponds to the woman’s trimester when the bloodwork was taken.

(ii) Breastfeeding and Postpartum Women: • The data collected must be taken once during the postpartum period, ideally 4-6 weeks after delivery. • Breastfeeding women 6-12 months postpartum, no additional blood test is required if a blood test (taken after delivery) was already obtained and documented by the WIC local agency.

(iii) Infants: • The bloodwork must be collected between 9-12 months. • However, bloodwork may be collected early by the provider for infants 6 - 12 months old under certain circumstances (i.e. on low-iron formula, preterm and low birthweight infants, fully breastfed infant, and when deemed prudent based on a case-by- case basis). RI Webs will accept anemia-screening results for infants starting at 6 months of age to meet this need. WIC is NOT responsible for conducting anemia screenings before the age of 9 months. • If no nutrition risk factor can be determined, and they are due for blood work but it has not yet been collected, a blood test must be performed on-site by WIC or be obtained from a clinician-before the person can be determined to be eligible for WIC services.

(iv) Child: • Children need bloodwork at their initial certification as a child at 12 months of age (blood work done between 9-12 months of age may be used for this certification). • Blood work is again required between 15 and 18 months of age

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respectively • Thereafter, if blood values were normal, bloodwork should be done every 12 months • However, if blood values were low, blood work must be done again in 6 months • Bloodwork results may be deferred for up to 90 days after the date of WIC certification, but only for patients with at least one nutrition risk factor at the time of their WIC appointment. • If no nutrition risk factor can be determined, a blood test must be performed on-site by WIC, or be obtained from a clinician, before the person can be determined to be eligible for WIC services.

Example:

CHILD (9-12 months) Blood test is required. Results are normal. CERTIFICATION:

CHILD (15-18 months) New blood test is required. Results are RECERTIFICATION normal.

CHILD (21-24 months) New blood test is not required, because RECERTIFICATION results were normal at last certification.

CHILD (27 –30 months) New blood test is required. Blood test was RECERTIFICATION: not done at last certification.

All children must be screened at least once per year.

Follow up: Follow up monitoring of blood values of persons with low hemoglobin/low hematocrit is largely the responsibility of health care providers and should be treated as a medical concern. Therefore, if low hemoglobin/low hematocrit is suspected, the following will occur:

a. Notations in the participant’s file with respect to nutrition risk factors listed and priority as appropriate. b. Document the date the nutrition risk data were taken if different from the date of

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certification. c. Inform the woman or parent/guardian of the outcome and meaning of the blood test. d. Provide follow-up nutrition education, if appropriate. e. Make adjustments in the food package, as appropriate f. Make referrals to health care or social services, as appropriate.

Note: The results of blood lead screenings may not be entered into RI Webs more than 180 days after the certification visit.

A certification will be suspended if anemia screening results are not entered within 90 days of the certification visit.

(e)

These tests may not otherwise be avoided unless:

The agency has received a signed statement by a recognized member of the clergy to the effect that the clergy person as a member of that clergy person’s religious body knows the applicant, and that the laws or rules of that religious body prohibit its members from having any test for blood iron performed on them.

4. Minimum Immunization Screening and Referral Protocol in WIC.

CDC and the American Academy of Pediatrics developed the following minimum screening protocol specifically for use in WIC Programs. It is not meant to fully assess a child’s immunization status, but allows WIC to effectively fulfill its role as an adjunct to health care by ensuring that children who are at risk for under-immunization are referred for appropriate care.

Minimum Screening and Referral Protocol a. When scheduling WIC certification appointments for children under the age of two, advise parents and caretakers of infant and child WIC applicants that immunization records are requested as part of the WIC certification and health screening process. Explain to the parent/caretaker the importance that WIC places on making sure that children are up to date on immunizations, but assure applicants that immunization records are not required to obtain WIC benefits.

b. At initial certification and subsequent certification visits for children under the age of two, screen the infant/child’s immunization status using a documented record. A

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documented record is a record (computerized or paper) in which actual vaccination dates are recorded. This includes a parent’s hand-held immunization record (from the provider), an immunization registry, an automated data system (KIDSNET), a client chart (paper copy), and the WIC Medical Information Sheet, signed by the health care provider. RIWEBS provides the staff to view immunization from KIDSNET, in the WIC IS system.

c. At a minimum, screen the infant/child’s immunization status by counting the number of doses of DtaP vaccine they have received in relation to their age, according to the following table:

Age: Minimum Number of DTaP 3 months 1 5 months 2 7 months 3 19 months 4

d. If the infant/child is not fully immunized: i. Provide information on the recommended immunization schedule appropriate to the current age of the infant/child. ii. Provide referral for immunization services, ideally to the child’s usual source of medical care.

e. If a documented immunization record is not provided by the parent/caretaker or cannot be matched in KIDSNET: i. Provide information on the recommended immunization schedule appropriate to the current age of the infant/child. ii. Provide referral for immunization services, ideally to the child’s usual source of medical care. iii. Encourage the parent/caretaker to bring the immunization record to the next certification visit.

5. The Competent Professional Authority records the results of the assessment on the appropriate Nutritional Assessment Sheet.

6. The Competent Professional Authority determines the applicant's nutritional risk and determines that both the computer generated risks and CPA determined risks are appropriate in RI WEBS.

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7. The Nutrition Assessment information collected during the appointment used to determine nutrition risk is recorded in the applicant's electronic file.

8. If the applicant meets all eligibility criteria, including nutritional risk, the local agency personnel will proceed to certification (or recertification) procedures.

C. Priority System for Nutritional Risk Criteria

1. The following priorities shall be applied by the Competent Professional Authority. When vacancies occur after a local agency has reached its maximum participation level, these priorities will assure that those persons at greatest nutritional risk receive Program benefits, in accordance with WIC Risk Criteria. In all cases, assess for and select the highest priority for which a person is qualified. The RI WEBS computer system will-assign all applicants a subpriority based on the following criteria:

Income

Eligible participants will be subprioritized first according to income.

 Those applicants with incomes <185% of the federal poverty guidelines will be subprioritized first in each of the priorities.  Applicants whose income are >185% and <250% of the federal poverty guidelines will be prioritized second.

After applicants are subprioritized by income, they will be subprioritized as follows:

A: Applicants with risk factors that place them at high risk. B: Children up to 24 months of age. C: Applicants who are not at high risk.

The computer will automatically assign the highest priority and subpriority for each applicant.

2. A person, certified as an infant, whose certification period extends beyond 12 months of age, shall carry the infant priority if such priority is higher than any child priority he/she would otherwise be assigned.

214 NUTRITION EDUCATION - BREASTFEEDING

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The WIC program is committed to promoting breastfeeding as the optimal choice for infant feeding. To ensure consistency in breastfeeding promotion across the state within WIC, the following protocols have been developed: a. All prenatal applicants shall received breastfeeding education by either the WIC nutritionist or peer counselor, and ideally from both. b. Fully breastfeeding infants should not receive infant formula during the first month of life to ensure milk supply and successful feeding has been developed. Up to one can of formula may be added during the first month of life at the discretion of the WIC nutritionist for an infant who is considered mostly breastfeeding. This occurs after an assessment with a CLC in the clinic. c. Postpartum women must be seen by a nutritionist or peer counselor prior to adding formula to their WIC food package. d. Formula that is issued to a breastfeeding participant must reflect the appropriate breastfeeding category as follows: Fully Breastfeeding = no formula Mostly Breastfeeding = less than half formula package requested (0-1 can formula in the first month). *Some Breastfeeding = greater than half formula package requested * Mom with breastfeeding status of “Some Breastfeeding” will remain an active participant after the infant turns 6 months old but will no longer receive a food package. A. Breastfeeding Peer Counselor (PC) Program Support

Local agency WIC Nutritionists and Support Staff will consistently: 1. Collaborate with the PC to support breastfeeding clients. 2. Advise breastfeeding clients to call the WIC office to report their deliveries. 3. Provide prenatal and postpartum clients with PC contact information in accordance with the state and local WIC agency Breastfeeding Peer Counselor Program Descriptions. 4. Use appropriate questions to ask whether clients are breastfeeding (e.g. "What are your plans for feeding your baby?" or "How are you feeding your baby?" instead of "Are you breastfeeding or bottle-feeding?"). 5. Record and report new deliveries and problem referrals to the PC on the same day that they are reported to the WIC office. 6. Refer prenatal and postpartum women to the PC whether the PC is on-site or off-site according to state and local WIC agency protocol. 7. When possible, refer client requests to increase formula in a breastfeeding food package to the PC prior to changing the food package.

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8. Make necessary follow-up appointments for the PC in RI WEBS. 9. Respond to client alerts entered by the PC in RI WEBS. 10. Follow any other guidelines outlined in the state or local WIC agency Breastfeeding Peer Counseling Program Descriptions to support the Breastfeeding Peer Counselor Program.

B. Criteria for Breastfeeding Referral 1. Referral to Medical Doctor  Breast infections (temperature above 101 degrees, possibly along with localized redness and heat and/or plugged duct symptoms of localized pain and firmness)  Slow weight gain of infant (as perceived by mother)  Jaundiced infant (yellowish tinge to skin as perceived by mother)  Fewer than 6 wet diapers in 24 hours for infants from 4 days to 4 months old  Fewer than 3 stools in 24 hours for infants from 4 days to 3 weeks of age 2. Referral to Lactation Consultant (through Warm-Lines)  Sore nipples  Plugged ducts (localized pain and firmness)  Premature infants  Sick or hospitalized mother or infant  Infants who refuse to nurse  Infants with special health care needs (i.e., developmental disorder)  Mothers on medications

Education Materials 1. Utilize nutrition education materials as a teaching tool to complement counseling: a. Tailor distribution to client concerns and stage-specific information b. Highlight details in relevant materials to complement discussion c. Distribute only one or two relevant brochures at each visit 2. Only WIC Nutritionists should distribute and discuss WIC nutrition brochures. 3. WIC staff must receive approval from the State WIC Breastfeeding Coordinator to distribute breastfeeding brochures and materials not included on the WIC Nutrition Education Materials Order Form or on the following list of additional WIC-approved resources.

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215 WIC BREASTFEEDING PEER COUNSELOR PROGRAM PROTOCOL

(Additional details included in 214 Nutrition Education section) A. Peer Counselor Responsibilities (also included in section 250 F)

The WIC Breastfeeding Peer Counselors will consistently: 1. Project a positive image about WIC and provide information and services consistent with WIC’s philosophy. 2. Provide culturally appropriate individualized and/or group peer counseling sessions for pregnant and breastfeeding WIC participants. 3. Comply with all personnel guidelines applicable to staff at the local WIC agency including reporting to work as scheduled, notifying local agency WIC Coordinator of absences and illnesses in a timely manner, following through with supervisor directives, etc. 4. Attend relevant meetings and trainings as requested by State WIC Breastfeeding Coordinator or local agency WIC Coordinator. 5. Work collaboratively with WIC staff to maximize breastfeeding initiation and duration at the WIC site. 6. Work autonomously, under the supervision of the local agency WIC Coordinator, in the clinic setting and at home to establish and maintain relationships with pregnant and breastfeeding clients and maintain documentation. 7. Develop and demonstrate basic organizational skills to effectively track participants. 8. Comply with guidelines outlined in the state and local WIC agency Breastfeeding Peer Counseling Program Descriptions. 9. Utilize client-centered counseling techniques learned through Peer Counselor and other relevant trainings. 10. Strive to achieve competency in the skill areas outlined in the Peer Counselor Competency Checklist. 11. Contact prenatal and postpartum clients and follow-up on referrals in accordance with the state and local WIC agency Breastfeeding Peer Counseling Program Descriptions. 12. Document all personal contacts with WIC participants according to program guidelines.

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13. Comply with all other documentation requirements according to program guidelines. 14. May receive phone calls at home or by pager from either WIC staff (making referrals) or WIC clients (providing breastfeeding support) or both when not present at the WIC site. B. Counseling Strategies 1. Maximize opportunities to contact women in-person rather than on the phone. 2. Utilize client-centered counseling techniques taught in Peer Counselor training. 3-Step Counseling Strategy 1. Ask open-ended questions 2. Affirm clients concerns 3. Educate to concerns 3. Utilize nutrition education materials as a teaching tool to complement counseling: a. Utilize only WIC-approved brochures and AV materials (see Paperwork section) b. Tailor distribution to client concerns and stage-specific information c. Highlight details in relevant materials to complement discussion d. Distribute only one or two relevant brochures at each visit C. Client Contact Prioritization

Prioritize daily client contacts in the following order: 1. On-site participants 2. Problem referrals 3. New deliveries 4. New referrals 5. Routine follow-up calls a. Late prenatal b. Early postpartum c. Mid- to early prenatal d. Mid- to late postpartum

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D. Telephone Contacts 1. Make sure your client has consented to receive phone calls at home, particularly teen moms. The telephone numbers of women who have not consented should not be entered into the database or should be entered with a dummy number. 2. Find out from the client whether it is okay for you to identify yourself when you call. 3. Ask for the client using only her first name when you call. Do not mention WIC. E. Prenatal Referrals Purpose  Assess a woman’s knowledge of breastfeeding and interest in choosing breastfeeding as infant feeding method  Address concerns or barriers to breastfeeding and provide information on benefits of breastfeeding  Help women make an informed choice about infant feeding method without being critical or making women feel defensive or inadequate Protocol  All prenatal women should be referred to the Breastfeeding Peer Counselor at intake according to state and local WIC agency program guidelines unless the woman is extremely resistant or breastfeeding is medically contraindicated  Use computer reports or alternate system to routinely identify, track and contact prenatal participants at each site who were not referred Paperwork  Document all contacts within 1 week  Document inability to contact participants if unsuccessful after 2 weeks Timeframe Initiate contact with referred prenatal women within 2 weeks of receiving referral or staff schedules a follow-up appointment for client with PC within a month Method Phone, mail, in-person F. Prenatal Support Purpose Provide lactation information and support for women intending to breastfeed Protocol  A minimum of 2 contacts should be made with all referred prenatal participants who intend to breastfeed  Contact prenatal participants who do not intend to breastfeeding in accordance with local WIC agency PC program guidelines  Use WIC Breastfeeding Peer Counselor Prenatal & Postpartum Assessment Form (WIC #82) as guideline for discussion  Use computer reports or alternate system to routinely identify, track and contact prenatal participants at each site who were not referred  Make referrals to other health care professionals for breastfeeding

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contraindications (e.g., inverted nipples, previous breast surgery, etc.)  Advise breastfeeding clients to call the WIC office to report their deliveries Paperwork  Document all contacts within 1 week  Document inability to contact participants if unsuccessful after 2 weeks Timeframe Preferably 1 contact at each trimester (6-9 months, 3-6 months, 1-3 months) and again at 2-4 weeks before anticipated due date Method Phone, one-on-one counseling, group class, mail (if no phone number available) G. Postpartum Support Purpose  Assess how breastfeeding is going and provide encouragement and support  Identify common breastfeeding problems and provide problem-solving information and support  Make referrals to other health care professionals for complicated or unresolved breastfeeding problems (see following “Criteria for Breastfeeding Referral”) Protocol  A minimum of 2 contacts should be made within the first two weeks postpartum and again after the first 2 weeks postpartum (4 contacts total)  Contact breastfeeding participants as soon as possible after delivery  Attempt to schedule an in-person appointment ASAP when necessary  Use WIC Breastfeeding Peer Counselor Prenatal & Postpartum Assessment Form (WIC #82) as guideline for discussion  Use computer reports or alternate system to routinely identify, track and contact postpartum participants at each site who were not referred  Make referrals to other health care professionals for complicated or unresolved breastfeeding problems (see following “Criteria for Breastfeeding Referral”) Paperwork  Document all contacts within 1 week  Document inability to contact participants if unsuccessful after 2 weeks Timeframe During first 2 weeks postpartum:  Contact deliveries reported through WIC Infant Delivery Log and WIC Lactation Consultant Referrals by phone within 24 hours of receiving report  Contact deliveries identified using “Due Date Follow-up Report” (Report 400B) or another tracking method 2-3 days after anticipated due date  Follow-up on contacts within 2-3 days or as requested by participant  Follow-up on problems within 24 hours (see Problem Referrals) After first 2 weeks postpartum:  Preferably contact at 2-3 weeks, 4-8 weeks, and 3-4 months postpartum  Maintain contact as needed or as requested for entire breastfeeding duration

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Method Phone, in-person, mail (only after first 2 weeks) H. Problem Referrals Purpose  Provide problem-solving information and support Protocol  Contact client by phone within 24 hours of receiving referral  Attempt to schedule an in-person appointment ASAP when necessary  Make referrals to other health care professionals for complicated or unresolved breastfeeding problems (see following “Criteria for Breastfeeding Referral”) Paperwork  Document successful contact within 1 week  Document inability to contact participants in unsuccessful after 3 days. Place follow-up phone call to WIC staff person who made referral to PC and document in chart within 1 week of referral. Timeframe  Follow-up on referrals by WIC staff within 24 hours of receiving referral  Follow-up contact with client within 24 hours of problem discussion Method In-person (preferred), phone

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216 NUTRITION DOCUMENTATION

A. Documentation purpose

1. To ensure the quality of nutrition services by identifying risks and/or participant concerns, facilitating follow-up and continuity of care (enabling WIC staff to “pick-up” where the last visit ended by following-up on participant goals, reinforcing nutrition education messages, etc.) 2. To ensure the integrity of the WIC Program through documentation of nutrition services data used for eligibility determination and WIC Participant and Characteristics reporting.

B. Documentation procedures

1. Certifications, Recertifications, and High-Risk Follow-ups a. All certification, recertification, and high-risk follow-up contacts must be documented in the SOAP note section of RI Webs. b. SOAP note information should be documented in the appropriate section of the SOAP note (i.e. “S” should include subjective information only, “O” should include objective information only, “A” should include assessment information only, and “P” should include plan information only). NOTE: The “P” section of the SOAP note should document a plan of action for the next follow-up visit. This section should NOT be used to document topics discussed – topics discussed should be documented in the “A” section. If there is no clear plan established for the participant, document a possible stage of change the participant may be in. For example: “Parent will contemplate importance of increasing daily servings of vegetables in achieving a healthy weight for her child.”

2. SNEC (Secondary Nutrition Education Contact) a. All SNEC’s should be documented in RI Webs in either of the following ways: 1. A brief note in the general note section that states any pertinent information about the participant that will be useful for follow-up or general reporting purposes. 2. A selection of a nutrition education topic in the nutrition education contact tab of the participant folder. 3.SNEC (Secondary Nutrition Education Contact) a. All low-risk SNEC’s should be documented in RI Webs in either of the following ways: 1. A brief note in the general note section that states any pertinent information about the

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participant that will be useful for follow-up or general reporting purposes. 2. A selection of a nutrition education topic in the nutrition education contact tab of the participant folder. 3. Other Nutrition Assessment Documentation Information

a. If a dietary risk factor is selected by the nutritionist, the rationale for it’s’ selection must be documented in the note.

For Example: Qualifying rationale for the selection of 411 risk factor – “inappropriate nutrition practices for infants” should be explained in the note (bottle use for juice, early introduction to solids, cereal in bottle, etc.). b. Should a participant miss a nutrition education appointment, local agency staff, for purposes of monitoring and further education efforts, should document this fact in the general notes section of the participant file in RI Webs or choose “No show for Nutrition Education” in the Nutrition Education Contact tab. c. State agency nutrition staff shall not provide nutrition assessment services (including food package assignments) remotely to local agency participants in the absence of local agency nutrition staff. In the event of planned and/or unplanned nutrition staff absences at local WIC agencies, staff must make their own accommodations to serve clients at the local agency level.

Food package 3 Documentation: Key points: WIC-23 A, icd-9 codes, MA payer first resort, additional foods if ok’d by md, whole milk for >2 year old w/ qualifying medical condition, milk substitutions form

4. Other Nutrition Assessment Documentation Information a. If a dietary risk factor is selected by the nutritionist, the rationale for its’ selection must be documented in the note. For Example: Qualifying rationale for the selection of 411 risk factor – “inappropriate nutrition practices for infants” should be explained in the note (bottle use for juice, early introduction to solids, cereal in bottle, etc.). b. Should a participant miss a nutrition education appointment, local agency staff, for purposes of monitoring and further education efforts, should document this fact in the general notes section of the participant file in RI Webs. c. State agency nutrition staff shall not provide nutrition assessment services remotely to local agency participants in the absence of local agency nutrition staff. In the event of planned and/or unplanned nutrition staff absences at local WIC agencies, staff must make accommodations to serve clients at the local agency level. d.

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217 DENIAL OF ELIGIBILITY

1. If the applicant is determined ineligible for the Program, or there are insufficient Program funds to enroll the applicant, local agency personnel will complete duplicate copies of WIC-9A, Program Denial/Termination (Appendix).

2. Local agency personnel will explain to the applicant or caretaker of the applicant the reason(s) for denial of eligibility for program benefits and provide the person with a copy of the completed form in the appropriate language.

3. Local agency personnel will inform the applicant or caretaker of his/her right to appeal any decision made by the local agency regarding his/her eligibility for the program.

4. Local agency personnel will provide the applicant or caretaker with the WIC-14, Fair Hearing Information. A WIC-15, Request for Fair Hearing form, will be given if the applicant expresses a wish to appeal a denial. Information about available resources for legal counsel must be given.

5. Local agency personnel will ensure that a completed copy in English, of the Denial of Eligibility form and other eligibility determination documents are signed by a WIC staff person and are retained in the applicant/participant's file. If the copy of the WIC-9A provided to the applicant or caretaker is in a foreign language, that language should be indicated on the bottom of an English language version of the form.

6. A complete record should be made of dates of activity, assessment data and reasons for denial.

7. If the denial is due to insufficient Program funds, and the applicant meets all other eligibility criteria, place the person's name on the appropriate waiting list. Determine whether another agency may be able to serve the person and refer as appropriate. If waiting lists are long and low priority applicants may not be reached in a reasonable period of time, consult with the state agency to see if a portion of the waiting list may be discontinued.

8. If the denial is due to reasons other than insufficient Program funds, the applicant/participant may reapply whenever circumstances change.

9. Local agency personnel will provide information about other potential sources of food assistance in the local area to individuals who apply in person to participate in the WIC Program, but who cannot be served because the Program is operating at capacity in the local area.

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218 FOREIGN STUDENT ELIGIBILITY

First, U.S. citizenship is not a condition of WIC eligibility. Therefore, foreign students and other aliens cannot be denied participation in the WIC Program solely on this basis.

A person entering the country as a foreign student is allowed entry solely to pursue a full course of study at an established institution of learning or other recognized place of study in the U.S., particularly designated by the student and approved by the Attorney General after consultation with the Office of Education. The alien spouse and unmarried minor children of any such student if accompanying or following to join the student are classified by the Immigration and Naturalization Service (INS) as foreign students. However, participation in the WIC Program may jeopardize a foreign student's visa because it may be construed by INS as evidence that the participant has become a public charge. Any children born to foreign students during their stay in the United States may participate in WIC without jeopardizing their parents' visas. Local agencies should implement the following procedures:

1. If the local agency believes or knows for a fact that the applicant is an alien, the local agency should tell the applicant that participation in the WIC Program could jeopardize retention of his or her visa, if the financial situation which makes them eligible for WIC existed before entering this country. Refer the alien to the local INS office for further information.

2. If, after the local agency cautions the alien applicant of the possible consequences of his or her participation in WIC, the applicant still wants to apply for benefits, the local agency should require documentation of income eligibility, since a prerequisite for a foreign student visa is economic self-sufficiency. The local agency can require that the alien submit the same financial information that was submitted to INS to obtain a visa or give written authorization for the agency to obtain any and all income information from INS.

3. If the student is self-supporting, he/she must document to INS that he/she has sufficient funds to cover all living costs for the planned years of study including living expenses.

4. If the student is dependent on financial support from his parents or other persons, the sponsoring persons may complete and sign an INS Form I-134 outlining their income and assets, and their ability to support the alien student. The student should have copies of this documentation or other documents such as an IAP-66 or I-20.

5. Eligibility should be denied if income documentation is incomplete. Fair Hearing rights must still be made available, however.

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6. WIC regulations specifically restrict the use or disclosure of information obtained from program applicants or participants to persons directly connected with the administration or enforcement of the WIC Program. All information provided by applicants and participants, including their names and addresses, is covered by this restriction. Sharing such information with the Immigration and Naturalization Service (INS) would not be in accord with program regulations. In other words the WIC Program is not obligated to and is restricted from sharing any information on a participant with INS.

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219 OTHER ALIENS

o U. S. Citizenship is not a condition of WIC eligibility.

o WIC does not need to have any information about an applicant's alien status.

o Benefits can not be denied on the basis of alien status.

o WIC regulations prohibit the sharing of any information with INS.

o Aliens must provide proof of identification, residence and income, just as any other applicant must.

o Eligibility should be denied if income documentation is incomplete.

o Illegal aliens already in a health center or clinic for health care can use that health center's existing documentation as a source of documentation for identification.

o If any applicant is receiving benefits from Medicaid, Food Stamps, AFDC or GPA, it can be used as income documentation for WIC.

o Written anecdotal documentation from a reliable, independent third party individual, can be accepted as documentation.

o Refugees must provide proof of income just as any other applicant must, whether employment or documentation of support by others.

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220 - COMPLETING CERTIFICATION

221 CERTIFICATION PROCESS

A. Description

Certification is the total process by which an applicant is determined eligible, is processed to receive WIC benefits, is informed of acceptance (certification) to the Program and his/her rights therein and is then given checks with which to purchase supplemental foods. Most eligible participants will receive benefit checks at their initial certification appointment. Legally required time frames for completing this certification process for participants are as follows:

Within 10 days of the date of the first request for available (i.e. funded) Program benefits, for pregnant and Breastfeeding women eligible as Priority I participants, infants under 6 months of age, and members of migrant farmworker households who soon plan to leave the jurisdiction of the local agency.

Within 20 days of the date of the first request for available (i.e. funded) Program benefits, for all other applicants.

B. Steps

The entire certification process, therefore, is the completion of several steps:

Receiving application for available (i.e. funded) Program benefits, determining eligibility, completion of the Eligibility Form and processing the applicant to receive Program checks. This certification process is to be accomplished within the timeframes cited above. Completion of the Eligibility Form is outlined in Section 222.

Receiving an application for Program benefits and determining eligibility have been outlined in Section 210.

C. Processing

Processing a certification requires documentation of the following steps: Completion of the Eligibility Form (WIC-5) Anthropometric and Hematological Screening Nutrition Assessment / Risk Determination Issuing WIC Checks

At a certification / recertification visit, the WIC checks must not be issued by the same person who completed the nutrition assessment. If such separation is not possible due to staffing issues, agencies must request from the state office

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permissions to both assign risk and print the food benefits. A copy of the schedule for the day is faxed to the state office. All children certified are compared to the state KIDSNET system as verification the individuals exist in RI. All women are given one month worth of benefits and the next and alternate staff member provides WIC services to the woman. There must be proof within the certification record that the certification steps were completed by more than one WIC employee.

D. Persons Who Cannot Sign Their Names

Persons who cannot write their names are permitted to make their mark (x) on the following documents:

1. Eligibility Agreement

2. I.D. Folder

3. WIC Checks

Print the person's name next to the mark. Marks must always be witnessed by a full WIC staff member signature and title. The vendor will witness the countersignature at the store (See Appendix - WIC Check).

222 ELIGIBILITY AGREEMENT

A. The Eligibility Agreement must be completed before checks are issued to the participant. This form documents in the file those items required for eligibility determination. All of the following items must be completed in RIWebs under the Guided Script which will then print out the form (WIC-5):

1. Household size - as defined in Section 210

2. Gross income - as defined in Section 210

3. Frequency of income - weekly, bi-monthly, monthly or yearly

4. Source of income-whether name of employer, social security, savings, public assistance case number or other (see Section 212)

5. Verification of address - as explained in Section 210

6. Proof of identification - for both the applicant and payee if different (see Section 210)

The applicant must sign the form to verify that information is correct and items are agreed to. A WIC staff member must sign and date the form and retain a copy in the

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applicant's file. If explanation of the form is given in a foreign language, the language must be indicated on the bottom of the form.

B. As part of the certification process, local agency personnel must fully explain the WIC Program to the payee, including a description of the participant's rights. This is accomplished and verified through use of the Eligibility Agreement (WIC-5) form. This includes a summary of information about WIC and the participant's rights thereon.

1. The Eligibility Agreement should be signed and a copy issued to all payees at certification. The form should also be signed and issued at all recertifications.

2. The Rights and Obligations portion of the Eligibility Agreement shall be read by or to each applicant or caretaker of the applicant at the time of signing of the form. Where a significant proportion of the area served by a local agency is composed of limited or non-English speaking persons, the sentences shall be stated to them in a language they can understand.

3. Complete the Form and ensure that the payee signs and dates it. If needed, fill in the language used for the Rights and Obligations portion of the form. If the payee can not date his/her signature, the staff person can date and initial the form.

4. Place the signed form in the participant's file.

5. Give a copy of the Eligibility Agreement and the Information and Rules to the payee in the appropriate language.

6. Referrals shall be made to the SNAP, Medical Assistance (RIte Care) and the RI Works Program as appropriate. Information shall be provided including pamphlets, telephone numbers, etc. (see Outreach Sec. 5)

C. Refer to Section 244 – D for use of the Third Party Release to Disclose WIC Information (WIC- 101).

225 IDENTIFICATION FOLDER AND ALTERNATE SHOPPER

No one may pick up or cash WIC checks without a WIC Identification Folder, authorizing that person to do so. For the person picking up checks for the first time at a clinic: official photo identification must be presented.

A. Regular Identification Folders

1. The regular ID folder is issued at initial certification. Each WIC participant must have a WIC ID folder with payee name, payee signature, WIC number, and, if desired by the

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payee, an alternate shopper's signature.

2. Participant Who Wishes an Alternate Shopper

(a) When a participant has been certified, the local agency should ask the payee if they would desire an alternate shopper. If possible, the payee and the alternate shopper should both sign the proxy form (WIC-7C) and the Identification Folder at the same visit. Only the payee should be issued an ID folder. The alternate shopper does not receive his/her own ID folder.

(b) The alternate shopper must be either an adult or an emancipated minor (parenthood, marriage, court, self-sufficiency with relinquishment of parental rights and duties). In cases of emergency, local agencies should contact the state agency for permission to authorize a non-emancipated minor on a temporary basis.

(c) An individual may not act as an alternate shopper for more than five participants or three families at any one time. Where this policy poses a hardship (for example in a facility for the homeless), the state agency will consider the participants' access to full WIC services and the need for allowing an exception.

(d) One proxy form may be used for an entire family but must be cross referenced in each family member file.

(e) If the alternate shopper cannot come to the agency to sign the forms:

(I) Complete the proxy form (WIC-7C), write None in the line for Alternate Shopper.

(ii) Ask the payee to sign it, staff signs and dates it. File in participant’s file.

(iii) Give a second proxy form to the payee, with alternate Shopper’s name printed on it.

(iv) Write the Alternate Shopper’s name on WIC ID folder. Caution the payee to have only the named alternate sign the folder and to have it signed before shopping.

(v) Instruct payee to have Alternate Shopper sign the proxy form and the ID folder and bring both back the next time. Issue only one month of checks at this time.

(vi) Put a Alert in computer, so that the next time the payee comes in to

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the agency the message will inform staff that a “proxy is pending”.

(vii) When the payee or alternate returns for the next set of checks, verify the alternate's signature on the ID folder against that on the proxy.

(viii) Void the prior proxy and file the new one. If payee doesn’t bring back the proxy, issue a new ID folder and cross out “Alternate Shopper” sections on ID folder.

(ix) Repeat this process if the participant wishes to change or add an alternate shopper.

4. Participant Who Does Not Wish an Alternate Shopper

Place a blank proxy form marked "None" in the record or "proxy file".

5. Update of Proxy Forms

(a) Proxy forms must be updated at every recertification appointment.

(b) Any additions / deletions made must be reflected in the proxies of other family members and include staff’’s signatures and date when adding a new family member.

B. Temporary Identification Folder

1. A temporary ID folder may be issued to a payee alternate (other than the alternate on the regular ID or in the case of no alternate on the regular ID) if the alternate applies at a WIC agency with a signed Request for proxy form, WIC-7C, from the payee, along with the payee's regular I.D. folder.

2. The WIC worker, upon receipt of the regular ID and the signed Request for proxy form, will prepare a temporary ID. The worker will fill in payee name, WIC number, alternate name, date issued, expiration date (may not exceed 30 days), and authorizing agent signature. The WIC worker will require the alternate to sign under Alternate Signature before leaving the office. The Alternate will be instructed that he/she must obtain the payee's signature before the ID folder becomes valid.

226 CERTIFICATION PERIODS

A. Program benefits should generally be based upon certifications conducted in accordance with the following time frames:

1. The recertification date for pregnant women is up to six weeks after the expected delivery date. The delivery and recertification dates may be changed for suitable documented

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reasons. The women should be promptly reevaluated at the recertification date for certification as postpartum or breastfeeding. (Note, federal regulations allow for certification for up to six weeks postpartum but this should only be used in special situations). All postpartum women shall be recertified along with their infants so that their WIC category is reflective of their current infant feeding status. This will ensure that breastfeeding rates are more accurately reported and will also ensure they receive the most appropriate food package.

2. Postpartum women may be certified for up to 6 months postpartum.

3. Breastfeeding women shall be certified for up to the child’s first birthday.

4. Extended Certification: WIC Infants less than 6 months of age shall be certified until their first birthday. Their Extended Certification period will end on the month of their first birthday.

Ensure these infants are provided with:

Quarterly nutrition education contacts including follow-up Nutrition Assessment with anthropometrics. (See Section 430-Nutrition Education)

Available and continuous health care services. (See Section 410-Health Care Support)

After the initial Extended Certification Period, all repeat certifications will occur at 6 month intervals.

Standard Certification: Infants 6 months of age or older shall have Standard Certification periods ending no later than 6 months from the certification date.

5. Children should be certified at intervals of approximately 6 months and ending on the child's fifth birthday.

B. If the certification period of a priority I, II, or IV infant extends beyond the change of WIC category, from infant to child, the priority will be continued until the next certification is performed. Priorities will only be changed at recertifications.

C. Anthropometric measurements required for certification may precede the date of certification by up to 60 days. Hematocrit/hemoglobin measurements must follow the CDC’s periodicity table and must be received in the WIC office by up to 90 days from date of certification. Elevated blood lead data may be up to six months old.

Medical data on pregnant, breastfeeding, and postpartum women must both be taken within 90 days of certification and be reflective of their status at the time of certification. Pregnant women should be certified until the end of their pregnancy and up to six weeks after.

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D. Variable Certification Periods and Benefits:

1.

Eligible applicants living in a homeless facility or institution which is not listed as authorized or unauthorized by the State or in a facility because there is no other shelter alternative available in the local agency's service delivery area, should be certified for a full certification period. The State agency should be notified so that compliance with required conditions can be determined. If a homeless facility has been determined to be unauthorized, because of non- compliance with required conditions, certification should continue to the end of the certification period for residents of that facility. WIC certified residents of such a facility or one which ceases to be authorized by the State agency, during the course of the participant's initial certification period, may apply for continued benefits and can be certified again, but issuance of WIC foods, except infant formula, should be discontinued until the accommodation's compliance is achieved or alternative shelter arrangements are made. If certified under those conditions the participant should continue to receive all other WIC benefits, such as nutrition education and health care referral services. Provide such participants with information about any other overnight facilities in the area which are authorized by WIC (see Appendix Section 200 for list of WIC authorized facilities).

2. Applicants who may have a temporarily low income, such as strikers, may be given a shorter certification period based on an anticipated increase in income sooner than six months after the date of certification.

3. Persons transferring from other states authorizing longer infant certification periods and who present a valid VOC card must be certified for such longer certification periods.

227 REAPPLICATION

It is a goal of the WIC Program to reach all persons having the greatest nutritional risk and need for benefits. Since funds are not available to serve all of those in need who are otherwise eligible for the program, each person's need must be evaluated in light of the need of other persons who have applied at the agency for program benefits. The evaluation of nutritional risk at the time of the reapplication, then, must take into consideration the nutritional risk of other persons on the waiting list.

Advise all participants at the time of application and reapplication of the possibility of termination should other persons on a waiting list have a greater nutritional risk.

Each participant shall be notified at least 15 days prior to the expiration of each certification period that eligibility for the Program is about to expire.

For non-English speaking persons, translated notices are available for information purposes. The signed

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document, a copy of which is filed in the record, should be the translated version. A. Persons Appropriate for Reapplication 1. The local agency will give or mail to the participant due for recertification a WIC-8 Reapplication form and WIC-2B or 2A Physician Referral for. A copy of the WIC-8 is kept in participant file or reapplication folder.

2. Participants appropriate for reassessment shall be given a reapplication appointment as stated in procedures for "Determination of Eligibility" (Section 210). Include the appointment date on the WIC-8.

3. Proceed with eligibility determination procedures for categorical, residential, and income eligibility requirements.

4. For participants still eligible according to these criteria, the condition(s) of nutritional risk must be re-evaluated. If Medical/Nutritional information from an outside health provider is needed, instruct the participant to have the health provider complete the WIC-2B or 2A form.

5. If a person does not appear for reapplication or does not provide required information, check to ensure a copy of the WIC-8 is in the record. The participant will be terminated automatically by the computer.

B. Persons Being Recertified:

1. Check identification folder and issue a new one if necessary.

2. Complete the Eligibility Agreement (1 copy to participant, 1 copy to record).

C. Persons Not Being Recertified 1. If the participant is not going to be recertified due to ineligibility based on category, income, residence, nutritional risk or lower priority classification than individuals on the waiting list, program termination procedures will be followed.

2. Complete WIC-9B Program Denial/Termination (1 copy to participant, 1 copy to record).

3. Computer will terminate automatically.

4. Give Fair Hearing information and place on Waiting List, if there is a nutritional risk.

Note that the 15 day notification requirement is met if the person was issued Reapplication Notice (WIC-8) at least 15 days before end of Recertification Due Date.

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230 TERMINATION FROM PROGRAM

A.

Reasons for Termination

01 Categorically Ineligible 02 Delayed Blood Work Overdue 03 Fraud or Abuse 04 Incomplete Certification 05 Moved Out of State 06 Non-participation 07 Not Recertified 08 Other 09 Over Income 10 Participant Died 11 Participant Requested Termination 12 Placed on Waiting List 13 VOC Recertification 14 Woman Stops Breast-feeding After 6 Months

B.

For non-English speaking persons, translated notices are available to be given for information purposes. The signed document, to be filed in the record, should be the English language version.

C.

Termination During Certification Period

1.

Participants should be terminated (disqualified) during the certification period for termination reasons 01, 02, 03, 05, 06, 09, 10, 11, and 14 above (230A) based on the evidence of changes in circumstances received by the local agency. However, persons certified because of adjunctive eligibility with RI Works, SSI, Medicaid, and SNAP can not be terminated at mid-certification solely based on cessation of benefits from one or more of those programs. Such terminations need to be carefully evaluated for regulatory and procedural requirements (Abuse-Sec. 242, Income-Sec. 212 No.8). Other reasons may include, but are not limited to; voluntary withdrawal, changes in breastfeeding status, refusal to give residence information after moving, living in a homeless facility or institution which has lost its authorization with WIC or not making available and/or refusing to utilize supplemental foods on a continued basis.

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-2- Termination during a certification may not be done for caseload management reasons without specific authorization from the state agency.

2.

Funding Shortage

If the state agency experiences funding shortages, Program benefits may be discontinued to a number of participants. This procedure may only be carried out upon and in accordance with direction by the state agency. No new participant may be added during the period of such discontinuance.

If benefits are discontinued during a participant's certification period provide the participant with a copy of the WIC-9A, Program Denial/Termination form at least fifteen (15) days before the termination is effective. Retain one copy in the participant's file for documentation. Enter the code "07" in the QWIC demographic screen.

3.

Failure to Pick Up Checks

The Eligibility Agreement serves as notice to participants that they will be terminated if they fail to pick up checks two (2) months in a row.

4.

For others found ineligible for the program during the certification period:

(a) Complete two copies of the Program Denial/Termination form (Appendix WIC-9A). Retain one copy of the form in the person's file for documentation.

(b) Provide the participant with a copy at least fifteen (15) days before termination. At the same time, provide the person with the Fair Hearing Information form. A Request for Fair Hearing form should be provided if the person wishes to appeal. Exception: If a homeless facility or institution losses its authorization for WIC, all participants residing in it must receive 30 days notice of the need to sever connection with the homeless facility or institution or be terminated. Provide such persons with a Program Denial/Termination form

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-3- explaining the circumstances and informing them about any other overnight facilities in the area which are authorized by WIC. If a participant becomes homeless after having been certified for WIC and moves into a homeless facility or institution he/she shall be allowed to complete the certification period regardless of whether the facility is a WIC authorized homeless facility.

D. Termination at End of Certification Period

1. If a participant is not going to be considered for recertification due to categorical ineligibility or to ineligibility due to having a lower priority classification than individuals on the waiting list:

(a) Complete two copies of the WIC-9A, Program Denial/Termination form. Retain one copy in the participant's file for documentation.

(b) Provide the participant with a copy at least fifteen (15) days before the expiration of each certification period.

2. Recertification being considered

(a) Complete two copies of the WIC-8, Reapplication Notice. Retain one copy in the participant's file for documentation.

(b) Provide the participant with a copy of Reapplication Notice at least fifteen (15) days before the expiration of the certification period.

(c) Follow recertification procedures (Sec. 226 - Reapplication).

E. Documentation of Termination

In addition to completion of forms mentioned above, documentation of some terminations should be included in a progress note. A progress note should be written if the participant is terminated for:

06, no check pick-up for 2 months 07, failure to recertify

Progress notes should include the following:

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- date of documentation - specific reason for termination from the Program must be written out. Do not use codes. - signature and title of WIC staff person

All termination codes must be entered into the RI WEBS system, on the demographic screen.

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240 PARTICIPATION PROCEDURES

241 Participant Transfers and I.D. Number Changes

A. Verification of Certification Reports

Verification of Certification (VOC) reports are used in each of the Rhode Island WIC Programs. These cards are completed for WIC participants who are relocating to areas outside the State of Rhode Island or those eligible for the WIC Overseas Program.

WIC participants from other jurisdictions with current Verification of Certification cards or Department of Defenses Verification of Certification Report (VOC), must be enrolled in local agency programs in the next available funded opening. If placed on a waiting list, the transferring participant shall be placed ahead of all waiting applicants regardless of their nutritional risk criteria.

The local agency must accept verification of certification as proof of eligibility until expiration of the certification period.

If the applicant lacks a VOC report, local staff may call or write to the transferring agency to obtain or verify needed information. If required by the out of state agency, send an Authorization To Obtain Confidential Information form (WIC-24) signed by the caretaker/applicant. Such Transfers are to be enrolled as soon as information is sufficient.

B. In State Agency Transfers

1. Transferring Agency

(a) When a participant requests a transfer to another agency, select the appropriate agency for transfer.

(b) Call to notify the receiving agency of the transfer and to give the participant's name and I.D. number. Make an appointment for the participant at the receiving agency, if appropriate. If participant is due to recertify the same month, the Payee should keep the existing recertification appointment(s) and then transfer.

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-2- If checks are due to be issued, give one month, thereby giving receiving agency time to get client into RI WEBS system.

(c) Do not terminate the transferring participant from your caseload. Put a termination notice in the chart and give one to the participant.

(Note: The receiving agency must put the participant's I.D. number into the computer to pull the chart into their agency when transferring the participant.)

2. Receiving Agency

(a) When receiving a participant transfer, enter the participant number into the computer. The participant must receive the next available opening, regardless of priority. Use the full 8 digit number from the old agency.

(b) Document proof of residency and identity on the Eligibility Agreement form. Have Payee sign the Transferring Agreement and give a Proxy form to be completed.

(c) Note completed transfer in the progress note. Issue an ID Folder to the participant.

C. Out of State Transfers

1. Transferring Agency

(a) If a participant requests a transfer out of state, determine the date of the move and the last set of checks to be issued from the transferring agency. Checks may be issued up to the day the person moves from the state.

(b) Print a VOC report and give it to the participant after issuing the last set of checks. Follow instructions as follows:

i) The authorized agent must request the VOC in person and present an ID. If an authorized agent cannot request a VOC

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-3- report in person, the report must be sent to the specified out- of-state agency directly. Only the receiving agency or the authorized agent may make this request.

(ii) The person printing the VOC report is the local agency official. The official's name should be printed clearly above his/her signature on the paper.

(c) Terminate the participant.

(d) If a transferring participant or a WIC program in another state requests any information about a participant, such information may be transferred either to the participant (or guardian), or, for purposes of coordination of health care, to qualified personnel and health care providers within the health care system. No information may be given to any other party unless the request is made by the participant/guardian or a proper release of information form is received (Section 243).

2. Receiving Agency

(a) When receiving a participant transfer, enter the participant on the computer. The participant must receive the next available opening, regardless of priority. If the VOC report is incomplete, attempt to verify missing information. However, if the VOC card includes the minimum requirements of the participant name, when the certification period ends, and the name and address of the local agency, the next available opening must be given to the participant. Individuals presenting a valid VOC report must provide proof of residency and identity.

(b) Document Proof of residency and identity in the computer. Have Payee sign an Eligibility Agreement for any person transferring into the agency. Also give Payee A Proxy form to be completed.

(c) Staple the VOC report to the participant chart if out of state. Issue an ID folder to the participant.

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D. Department of Defense WIC Overseas Program

The Department of Defense (DoD) is authorized by law to establish and operate a program like WIC, using DoD funds, for United States (U.S.) active duty military personnel and other support staff stationed overseas and their dependents.

The Transferring Agency

1. State and local agencies must issue WIC VOC reports to WIC participant affiliated with the military who will be transferred overseas. 2. WIC clinics are not responsible for screening and determining eligibility for WIC Overseas Program eligibility. 3. WIC participants issued VOC reports when they transfer overseas must be instructed of the following: a. There is no guarantee that the WIC Overseas Program will be operational at the overseas site where they will be transferred b. By law only certain individuals are eligible for the WIC Overseas Program c. Issuance of a WIC VOC report does not guarantee continued eligibiltiy and participation in the WIC Overseas Program. 4. All information on the VOC card must be completed, because WIC Overseas Program personnel cannot readily contact a WIC Program to obtain further information. All VOC reports must contain the following: a. The name of the participant b. The date the certification was performed c. The date income eligibility was last determined d. The nutrition risk conditions of the participant e. The date the certification period expires f. The signature and printed or typed name of the certifying local agency official g. The name and address of the certifying local agency h. An identification number or some other means of accountability Special emphasis should be place on ensuring local agencies specify the nutrition risk conditions on the VOC report and avoid the use of codes. 5. Follow the procedures described for an out of state transfer.

Acceptance of WIC Overseas Program VOC Reports

1. State and local agencies must accept a valid WIC Overseas Program VOC report presented at a WIC clinic by WIC Overseas Program participants returning to the

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-5- U.S. from an overseas assignment. 2. In accepting a VOC report, minimally the following elements on the cards are absolutely essential: a. The participants’s name b. The date the participant was certified c. The date that the current certification period expires WIC Overseas Program participants arriving in a WIC clinic and showing a VOC report with only these three pieces of information should be treated just as if the VOC card contains all of the required information. 3. Individuals presenting a valid VOC report must provide proof of residency and identity, with limited exception, in accordance with WIC Program regulations and policies. 4. Follow the procedure for an out of state transfer as outlined above.

242 Program Violations or Abuse/Multiple Participation

A. Local Agency Procedures for Minimizing or Determining Abuse or Violations

As the primary contact with participants, and source of information given to participants, local agencies play a crucial role in preventing, uncovering, and correcting participant violations of Program procedures. Local agency activities should include the following:

1. Careful documentation of income, nutritional risk, and other eligibility data.

2. Educational efforts and provision of materials aimed at making participants aware of Program rules, regulations, and correct redemption practices, and of the importance of these rules to themselves and the Program.

3. Review of check redemption practices and utilization of supplemental foods.

4. Developing a relationship with participants, based on mutual concern and interest in the nutritional benefits and integrity of the Program, which encourages the flow of information regarding participant and vendor practices through:

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-6- a. periodic interviews regarding shopping and redemption practices and vendor practices.

b. specific interviews when requested by the state agency regarding specific concerns.

c. reporting data obtained in a usable manner to establish conclusions about participant or vendor practices and as evidence in subsequent actions.

d. obtaining statements from participants when an investigative action has been initiated.

B. Program Abuse

(All references to "Participant" also apply to any parent, guardian, payee, applicant, or alternate shopper as appropriate).

1. Definition of Abuse and Violation

CATEGORY I Participant abuse of the Program, Category I, includes, but is not limited to, knowing and deliberate:

a. Misrepresentation of circumstances or concealing or withholding information to obtain benefits.

b. Sale or exchange of supplemental foods or food instruments with any individuals or entities except those duly authorized to receive checks or foods and in accordance with WIC Program rules.

c. Receipt of credit or refund in exchange for WIC food instruments or food items from any party.

d. Dual/Multiple Participation (C below).

e. Committing a Category II violation after having been warned or disqualified for a previous Category I or II violation or committing a total of three Category II violations separately or in combination.

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f. Committing two Category III violations following any disqualification for violation(s).

g. Physical abuse, or threat of physical abuse of Program, clinic, or vendor staff.

h. Failure by the participant to utilize, or failure of the payee to make available to the participant, the supplemental foods in any month.

i. Participating in WIC at any local agency while disqualified at any local agency.

CATEGORY II

Violations of Program rules, Category II, shall include but not be limited to committing or attempting:

a. Misuse of food instruments or supplemental foods, other than a Category I violation.

b. Purchasing food or other items other than the authorized allowed WIC supplemental foods.

c. Redemption of checks outside the use dates listed on the check.

d. Redemption of WIC checks after they have been reported lost/stolen.

e. Committing a Category III violation after having been warned or disqualified for any violation or committing a total of three Category III violations, separately or in combination.

f. Signing the check before the price of the WIC food is entered on the check or when not in the presence of the store personnel.

g. Redeeming WIC checks with anyone other than a vendor which is authorized to accept Rhode Island WIC checks.

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2. Procedures

a. When evidence of possible abuse or violations is uncovered, the local agency shall consult with state agency staff concerning a course of action.

b. When the evidence is lacking, or when further action is counter to the effective and efficient administration of the Program action by the local agency may be deferred or halted. Further efforts may be made to verify or monitor possible abuse or violation.

c. If a finding of abuse cannot be substantiated, or if other mitigating circumstances exist, the local agency will counsel the participant:

i. Inform the participant that there is some evidence that abuse or violation may have or has taken place.

ii. A participant may not be required to admit to guilt.

iii. Warn the participant that any information given may be used against him/her in determining sanctions or in any appeal proceedings.

iv. Inform the participant as to the practice or practices which are abuses or violations of the Program and the penalties of disqualification and/or prosecutions which such practices may result in. Describe the correct procedures to be followed by participants in obtaining and utilizing benefits, including the reasons.

v. Offer the opportunity to ask any questions concerning the matter.

vi. The content of the counseling session, any warnings and the participant's response should be carefully documented in the record. If requested, forward a copy to the state agency.

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-9- vii. If the participant refuses to cooperate with the counseling process, review the case for possible disqualification from the Program, based on the available evidence.

d. If a finding of abuse or violation can be substantiated, sanction procedures may be initiated.

e. If needed, the local agency may request advice or assistance from the state agency, at any point.

3. Sanctions

a. Authority - Local agency appropriate sanctions for abuse or violations of the Program in accordance with this procedure. The local agency shall confer with the state agency, before imposing any sanction. The State Agency reserves the authority, in particular instances, to direct that sanctions be imposed by the local agency or that sanctions be modified or not imposed.

b. When sanctions are to be imposed, the local agency shall notify the participant by registered mail, return receipt requested, that there is evidence that he/she has engaged in violation(s) or abuse of the Program. Notice of imposition of the sanction may be included or deferred until further steps are completed.

c. The participant should be advised of the sanction to be imposed for the abuse or violation, and/or the effective date of the sanction (giving at least fifteen day's notice). He/she should be offered an opportunity prior to the imposition or effective date of the sanction to meet in conference to present any information or evidence that the information is in error, that the violation did not take place, that extenuating circumstances exist, or that severe hardship or serious health risk may result from Program disqualification.

d. The competent professional authority shall determine whether a serious health risk may result from Program disqualification.

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e. The local agency may consider a serious health risk to the participant and other relevant factors in determining whether or not the sanction should be waived in a particular case.

f. If restitution by the participant is required under section 246.23(c) of USDA Regulations such restitution will be in cash and will equal the value of Program benefits improperly issued unless it is determined that the recovery would not be cost effective.

g. If not waived or modified, the following sanctions shall apply:

Category I - Disqualification for three months and, if appropriate, restitution of the value of benefits improperly issued.

Category II - Disqualification for one month and, if appropriate, restitution of the value of any benefits improperly received.

h. In the event of physical abuse or threat of physical abuse of staff (1.,f., above), the sanction may be imposed without offering a conference as above (3, c), or despite a determination of health risk (3, d), if appropriate to protect the safety of staff. Notify the participant as in 3, j below. Such abuse during a certification appointment may prevent the completion of the certification/recertification and lead to denial of eligibility or failure to recertify.

i. Before disqualifying a child participant, the local agency may determine whether the abusive person can be excluded from the agency and an acceptable alternative payee utilized.

j. If not already accomplished, the participant shall be given fifteen day notification by certified mail, return receipt requested, of the implementation of the disqualification from the Program. Any notice of violation or disqualification shall include the Fair Hearing statement, request, and information forms. Specify the date that the person may reapply for the

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-11- Program. This date should allow for enough time in advance of the end of the disqualification period for the person to be reinstated in the following month.

k. After this period, the local agency shall review the eligibility of the participant as a new applicant.

C. Dual/Multiple Participation

1. The Rhode Island Department of Health WIC Office should print monthly printouts of all possible dual participants.

2. Whether discovered through participation reports or other sources, once dual participation is verified, do not issue checks. The local agency with which the participant has the next scheduled appointment or check pickup shall:

(a) Discuss dual participation with participant.

(b) Inform participant that dual participation is not allowed.

(c) Have participant determine which agency he/she prefers.

(d) Retrieve WIC ID folder of other agency and send it to the Rhode Island Department of Health WIC Office.

(e) Determine with the state agency whether checks should be issued. The dual benefits received should, in most cases, be applied towards the current or next month.

(f) Notify in writing the state agency as to local agency preference, and steps that have been taken.

(g) Terminate the participant from one agency.

3. The circumstances of the dual participation will be reviewed by a state supervisor and local agency liaison and the local agency. This review will especially include a determination as to whether the child participants have been receiving the supplemental foods.

4. The state and local agency shall then determine the severity of the

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-12- violation, procedures to be followed, and sanctions, if any, to be imposed (see procedures for B. Program Abuse, above and D, Other Violations...,below).

5. If the participant refuses reduction of service to one local agency or persistently denies dual participation, in the face of conclusive evidence or there is evidence of deliberate dual participation, a supervisor at the State agency and the WIC coordinator at the local agencies involved shall review the case for disqualification from the Program.

D. Other Violations of Program Rules

CATEGORY III

1. Violations of Program rules, Category III, shall include but not be limited to:

a. The violations described above where evidence indicates absence of intent or deliberateness or where other extenuating circumstances would not support a conclusion of Program abuse.

b. Failure by the participant to utilize, or failure of the payee to make available to the participant, all of the supplemental foods in any month.

c. Failure to inform the local agency of a change in address, residence, or other circumstances which might have an effect on eligibility.

d. Failing to report any unused WIC foods to the local agency WIC staff.

e. Any other violation of Program regulations, rules, or procedures, not classified as Category I or II.

f. Attempting any violation of Program rules.

2. When there is reasonable evidence of such violations, the local

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-13- agency will notify the participant (contact, telephone, mail etc.) and offer an interview to consult with and counsel the participant covering relevant topics, such as:

a. What occurred and where in a manner indicating that the participant is given the benefit of the doubt.

b. Advise the participant that the practice is in violation of Program regulations or procedures and warn that person that any information given may be used against him/her in determining sanctions or penalties or in any subsequent appeal procedure, and of the penalties that may be instituted for such practices.

c. Counsel and educate the participant on the proper procedures to be used, indicating the correct procedures and why they are necessary. Offer the participant the opportunity to ask any questions and answer them.

d. A determination will then be made of the participant's intention, the severity of any violation, and of the participant's cooperation in attempting to change the practices. The local agency will then take appropriate additional measures as warranted.

e. Additional measures may include:

i. A warning letter, indicating further violations would be grounds for more severe penalties or for establishing a case of abuse.

ii. Cancellation of checks or reduction or deletion of items in the food package as determined by the competent professional authority as being unusable, unneeded, excess benefits, or not being made available to the participant.

iii. Disqualification for one month if the investigation or review reveals that the participant is ineligible or violates Program rules, regulations, or requirements twice within a 24 month period. Disqualification for

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-14- three months for three violations within a 24 month period.

iv. If restitution by the participant is required under section 246.23(c) of USDA Regulations such restitution will be in cash and will equal the value of Program benefits improperly issued unless it is determined that the recovery would not be cost effective.

f. Document in the record the efforts for counseling, content, and the response of the participant.

E. Prosecution of Fraud and Abuse

1. All instances of fraud, abuse, misrepresentation, etc. must be reported to the State WIC Office.

2. The State Agency may, at its discretion, refer cases which appear to violate the provisions of RIGL Section 23-13-17 may be referred to federal, state or local authorities for prosecution.

F. USDA "Whistle Blower Hotline" for Fraud Control

Reports of fraud or abuse are usually handled by the local or state agency. Participants or other citizens may, if they prefer, report suspected fraud by stores or participants to the USDA by calling the toll free hotline (1-800-424-9121) or writing to:

United States Department of Agriculture Office of Inspector General PO Box 23399 Washington, DC 20024

They may remain anonymous. They should try to give details of the fraud or abuse such as names, places, times and other information.

243 Guidelines for WIC Medical Record Organization

Each local agency should have a method of organizing records which is suitable to the

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-15- individual needs of the agency. (Note: See Section 600 re: Retention of Records)

The advantages of having a system of WIC medical record organization are as follow:

1. All records are in uniform order

2. Local agency personnel know where to find forms

3. Records are organized for outside auditors

4. Easy to recognize missing forms

5. If record is bound, less likely to lose forms

A medical record has many purposes, below a few are listed:

1. Communicates with other members of the health care team such as nurses, social workers, clerks, nutritionists. Verbal communication is informative but is often sporadic due to time limitations. Verbal communication never replaces the need for written documentation which has the potential to reach all members of the health care team.

2. Monitors a participant's progress while participating on the Program.

3. Integrates care for the individual participant. Promotes and assists coordination between WIC staff and health care team.

4. Documents communications with participant.

5. Refreshes memory regarding participant before a recertification or second nutrition education visit. Ideally, previous SOAP notes should be reviewed before seeing the participant. This makes the patient feel comfortable and it reinforces that the nutritionist cares about the patient.

6. Documents compliance with professional, legal and regulatory standards. Provides protection against liability and sanctions. Permits quality assurance.

Many WIC medical record formats are possible. Records may be bound in the center or at the top of the folder. If individual agencies would like assistance in designing a system suitable tot he needs of their agency contact the state WIC office.

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-16- The following are recommendations of recognized authorities and this office in terms of medical records:

1. All progress notes and high risk care plans should be entered into the computer.

2. Have all WIC forms from the certification period together in the supporting documents section of the medical record. Each agency should establish an order for the WIC forms in the medical record and have all records in this order for subsequent certifications.

Progress Notes (WIC Nutrition and Risk Assessment forms WIC -3B, 3C, 3D, 3E).

The dictionary definition of progression is sequence. SOAP notes should show a progression or sequence of events from first visit to termination from the Program. All significant actions or sessions with the participant should be recorded in the progress notes. Local agency nutritionists should record DNKAS, terminations, non-standard food package changes, transfers into or out of an agency, and prorating of checks.

Progress Note Dos:

1. Do record information in chronological order.

2. Do accurately and carefully record data obtained through interview, observation, and measurements.

3. Do be brief without sacrificing essential information or facts.

4. Do document opinion if it is your professional opinion.

5. Do record all visits with the participant.

Progress Note Do Nots:

1. Do not use white out in progress note or in any part of the WIC record. If a mistake is made, draw one line through the mistake, initial it and write correct information.

2. Do not use professional jargon as those outside the profession may not understand.

3. Do not use unconventional abbreviations. Refer to following list of accepted abbreviations - use only these in the progress notes.

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-17-

4. Do not be critical of treatment carried out by others.

5. Do not make remarks that would indicate bias against the participant.

Progress notes are to be done using the SOAP format. SOAP note format should include the following:

S: Subjective information that the CPA observes ie: overweight, underweight, etc.

O: Objective information that is measurable ie: height, weight, hematocrit, etc.

A: Assessment. Write an assessment of the client's nutritional status based on the subjective and objective information.

P: Plan. Set out the plan of care and action that the client chooses to address which may or may not have been elicited from the nutrition assessment.

Supporting documents

The following is a listing of some WIC forms which will be found in the supporting documents section of the WIC medical record and recommendations for their use.

1. WIC Nutrition and Risk Assessment Forms (WIC 3B, 3C, 3D, 3E)

2. Eligibility Agreement - a copy of this form must be filed in each participant record for every certification. Also, if two family members are in for certification on separate days, a new agreement needs to be filled out for each day's appointment.

3. Proxy form - one form is required for each family. The form must list all participants receiving WIC in that family. If the copy will be kept only in one family member's record, it must be cross-referenced in the remaining family members' records. If a new proxy is desired, a new form must be completed and all old forms are to be kept as a permanent part of the record. If a payee does not want an alternate shopper, a copy of the proxy form should be signed by the payee with none listed as the alternate shopper.

4. Recertification notices- recertification notices must be kept in the record. If the physician sends information in for the participant that form must also be filed in the record.

5. Termination/denial notice - a copy must be kept in each participant record.

6. Medical verification for special formula or medical conditions must become a permanent part

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-18- of the medical record.

244 Confidentiality and Release of Health Care Information

A. Confidential health care information means all information relating to a patient's health care history, diagnosis, condition, treatment or evaluation. Disclosure of other information obtained from applicants or participants, including name or address, is also to be restricted as described below.

B. Limitations on Disclosure

(1) Each agency shall restrict the use of disclosure of information obtained from Program applicants or participants to persons directly connected with the administration or enforcement of the Program and to those public health or helping organizations listed on the Participant Agreement which the state agency has designated, for purposes of establishing eligibility for other programs or services which may be of help to the participants for such programs.

(2) Any person seeking permission to inspect WIC records shall provide his identity and shall state his reasons for making such a request.

(3) A patient's confidential health care information shall not be released or transferred without the written consent of such patient or his authorized representative, on a consent form meeting designated requirements. (See (4) below).

(4) Consent forms for the release or transfer of confidential health care information shall contain the following information.

(a) A statement of the need for and proposed uses of such information.

(b) A statement that all information is to be released or clearly indicating the extent of the information to be released.

(c) A statement that such information will not be given, sold, transferred or in any way relayed to any other person not specified in the consent form or notice without first obtaining the individual's additional written consent on a form stating the need for the proposed new use of such information or the need for its transfer.

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-19- (d) A statement that the consent for release or transfer of information may be withdrawn at any future time.

C. Use of WIC Eligibility Agreement Release of Confidential Information

1. The patient, or the patient's authorized representative, should be given a copy of the Eligibility Agreement in the appropriate language, to read. If he or she is unable to read, and understand the form, an appropriate explanation of its contents should be given, so that the rights of confidentiality are understood.

2. All WIC applicants or their guardians must sign an English language eligibility Agreement form which must be filed in their records. The completed form in the record will suffice for requests by federal, state, or local Rhode Island WIC Program agencies or authorized agents, staff, or representatives, or authorized agents of the Rhode Island Department of Health. The form must be witnessed and signed by a WIC staff person.

3. An Eligibility Agreement form, if the patient is unable to sign it, must be signed by he patient's authorized representative. Parents or authorized representatives may sign for or on behalf of minors. For persons legally incompetent to affix their own signature, a reason why the patient cannot sign must be supplied.

4. An Eligibility Agreement form, in the event that the patient is competent but cannot sign by written signature should be marked by the patient with an (x). Such signature must be witnessed and signed that the patient is unable to affix her written signature.

5. For WIC related confidentiality purposes, the form need only be signed once, unless there is a participant or payee name change, a change in guardianship or the release is withdrawn in writing. A copy of any such withdrawal must be filed in the record. Invalid release forms should be voided and kept in the record.

6. If the consent is withdrawn, however, the agency must review whether the withdrawal prohibits the determination of eligibility or Program compliance, or whether information is denied that is needed to implement, administer, enforce, or monitor the Program. Such withdrawal may be grounds to terminate participation.

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-20- 7. A patient's confidential health care information shall not be released or transferred without presenting the written consent of such patient or his authorized representative, on a consent form meeting designated requirements (see B. (4) above).

8. A WIC patient or the authorized representative of such WIC patient may review the patient's record at any time so long as it is in the presence of a WIC official or competent professional authority. Copies of health care information appropriate for release, subject to the execution of a proper authorization, may be supplied, upon request, to the patient or patient's authorized representative at the usual or customary cost.

D. The WIC Eligibility Agreement (WIC –5) provides consent for releasing medical, nutritional and/or demographic information from the WIC record to:

1. Public Welfare Programs through the RI Department of Human Services – Food Stamps, Medicaid and Family Independence Program, 2. Public Health Programs through the RI Department of Health –Early Intervention, Lead Poisoning Prevention and Family Outreach Programs 3. University of Rhode Island – Cooperative Extension Program, 4. Other programs the participant agrees to be referred to, 5. The participant’s health care provider.

i. The WIC Eligibility Agreement does not provide consent for WIC data to be shared with third party entities. An example of a third party entity would be Head Start or Lead Centers.

ii. To obtain parental / guardian consent for sharing WIC data with third party entities, an additional written consent form is required (WIC – 101).

iii. The Third Party Program Release Authorization Form ( WIC 101) should not be given until the WIC applicant’s eligibility has been determined. The participant or the participant’s authorized representative’s decision to authorize or deny release of WIC Program information to a Third Party should have no impact of their eligibility determination.

iv. The participant, or the participant’s authorized representative, should be given a copy of the Release Authorization Form in the appropriate language, to read. If he or she is unable to read, and understand the

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-21- form, an appropriate explanation of its contents should be given, so that the rights of confidentiality are understood.

v. Once the WIC – 101 has been completed it must be updated by the parent / guardian at subsequent re-certifications and kept on file.

vi. If the consent is denied, the agency must forward this information to the State WIC Office on a regular basis.

vii. This permission may be withdrawn in writing at any time.

E. Penalties

1. Under the Rhode Island Confidentiality of Health Care Information Act (5- 37.3) the following penalties apply:

(a) Civil Penalties--"Anyone who violates the provisions of this chapter may be held liable for actual and exemplary damages."

(b) Criminal Penalties--"Anyone who intentionally and knowingly violates the provisions of this chapter shall, upon conviction, be fined not more than one thousand dollars ($1,000), or imprisoned for not more than six (6) months or both."

(c) "The civil and criminal penalties above shall also be applicable to anyone who obtains confidential health care information through the commission of a crime."

(d) "Attorney's fees may be awarded, at the discretion of the court, to the successful party in any action under this chapter.>"

2. Local agencies which violate state or federal laws or regulations concerning confidentiality can be subject to penalties as provided for in the WIC Local Agency Agreement and said laws and regulations

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- 1-

250-Operating Standards / Organization of WIC Staff Activities

251 Organization of WIC Staff Activities

A. General

Local agencies should set staffing patterns that most effectively use personnel resources and are in compliance with federal regulations and state rules and procedures. It is the local agency's responsibility to establish a staffing structure to operate efficiently and effectively within WIC rules and regulations given financial resources, agency organizational factors, and capabilities of available personnel.

B. Illustrative Responsibilities

For local agencies who employ staff with different qualification levels, the following position responsibilities are illustrative of those that can be delegated to each staff level:

1. Clerical and Support Staff Activities

- Administrative Tasks:

- Maintain appointment booking system and smooth patient flow. Participate in strategies to reduce no-show rates.

- Distribute WIC checks and maintain E-pad signatures.

- Document in client's individual chart when appointments are not kept.

- Maintain filing.

- Participate in agency outreach efforts.

- Prepare individual client file for use by competent professional authority during appointment.

- Prepare, distribute, and file recertification and termination notices.

- Maintain clinic supplies. Reorder when necessary.

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- 2-

- Assist with other clerical office duties as needed.

Certification:

- Verify applicants' proof of residency, income, and identification. Complete Applicant Agreement Form.

- Weigh and measure using standardized measuring techniques. Enter information into RI WEBS database.

- Perform finger stick to obtain blood sample and determine hemoglobin from sample.

- Complete confidentiality forms.

- Explain use of alternate shoppers and maintain completed alternate shopper forms in each client individual chart.

- Issue WIC I.D. card and V.O.C. documents to WIC participants.

WIC Participant Orientation:

- Describe the application process and benefits of the WIC Program.

- Acquaint participants with WIC Allowed Foods.

- Inform participants of their rights and responsibilities.

- Inform participants of how to use WIC checks.

- Provide translation of nutrition counseling for competent professional authority when needed (if bilingual).

2. CPAs Level I and Level II (Nutrition Assistants)

CPAs - Levels I and Level II may have the same responsibilities as clerical and support staff plus some responsibility for certification and nutrition education. Any agency which employs CPAs Level I and Level II must have a CPA-Level III (Nutritionist or Nurse) on staff in WIC to supervise the work of the CPA-Level I/II.

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- 3-

CPAs - Level I may certify and provide counseling to participants at secondary risk only.

CPAs - Level II may certify and provide counseling for participants at secondary- or high-risk.

CPAs - Level I

In addition to the responsibilities listed for clerical staff CPA -Level I may also perform the following tasks:

Certification:

- Interview clients and record health intake data.

- Complete nutrition assessment forms.

- Assess health and nutrition status using anthropometric measurements, hematologic data, nutrition assessment tools, and information from physician referral forms, medical records and applicants.

- Determine WIC eligibility, assign priority and risk status, prescribe food package, complete WIC assessment and certification documentation according to State and local agency standards.

Nutrition Education and Health Care Coordination:

- Provide at least two nutrition education contacts per certification period to all participants at secondary risk.

- Provide patient centered counseling on ways to meet dietary needs appropriate for the particular life stage of the participant.

- Set goals with the participant about nutrition and/or lifestyle changes that will reduce the their nutritional or medical risk.

- Encourage prenatal care and breastfeeding to prenatal clients. Support breastfeeding and encourage regular preventive health care for infants and children.

- Provide education to clients regarding the nutritional value of WIC food and the

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- 4- supplemental nature of the WIC Program.

- Conduct group nutrition education programs or demonstrations as assigned by nutritionist.

- Assist nutritionist with the development of nutrition education materials for participants.

- Communicate with participant's physician regarding health parameters and health care needs with the assistance of the nutritionist.

- Refer participants to other health or human agency services.

- Document nutrition education and referrals in the participants' WIC record.

CPAs - Level II

In addition to the responsibilities listed for clerical staff and CPAs - level I, CPAs - level II may also perform the following tasks:

Nutrition and Health Care Coordination:

- Determine nutrition education needs and follow up care for high-risk participants. Write high-risk care plans for each high-risk participant.

- Provide at least one first nutrition education contact and one high-risk follow up appointment per certification period.

- Recommend nutrition and/or lifestyle changes that will reduce the participants' high-risk nutritional or medical condition.

4. CPAs-Level III (Nutritionists, Registered Nurses, Physicians, and Certified Physician's Assistants)

CPAs-Level III may perform all certification tasks already mentioned for CPAs-Level I and II plus these professional tasks:

- Assist CPAs-Level I and II with coordination of patients' care with other health care professionals.

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- 5- - Develop nutrition education materials for use with participants. Develop nutrition education displays.

- Plan educational activities for participants.

- Provide guidance and technical assistance to CPAs-Level I and II staff.

- Provide periodic evaluation and training for CPAs-Level I and II staff.

- Provide coordination of agency's efforts to encourage and support breastfeeding.

- Perform quality assurance for all nutrition services including nutritional assessments, standards of care, and the quality of nutrition education as assigned by agency WIC coordinator.

- Assist with program planning and administration and staff training as assigned by agency WIC coordinator.

5. WIC Coordinators

Tasks for the local agency WIC Coordinator should include direct client service responsibilities according to her or his professional qualifications, along with the following management responsibilities:

- Assure preparation and submission of annual Local Agency Nutrition Education Plan and oversee the accomplishment of its objectives.

- Evaluate and assure agency compliance with conditions set forth in the local agency agreement, federal regulations, and state rules and procedures.

- Direct quality assurance for all nutrition services including nutritional assessments, standards of care, and the quality of nutrition education.

- Provide preservice and inservice training and performance evaluations for all local agency WIC staff.

- Manage participant caseload at the local agency.

- Develop and manage systems to ensure efficient and timely appointment scheduling and patient flow and to maintain low no-show rates at the local agency.

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- Supervise WIC check delivery system at local agency.

- Act as liaison for the local agency and State WIC Agency.

- Act as liaison for the local agency with other health and human service agencies in the community for outreach and referral purposes.

- Assist Agency Director with hiring WIC staff at Agency Director's request.

- Visit satellite offices at least one day a week to maintain staff contact and address needs.

C. Educational Background and Experience Requirements for CPAs

A Competent Professional Authority (CPA) is an individual on the staff of the local agency who is authorized to determine nutritional risk, prescribe food packages, and provide individualized counseling to participants.

In the Rhode Island WIC Program nutritionists with a degree in nutrition (bachelor's or master's), registered nurses, physicians, and certified physician's assistants automatically qualify for CPA-Level III status. State and/or locally trained paraprofessionals may be authorized to perform some CPA functions provided that they meet minimum qualifications set by the State Agency; receive appropriate training, evaluation, and supervision; and meet 100% of the competency standards set by the State Agency.

1. CPAs-Level III

Nutritionists with a degree in nutrition (bachelor's or master's) from an accredited university or college and registered nurses, physician's and certified physician's assistants automatically qualify for CPA-Level III status.

2. CPAs-Level II and I (Nutrition Assistants)

Prior approval must be obtained from the State WIC Agency before a Level II/I CPA is used as a CPA. Local agencies must carefully consider the qualifications of the potential Level II or I CPA. Any agency which employs CPAs Level II or I must have a CPA Level III on staff in WIC to supervise the work of the CPA Level II or I.

CPAs - Level I

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Occasionally we are fortunate to have local agency staff who have worked in WIC clinics performing clerical or clinic assistant functions and who do possess knowledge about nutrition, maternal and child health and have the skills and personal characteristics necessary to complete quality nutrition assessments and counseling.

Candidates for CPA - Level I status must:

a. have worked in a local health center or hospital outpatient services clinic (preferably a Rhode Island WIC Clinic) for at least two years.

b. have earned a high school diploma or G.E.D.

c. demonstrate good verbal and written communication skills.

d. demonstrate a sensitivity to the needs of WIC clients.

e. show an interest in nutrition and health care.

f. be able to achieve 100% competency in all areas on the CPA-Level I Competency Form.

CPAs - Level II

Candidates for CPA-Level II status must hold the following qualifications:

a. Registered dietetic technicians who have completed an American Dietetic Association (ADA) training program in clinical dietetics and have passed the ADA registration examination for diet technicians can be considered for CPA-Level II status.

b. Students who are near to the completion of a degree in nutrition (bachelor's or master's) from an accredited university or college can also be considered. The candidate must have satisfactorily completed the following core courses:

- Introductory Nutrition (fundamental concepts of the science of nutrition and applications to health and disease).

- Two intermediate nutrition courses (at least 6 credits total) such as:

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- 8- - Nutrition in Growth and Pregnancy - Obesity and Weight Control - Advanced Human Nutrition - Nutrition and Disease - Nutrition Education - Nutrition and Aging - Community Nutrition - Physiology - Biochemistry

- At least one supporting course in an area of sociology or psychology

c. Graduate nurses who have graduated from a program in professional nursing approved by the Rhode Island Board of Nurse Registration and Nursing Education and who is eligible to take the licensing examination for the professional nurse may also be considered for CPA-Level II status.

In order to continue as a CPA-Level II beyond this provisional pre-exam period, the applicant must satisfactorily pass the examination within one year of date of hire as a CPA-Level II. Once the candidate has passed the licensing examination for the professional nurse than they will be granted CPA-Level III status from the State WIC Agency.

d. All candidates for CPA Level II status must also be able to achieve 100% competency in all areas on the CPA-Level II competency form.

D. Process to Obtain Approval for CPAs-Level II and I (Nutrition Assistants)

The approval process for CPAs-Level II and I involves the following steps:

1. Local agency submits a CPA-Level II/I Candidate Form to the State WIC Agency. This should be the first step before beginning any CPA-Level II/I training. This Candidate Approval Form provides information to the State WIC Agency regarding the qualifications of the candidate, job responsibilities, training methods and schedule, and plans for continuing supervision and evaluation of the Level II/I CPA. Assistance with developing a plan and completing the form is available from the State WIC Nutrition Coordinator.

2. The local agency must then arrange a meeting with the State WIC Nutrition

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- 9- Coordinator to discuss the information submitted on the CPA Candidate Form. Any information that needs more detail or clarification will be discussed.

3. After the meeting the local agency must submit any revisions to the CPA Candidate Form to the State Agency.

4. Once formal approval of the Level II/I CPA Candidate is received from the State WIC Agency, the local agency will then provide training to the CPA candidate using state-provided training modules according to the approved training methods and schedule in their plan. State WIC staff are available to assist with this training and have the prerogative to participate in, monitor and review any aspect of the training at the option of the State WIC Nutrition Coordinator.

5. Once training has been completed, the local agency should evaluate the progress, suitability, and competencies of the CPA candidate.

6. The local agency should then arrange a date and time for the State WIC Nutrition Coordinator to visit the local WIC agency to administer the competency-based evaluation.

The Level II/I CPA-candidate must obtain 100% competency on the competency evaluation before the State WIC Agency can authorize the candidate as a CPA.

7. Once all requirements regarding qualifications, training, and competency-based standards have been met the State WIC Agency will issue a certificate that will authorize the Level II/I CPA to perform assessment, certification, and counseling functions according to state policies and procedures.

E. Supervision of CPA-Level II/I Staff and with SNEC Training

In order to maintain the quality of WIC nutrition assessments, counseling and referrals the work of CPA-Level II/I staff must be supervised by a CPA-Level III on-site in the counseling area to enable observation of assessment, certification, and counseling activities and to provide technical assistance and follow up training as needed. The CPA-Level III may be involved in performing WIC certifications or other work but should be aware of the general counseling environment. In addition, the CPA-Level III should be available to answer questions that arise during the assessment, certification, and counseling.

Periodic evaluations of counseling practices and chart audits are an important part of quality

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- 10- assurance in a health care setting. At least twice during the fiscal year an evaluation of the work of the CPA-Level II/I involving both direct observation of certification and counseling appointments and a chart audit should be conducted so that any problems can be identified and any further technical assistance or training can be provided.

A full review must include the observation of at least three complete appointments. These observations should include all of the assessment, certification, counseling, and documentation tasks that the CPA-Level II/I performs. An observation checklist is available from the State WIC Agency for this purpose. In addition at least 5 participant records should be reviewed for completeness and accuracy as well as for appropriateness of counseling and referrals. Chart audit forms are also available from the State WIC Agency. Observations and chart audits must be conducted by a CPA-Level III.

After the observations and chart audits have been conducted, the Level II/I CPA and the Level III CPA reviewer should meet to discuss any weaknesses or problems noted as well as to identify the strengths of the Level II/I CPA. A work plan should be developed that identifies areas for skills or knowledge development and the training and technical assistance that will be provided for the further development of the LEVEL II/I CPA.

Rhode Island WIC Program Procedure manual Sec 250.1 Section 250.1 - 1 -

WIC Breastfeeding Promotion Standards

Purpose The purpose of these promotion standards is to establish breastfeeding as the normative standard of care for infant nutrition, by encouraging WIC participants to breastfeed their infants; and to outline the framework for the support of breastfeeding participants.

I. The local agency (LA) shall provide a supportive clinic environment. A. All staff should promote breastfeeding as the normative standard for infant feeding. 1. Breastfeeding shall be visibly represented as the optimal way to feed all infants through the use of posters and/or other visual aids throughout the clinic environment. 2. Formula shall be stored where applicants and participants can not see it and no formula advertising or displays should be visible at any time. 3. Breastfeeding shall be referred to positively by all WIC staff and staff shall assume all women will initiate breastfeeding. 4. Participants should feel comfortable breastfeeding their infants in the clinic and asking questions about and discussing breastfeeding with any staff. 5. All staff must be competent in basic breastfeeding support and understand the benefits of breastfeeding

B. Every pregnant participant should receive breastfeeding education. 1. All prenatal applicants shall receive breastfeeding education by either the WIC nutritionist or peer counselor, and ideally from both.

C. Every breastfeeding participant shall receive breastfeeding support. 1. Breastfeeding infants should not receive infant formula during the first month of life to ensure milk supply and successful feeding has been developed. Up to one can of infant formula may be added during the first month of life at the discretion of the WIC nutritionist for an infant who is considered mostly breastfeeding. 2. All postpartum women must be seen by a CLC-certified nutritionist or peer counselor prior to adding formula to their WIC food package. 3. Formula that is issued to a breastfeeding participant must reflect the appropriate breastfeeding categories as follow: Fully Breastfeeding = Receiving no formula benefits Mostly Breastfeeding = Receiving less than half of the full formula package (0-1 cans of formula in the first month). *Some Breastfeeding = Receiving more greater than half applicable full formula package * Mothers with breastfeeding status of “Some Breastfeeding” will remain an active participant after the infant turns 6 months old but will no longer receive a food package.

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Breastfeeding Peer Counselor Program (PC) Purpose The WIC Breastfeeding Peer Counselor Program is designed to enable specially trained breastfeeding mothers, who are either current or former WIC clients, to help other WIC participants initiate and sustain breastfeeding. The WIC Breastfeeding Peer Counselors will: • Have breastfed their own children • Have participated in the WIC Program • Believe in the fundamental importance of breastfeeding as the primary nutrition source for most infants • Have completed received in-depth training on how to become a Peer Counselor • Are also culturally similar to and speak the same language as the WIC participants they support. The primary responsibility of the Peer Counselor is to establish a relationship with prenatal WIC participants by talking with them about the benefits of breastfeeding, and sharing their own individual experiences while breastfeeding in the hopes of developing a rapport. The Breastfeeding Peer Counselors prepare prenatal participants for their breastfeeding experience by educating them on how to get breastfeeding off to a good start and what to expect in the early weeks. They maintain their relationships with WIC moms for the entire breastfeeding experience, from the first few days after WIC moms deliver their babies to the days when they are weaning. They provide consistent and non- judgmental support; help moms overcome common breastfeeding problems; and help WIC moms access the breastfeeding services they need.

The effectiveness of the WIC Peer Counselor within the local agency is heavily influenced by the following: • Successful integration of the Peer Counselor and the peer counselor program into the local agency • There is a strong support of breastfeeding from leadership, nutritionists, and support staff • Effective peer counselor program supervision and monitoring • Appropriate, competitive levels of compensation • Team environment with all local agency staff • Inclusion of peer counselor in staff meetings and staff development opportunities • Appropriate levels of breastfeeding training for all local agency staff • Effective, individualized peer counseling policy development and implementation • Open communication between all members of the local agency staff • A documented strategy for the support of participants between different local agency staff involved in the care process.

Hiring, Training, and Peer Counselor Hours

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Hiring I. Hiring Breastfeeding Peer Counselors: A. Peer Counselors or other WIC staff members may refer prospective PCs to local WIC agencies. B. Local WIC agencies wanting to hire a PC must first contact the State WIC Breastfeeding Coordinator to ensure the availability of funding and training and to determine allocated weekly hours. C. Local WIC agencies should interview prospective PCs at the local agency site and then notify the State WIC Breastfeeding Coordinator of hiring decisions. II. When recruiting Breastfeeding Peer Counselors, LA’s shall choose mothers who: A. Are currently receiving WIC benefits or have received WIC benefits in the past. B. Have successfully breastfed at least one child for at least 6 months. C. Exhibit the belief that most women can successfully breastfeed their babies. D. Have sufficient English language verbal, reading and writing skills to complete training, effectively communicate with staff and clients, and maintain accurate records. E. Fluently speak (or have basic conversational abilities in) the primary language of the majority of the agency’s clientele. F. Are preferably similar in ethnicity, age, or other characteristics to the majority of agency clientele. G. Are preferably available to WIC clients outside of usual clinic hours. H. Have reliable access to a telephone if taking calls at home.

Training Breastfeeding Peer Counselors and Training: A. Beginning work: 1. Peer Counselors should shadow existing PCs and hospital-based lactation consultants as specified in the Loving Support through Peer Counseling Curriculum. 2. Peer Counselors should shadow nutritionists and support staff to see how agency should work. B. Additional training: 1. Peer Counselors must complete a 20-hour training coordinated by the State WIC office. 2. Prior to loaning out electric breast pumps, Peer Counselor must attend an electric breast pump training program offered by the State. C. Available PC training and shadowing hours are not restricted by allocated weekly PC hours and will be reimbursed by the State WIC office.

Hours Peer Counselor Hours:

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A. The State WIC Breastfeeding Coordinator will periodically calculate the number of hours allocated by the State WIC office to PCs at each site based on the caseload of pregnant and breastfeeding women at the site. B. The PC’s work schedule must allow for reasonable flexibility, meet the individual needs of participants, and allow the PC to attend meetings scheduled by the State WIC Office. C. The PC may work up to one-third of her total allocated hours from home. It is

strongly suggested that the agency allow the PC to work a minimum of one-

sixth of her total hours at home. A full-time PC may opt out of working hours

from home. D. The PC must report her hours in the timeframe and format required by the LA

Coordinator. E. Weekly hours will include attendance at meetings and trainings as requested by the State WIC Breastfeeding Coordinator or LA WIC Coordinator unless the State WIC Office has explicitly approved reimbursement for additional hours. PCs regularly scheduled to work less than 16 hours each week may be reimbursed for additional hours spent attending routine statewide PC meetings and staff trainings.

Peer Counselor Job Description

Job Description Local WIC agencies must submit an agency-specific PC job description to the State WIC office for review & approval before initiating or updating agency classifications. It must reflect the PC eligibility criteria described in this document and should integrate any other local agency requirements.

I. Breastfeeding Peer Counselors will consistently: A. Project a positive image about WIC, and provide information and services consistent with WIC’s philosophy. B. Utilize client-centered counseling techniques learned through Loving Support Training modules. C. Comply with all personnel guidelines applicable to staff at the local WIC agency including reporting to work as scheduled, notifying local agency WIC Coordinator of absences and illnesses in a timely manner, following through with supervisor directives, etc. D. Work collaboratively with other LA staff, under the supervision of the local agency WIC Coordinator, in the clinic setting and at home. E. Comply with guidelines outlined in the state and local WIC agency Breastfeeding Peer Counseling Program Descriptions. F. Strive to achieve competency in the skill areas outlined in the Peer Counselor Competency Checklist. G. Develop & demonstrate organizational skills to effectively track participants. H. Comply with documentation requirements according to program guidelines.

II. Breastfeeding Peer Counselors shall perform the following duties:

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A. Contact prenatal and postpartum clients and follow-up on referrals in accordance with the state and local WIC agency Breastfeeding Peer Counseling Program Descriptions. B. Provide culturally appropriate individualized and/or group peer counseling sessions for pregnant and breastfeeding WIC participants. Address specific concerns of expectant mothers. Correct misinformation, which may prevent a pregnant woman from breastfeeding. C. Share motivational materials with pregnant participants. D. Support women during a normal breastfeeding experience. Identify breastfeeding experiences that are not the norm & make an immediate, appropriate referral. E. Attend relevant meetings & trainings as requested by State WIC Breastfeeding Coordinator or local Agency Coordinator. F. Work collaboratively with WIC staff to maximize breastfeeding initiation and duration at the WIC site. I. May receive phone calls at home or by pager from WIC staff (making referrals) and/or WIC clients (providing breastfeeding support). J. Document all personal contacts with WIC participants according to program guidelines. Documentation Documentation-PC I. Daily: A. PCs will document all client contacts and referrals in the Breastfeeding Notes section in RIWEBS within one week of contact, preferably before leaving the clinic at the end of each workday B. Enter alerts for staff into RIWEBS, as needed, to ensure that clients receive breastfeeding support and counseling when PC is not present. C. PCs will file all WIC Lactation Consultant Referrals in the appropriate client charts.

II. Monthly: A. “Due Date Follow-up Report”: Generate this monthly to identify and contact prenatal and postpartum women who indicated that they planned to breastfeed or use an alternate system to routinely identify, track, and contact prenatal and postpartum participants. The Peer Counselor will refer to the participant record as needed to verify client contact information and most recent contact. B. Summaries: The following 2 forms must be completed for each calendar month & submitted to the LA Breastfeeding Coordinator or the LA Coordinator for review and signature by the 10th day of the month following the report month: 1. WIC Breastfeeding Peer Counselor Monthly Summary (WIC #81) = 1 monthly copy for each agency a. Complete 1 copy for each local WIC agency for each calendar month following instructions provided on form. b. Document “Outreach Activities” and “Other Breastfeeding Activities” as they occur to ensure accurate record keeping. 2. WIC Breastfeeding Peer Counselor Monthly Contact Record (WIC

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#83) = 1 monthly set for each site (see details below) a. Phone = phone contact; Clinic = in-person at WIC clinic; Mail = mail contact; Home – in-person at client home (PC must receive approval from local WIC agency to conduct home visits b. Complete one set of records for every local WIC agency site for each calendar month. c. Document even minimal client contact on Monthly Contact Record and in Breastfeeding Notes section on RIWebs. d. In OTHER section, PC may document attempted phone calls. e. Document client contacts when they occur to ensure accurate record keeping.

III. General information A. PC’s are required to ensure the security of client information carried between the WIC clinic and the PC’s home by keeping all client information close at hand, or securely locked in the trunk during stops between the clinic and home. WIC has confidentiality protocols apart from HIPAA guidelines and is therefore not required to adhere to specific HIPAA procedures. B. The PC will immediately alert their Local Agency Coordinator if anything containing client information is lost or stolen.

Supervision & Support

Peer Counselor Supervision A. The LA WIC Coordinator is the Peer Counselors’ immediate supervisor responsible for daily administrative, personnel issues, and monitors that the local agency PC is carrying out her designated program responsibilities. B. The LA WIC Coordinator must ensure the PC complies with all LA, and SA guidelines concerning the appropriate dissemination of health information, and abuse and neglect referral and reporting guidelines in accordance with state law. C. The PC must address all workplace concerns with the LA WIC Coordinator. If the PC is unable to resolve her concerns with her Coordinator, she must follow the rules outlined by her LA as far as whom she contacts next. D. The PC must comply with all personnel guidelines applicable to WIC staff at the LA. If personnel guidelines or other agency practices inhibit the ability of the PC to fulfill her job responsibilities, the local agency will need to negotiate an acceptable compromise with the State WIC office in order for the State to continue to support the program at that agency. State reimbursement for the WIC Breastfeeding Peer Counselor program is separate from the primary WIC funding stream. This policy ensures that the local WIC agencies effectively utilize these limited resources. E. The LA WIC coordinator is responsible for the integration of the WIC PC into the LA office environment by working with other LA staff to determine the best way to utilize PC hours at their individual agency.

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Support I. The State WIC Breastfeeding Coordinator: The State BF Coordinator is responsible for establishing the general work-related responsibilities of the Peer Counselor Program; evaluating program effectiveness; providing technical assistance to the local agencies; and monitoring that LA meets the requirements of Federal PC program guidelines.

II. Local Agency Program Support A. The PC must be housed in the physical WIC site to maximize client contact and foster collaboration with other WIC staff. B. The PC must have access to a phone at all times when working at the WIC site. C. It is strongly suggested that the PC have reliable computer access while working at the WIC site. D. The PC must have access to relevant paperwork and educational materials while working at the WIC site. E. The LA must accommodate a reasonably flexible schedule for the PC, preferably allowing her to schedule hours at home (see Hours below). F. The LA WIC Coordinator will coordinate clinic and staff schedules and promote collaboration between staff to maximize opportunities for PCs to contact women in-person rather than on the phone or by mail. G. If it is desired by the PC, it is strongly suggested that the LA allow WIC staff to contact the PC at home to refer new deliveries and clients with immediate breastfeeding concerns to the PC. In addition, the PC may elect for WIC staff to give her personal phone number directly to breastfeeding clients. H. The LA may provide the PC with a pager or voicemail at the clinic; if a pager or voicemail is not available the LA must have an alternate system to reliably convey client messages to the PC when the PC is not available to answer phone calls. I. The PC should contact WIC participants at the WIC site. If clients are seen by the LA, and the PC was unavailable during the time of the appointment, the PC may contact participants via phone, mail, email, or home visit if the LA approves home visiting. J. PCs that choose to conduct home visits must receive approval from their LA and comply with any state and LA liability guidelines associated with home visits. K. The LA WIC coordinator must support PCs in participating in the Certified Lactation Counselor Certificate Training Program (or another equivalent training) and other continuing education opportunities required by the State WIC Agency. L. LA WIC support staff and nutritionists will consistently: 1. Collaborate with the PC to support breastfeeding clients. 2. Advise breastfeeding clients to call the WIC office to report their deliveries. 3. Provide prenatal and postpartum clients with PC contact information in accordance with the state and LA Breastfeeding Peer Counselor Program Descriptions.

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4. Use appropriate, open ended questions to ask whether clients are breastfeeding (e.g. “What are your plans for feeding your baby?” or “How are you feeding your baby?” instead of “Are you breastfeeding or bottle- feeding?” 5. Record and report new deliveries and problem referrals to the PC on the same day that they are reported to the WIC office. 6. Refer prenatal and postpartum women to the PC, whether the PC is on-site or off-site, according to state and LA protocol. 7. When possible, refer client requests to increase formula in a breastfeeding food package to the PC, or if the PC is not available, to a CLC-certified staff member, prior to changing the food package. 8. Make necessary follow-up appointments for the PC in RI Webs. 9. Respond to client alerts entered by the PC in RI Webs. 10. Follow any other guidelines outlined in the state or local WIC agency Breastfeeding Peer Counseling Program Descriptions to support the Breastfeeding Peer Counselor Program.

III. Local Agency WIC nutritionists and support staff will consistently: A. Record new deliveries reported to the WIC office by phone or in person using the WIC Infant Delivery Log (WIC #84) and ensure that the PC receives all faxed WIC Lactation Consultant Referrals. B. Document prenatal, postpartum, and problem referrals for the PC whether the PC is on-site or off-site using the WIC Breastfeeding Peer Counselor Referral Log (WIC #80) and/or a full-sheet WIC Breastfeeding Peer Counselor Referral Form developed by the local WIC agency. C. Nutritionists will document referrals to the Breastfeeding Peer Counselor or another breastfeeding specialist in the participant records and will document client contacts regarding breastfeeding in the SOAP Notes in RIWebs. D. All nutritionists shall document notes in the chart, specific to the individuals’ needs. Postpartum breastfeeding notes shall generally be entered in the infant chart unless it has to do physically with the mom (sore nipples, breast infection, etc.).

IV. Local Agency Breastfeeding Coordinator A. Each local WIC agency may designate a Breastfeeding Coordinator. This person must be a nutritionist and preferably someone other than the local agency WIC Coordinator who is able to devote additional time and energy to planning and supervising breastfeeding activities. B. The LA Breastfeeding Coordinator serves the Peer Counselor in an advisory capacity by providing her with technical support in the workplace (e.g., helps to coordinate group counseling, plans breastfeeding functions with Peer Counselor, ensures that the Peer Counselor has access to tools to do her job).

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Materials

I. Utilize WIC-approved brochures listed on the WIC Nutrition Education Materials Order Form posted on the HEALTH Website. www.health.ri.gov/forms/onlineordering/form_wic_agency.php II. Utilize nutrition education materials as a teaching tool to complement counseling: 1. Tailor distribution to client concerns and stage-specific information 2. Highlight details in relevant materials to complement discussion 3. Distribute only one or two relevant brochures at each visit III. Only WIC Nutritionists should distribute and discuss WIC nutrition brochures. IV. WIC staff must receive approval from the State WIC Breastfeeding Coordinator to distribute breastfeeding brochures and materials not included on the WIC Nutrition Education Materials Order Form or on the following list of additional WIC-approved resources. V. Additional WIC-Approved Breastfeeding Resources 1. All information posted for parents on the Rhode Island Department of Health breastfeeding web pages at www.health.ri.gov/breastfeeding (web address included on law card) 2. The following materials posted on or linked to the Massachusetts Breastfeeding Coalition website at www.massbfc.org/parents/index.html: a. Making Milk is Easy! (Portugese, French or Italian only – use RI WIC: Breastfeeding Your Baby for English and Spanish clients). b. Resources listed on the RI WIC “Breastfeeding Your Baby” brochure. 3. US Department of Health and Human Services “Easy Guide to Breastfeeding for…” La Leche League pamphlets covering specific topics (only for high-literacy clients) 4. "The Breastfeeding Answer Book" by La Leche League International 5. Jack Newman website resources at www.drjacknewman.com 6. "A Medication Guide for Breastfeeding Moms" and “Medications and Mothers’ Milk” by Thomas Hale a. Information in Thomas Hale's clinical version of this book, "Medications and Mothers' Milk" and “A Medication Guide for Breastfeeding Moms,” can be sent directly to providers but is not appropriate to share with mothers. If a client has a question about a medication and breastfeeding, staff should contact the mother’s doctor directly and offer to fax the relevant page(s) from the Hale book(s).

b. When photocopying information from either resource, please include copies of:

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i. Cover sheet (page that includes publishing information and date) ii. Lactation risk category definition page iii. Relevant drug information page 7. Infant Risk Center at 806-352-2519. Clients who have questions about medications and breastfeeding can be referred to the Infant Risk Center (www.infantrisk.org). The Center is open Monday through Friday, from 8 a.m. to 5 p.m. CST and is free of charge.

Counseling Strategies and Client Contacts Counseling Strategies A. Maximize opportunities to contact women in-person rather than on the phone. B. Utilize client-centered counseling techniques taught in Peer Counselor and Grow and Glow Breastfeeding training. 3-Step Counseling Strategy 1. Ask open-ended questions 2. Affirm clients concerns 3. Educate to concerns C. Utilize nutrition education materials as a teaching tool to complement counseling: 1. Distribute only WIC-approved brochures and AV materials (see materials, page 9) 2. Tailor distribution to client concerns and stage-specific information 3. Highlight details in relevant materials to complement discussion 4. Distribute only one or two relevant brochures at each visit Client contacts I. Peer Counselor Client Contact Prioritization. Prioritize daily client contacts in the following order. 1. On-site participants 2. Problem referrals 3. New deliveries 4. New referrals 5. Routine follow-up calls a. Late prenatal b. Early postpartum c. Mid- to early prenatal d. Mid- to late postpartum

II. Telephone Contacts 1. Find out from the client whether it is okay for you to identify yourself when you call.

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2. Ask for the client using only her first name when you call. Do not mention WIC. III. Prenatal Referrals Purpose  Assess a woman’s knowledge of breastfeeding and interest in choosing breastfeeding as infant feeding method  Address concerns or barriers to breastfeeding and provide information on benefits of breastfeeding  Help women make an informed choice about infant feeding method without being critical or making women feel defensive or inadequate Protocol  All prenatal women should be referred to the Breastfeeding Peer Counselor at intake according to state and local WIC agency program guidelines unless the woman is extremely resistant or breastfeeding is medically contraindicated  Use computer reports or alternate system to routinely identify, track and contact prenatal participants at each site who were not referred Paperwork  In RIWebs, document all contacts within 1 week  In RIWebs, document inability to contact participants if unsuccessful after 2 weeks Timeframe Initiate contact with referred prenatal women within 2 weeks of receiving referral Method Phone or in-person

IV. Prenatal Support Purpose Provide lactation information & support for women intending to breastfeed Protocol  A minimum of 3 contacts should be made with all referred prenatal participants who intend to breastfeed  Contact prenatal participants who do not intend to breastfeeding in accordance with local WIC agency PC program guidelines  Use WIC Breastfeeding Peer Counselor Prenatal & Postpartum Assessment Form (WIC #82) as guideline for discussion (remember to summarize the information collected on this form in a Breastfeeding note on RIWebs).  Use computer reports or alternate system to routinely identify, track and contact prenatal participants at each site who were not referred  Make referrals to other health care professionals for breastfeeding contraindications (e.g., inverted nipples, previous breast surgery, etc.)  Advise breastfeeding clients to call the WIC office to report their deliveries Paperwork  In RIWebs, document all contacts within 1 week  In RIWebs, document inability to contact participants if unsuccessful after 2 weeks Timeframe At least 1 contact at each trimester (1-3 months, 3-6 months, 6-9 months)

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and again at 2-4 weeks before anticipated due date Method Phone, one-on-one counseling, group class, mail (if no phone number available) V. Postpartum Support Purpose  Assess how breastfeeding is going and provide encouragement and support  Identify common breastfeeding problems and provide problem-solving information and support  Make referrals to other health care professionals for complicated or unresolved breastfeeding problems (see following “Criteria for Breastfeeding Referral”) Protocol  A minimum of 2 contacts should be made within the first two weeks postpartum and again after the first 2 weeks postpartum(4 contacts total)  Contact breastfeeding participants within 24-48 hours of discharge  Attempt to schedule an in-person appointment ASAP when necessary  Use WIC Breastfeeding Peer Counselor Prenatal & Postpartum Assessment Form (WIC #82) as guideline for discussion (remember to summarize the information collected on this form in a Breastfeeding note on RIWebs).  Use computer reports or alternate system to routinely identify, track and contact postpartum participants at each site who were not referred  Make referrals to other health care professionals for complicated or unresolved breastfeeding problems (see following “Criteria for Breastfeeding Referral”) Paperwork  In RIWebs, document all contacts within 1 week  In RIWebs, document inability to contact participants if unsuccessful after 2 weeks Timeframe During first 2 weeks postpartum:  Contact deliveries reported through WIC Infant Delivery Log and WIC Lactation Consultant Referrals by phone within 24 hours of receiving report  Contact deliveries identified using “Due Date Follow-up Report” (Report 400B) or another tracking method 2-3 days after anticipated due date  Follow-up on contacts within 2-3 days or as requested by participant  Follow-up on problems within 24 hours (see Problem Referrals) After first 2 weeks postpartum:  Preferably contact at 2-3 weeks, 4-8 weeks, and 3-4 months postpartum  Maintain contact as needed or as requested for entire breastfeeding duration Method Phone, in-person, mail (only after first 2 weeks)

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VI. Problem Referrals Purpose  Provide problem-solving information and support Protocol  Contact client by phone within 24 hours of receiving referral  Attempt to schedule an in-person appointment ASAP when necessary  Make referrals to other health care professionals for complicated or unresolved breastfeeding problems (see following “Criteria for Breastfeeding Referral”) Paperwork  Document successful contact within 1 week  Document inability to contact participants in unsuccessful after 3 days. Place follow-up phone call to WIC staff person who made referral to PC and document in chart within 1 week of referral. Timeframe  Follow-up on referrals by WIC staff within 24 hours of receiving referral  Follow-up contact with client within 24 hours of problem discussion Method In-person (preferred), phone Criteria for Breastfeeding Referral Sometimes, Peer Counselors will need to yield to someone who has more experience. Peer Counselors can continue to offer support, even when yielding. 1. Referral to Medical Doctor  Breast infections (temperature above 101 degrees, possibly along with localized redness and heat and/or plugged duct symptoms of localized pain and firmness)  Slow weight gain of infant (as perceived by mother)  Jaundiced infant (yellowish tinge to skin as perceived by mother)  Fewer than 6 wet diapers in 24 hours for infants from 4 days to 4 months old  Fewer than 3 stools in 24 hours for infants from 4 days to 3 weeks of age 2. Referral to Lactation Consultant (WIC-assigned IBCLC)  Sore nipples  Plugged ducts (localized pain and firmness)  Premature infants  Sick or hospitalized mother or infant  Infants who refuse to nurse  Infants with special health care needs (i.e., developmental disorder)  Mothers on medications (IBCLCs will need to contact client’s doctor)

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SECTION 300

FOOD DELIVERY SYSTEM AND DATA PROCESSING

(Goals - III, Operations - 3)

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SECTION 300

FOOD DELIVERY SYSTEM AND DATA PROCESSING

310 - Local Program Computer Manual

See computer manuals:

1. Queue Manager 2. Service Site 3. Central Administration 4. Report Generator

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-3-

320 - CHECK ACCOUNTABILITY

GENERAL PROCEDURES

A. Food Instrument (Check Stock) Procurement and Distribution

1. An analysis of check issuance patterns of local WIC agencies is completed. Based on this information, a month-by-month delivery schedule, and a yearly projection of check usage are made.

2. The State agency orders check stock from an authorized supplier / printer based on the monthly delivery schedule. All check stock is preprinted with sequential document numbers. The range of check numbers is printed on the exterior of each case of check stock.

3. The blank check stock is released, based on the delivery schedule, and delivered to the State WIC Office. The suppliers packing slip is compared to the boxes of check stock delivered to ensure the complete order was received.

4. The delivery of check stock is entered into the WIC Check Stock Inventory using the check range on each box, and the stock is then stored in a secure, locked area.

5. Based on the monthly delivery schedule, boxes of check stock are logged out of the WIC Check Stock Inventory, electronically released to the agency in RI WEBS, and logged into the local agency delivery folder. The responsible same day delivery service delivers the checks to the local WIC site.

6. The local agency WIC staff person signs for the boxes of checks delivered. The blank check stock is stored in a secure, locked environment.

7. As blank check stock is needed for check issuance, one package of blank stock is moved from the individual box and inserted into the printer drawer. The drawer is to remain locked during clinic operating hours.

8. If the workstation issuing checks is vacant (i.e., for lunch), checks are locked in a secured area.

9. At the end of the workday, unused blank check stock is stored in a locked, secure area until reloaded into the designated printer on subsequent days.

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Check Issuance A. Participants receive local agency computer printed checks either monthly, bi-monthly or tri-monthly, or as preliminary certification under the following guidelines:

1. One month of WIC checks: High-risk participants, or those who benefit from more frequent contact with the WIC clinic, may be given one month of checks.

2. Two months of WIC checks: Some participants may benefit from bi-monthly contact with the WIC clinic and may receive two months of WIC checks.

3. Three months of WIC checks: Low risk participants may receive three months of WIC checks. Low risk WIC participants who should not receive three months of checks include: Participants with a history of lost ID folders or WIC checks, Foster parents (due to frequent custody changes) Participants without needed active health care engagements.

4. Care must be taken to continue to coordinate nutrition education contacts, recertification appointments, and notification of terminations/reapplications with check pick-up.

5. All participants must receive information on how to use the WIC / FMNP checks. Information provided shall include “first day to use” and “last day to use” check usage, importance of selecting WIC approved food items in allotted quantity (referring to WIC Approved / FMNP Approved Food Brochures) and signing check after vendor enters price of purchase.

B. All checks must be accounted for including lost, stolen, damaged or erroneously printed checks.

C. All checks shall be kept in a secure, controlled area as directed by the Rhode Island Department of Health WIC State office (State agency). .

D. The computer automatically logs, by password, the identity of the person issuing WIC checks. Local agency staff, therefore, should keep password secrecy and should log off the computer each time they leave the computer.

E. Correction fluid ("white out") may never be used on checks. If a mistake is made on a check, the check should be voided and reissued.

321 COMPUTER PRINTED CHECKS

A. END OF DAY PROCEDURE

1. Queue manager must verify that there are no print jobs remaining in the queue. Then he/she

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-5- is to log out of the application completely.

B. BEGINNING OF DAY PROCEDURE

1. Queue manager will log into the queue manager application and choose the appropriate check range. He/she should then perform a test print to ensure printer is using check stock and the check numbers match.

C. PROCEDURE FOR DISTRIBUTION OF CHECKS

1. To ensure that only authorized payees receive and sign for appropriate checks, WIC staff shall require identification verification against the checks for the participating members of the family. Proper identification shall be a regular ID folder, WIC-7A. As circumstances warrant, other positive identification may be accepted and explanation as to type and reason for failure to present an ID folder written in the general notes.

2. After proper identification procedures have been completed, verify all check numbers given to participants/payee against the corresponding numbers in the E-pad.

5. Each payee (or authorized alternate shopper) will sign the E-pad. This will provide both proof of check delivery to recipients and internal security and accountability.

6. Verify the signatures on the E-pad against the signature on the WIC-7A ID folder.

7. For unusable and/or missing checks, refer to use of the participant check history and void/reissue screens and to the section 330 for the policy on lost/stolen checks. Void unusable checks "in-hand." Stamp checks VOID and place checks in daily envelope. This includes checks printed in error. Any future dated checks that were printed in error should be voided and reprinted when the participant comes in for their next appointment.

8. The voided and returned checks must be kept for the requisite period, currently three years.

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-6- 322 Lost, Stolen or Damaged Check Procedure

(Operations Policy FD-1)

Goal

To protect the WIC Program from financial obligations resulting from the redemption of stolen WIC checks.

Procedure

The following procedures will be adhered to by local agency and Rhode Island Department of Health personnel in cases involving thefts, and/or loss of checks:

Notice to Police and State Agency

A. Report any suspected thefts immediately to the appropriate police department for investigation or verify that the participant has done so.

B. The local agency will phone the State agency with relevant information. The call should be directed to the staff member who maintains the "Bad Check” Register or, if absent, to the alternate. If both are absent, the staff person who takes the call will record the information in the register.

C. A log number will be issued to the local agency for each lost or stolen check. This number will be consecutive and entered into the register, along with DATE OF ALERT, CHECK NUMBERS, PARTICIPANT I.D. NUMBER, AND STATUS. Lost or stolen checks should NEVER be voided by the local agency.

D. Local agencies may request replacement of lost or stolen checks in exceptional circumstances.  Lost or stolen checks must not be replaced without authorization from the State agency. (see below)

Whenever WIC checks are replaced after being lost or stolen or destroyed, the Payee must sign an affidavit attesting to the fact that WIC checks are indeed missing and (s)he has no further knowledge of them. WIC-10A is the form designed for that purpose. Retain the original in the client's file, send a copy to the State Office and give the payee a copy.

The State agency will follow up by notifying the bank (when necessary) and coordinating with Vendor Staff (if alert to stores is called for). If the responsible State agency person is away for the day, the Program Chief should be notified of the register entry.76

The State agency liaison will verify that the appropriate police department has been notified of any reported theft.

When a completed WIC - 10 (WIC CHECK ALERT NOTICE) is received from a Local Agency, the responsible State person will file the form in the "Bad Check" log book and enter the receipt in the register. If a form is not returned within a week, that person will

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If replacement checks were authorized, the WIC-10 must include check numbers of the reissued checks, entered by either the local agency or if already submitted, by the State Agency after being notified by the local agency.

E. Vendor monitoring unit will immediately notify WIC vendors in the vicinity of the loss, if feasible. If extensive, a written notice will be prepared and delivered or sent to all vendors.

F. If a participant finds checks that were reported as lost or stolen, they should be returned to the local agency and, if appropriate, new checks reissued. Participants must be told that if they find their lost checks, they should not use them.

323 Erroneous Checks

A. Checks printed at the local agency, erroneously, may be voided and reissued by the local agency. This includes checks misnumbered, not lined up properly, blank, with the wrong food package or damaged before issuance. Checks in-hand may be voided as In-Hand.

B. If there is a significant check misnumbering problem, locals should call the state agency for assistance in straightening it out.

324 Misnumbered Checks

Note: Please verify the check numbers in the drawer with the next check number in the computer periodically throughout the day to minimize the number of misnumbered checks that leave the office.

When a misnumbering has occurred, contact participants who have received checks earlier in the day or on previous days to determine when the problem started. Ask participants to verify that the black and red numbers match on their checks.

When the beginning of the mis-numbered checks has been found, attempt to have all participants return their checks to be voided and then reissued. If checks have already been used, or a participant cannot be reached, notify the state office with those check numbers. The state office will then notify the bank of the mis- numbering. Please have both the red and black numbers available for the state office.

To fix a mis-numbering, determine which scenario you have: 1. Black number greater than red number 2. Red number greater than black number

Scenario 1

If the black number is greater than the red number, remove the checks from the drawer until the first check in the drawer matches the number in the computer. Stamp the unused checks with a VOID stamp and file with your other voided checks. Run a test pattern before issuing any more checks to verify that the check numbers now match.

Scenario 2

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If the red number is greater than the black number, press the red light and then the green light in Queue Manager. This will bring up the box asking you to verify the check box your agency is currently using. Select the correct box of the checks. When the next screen pops up to verify the first number in the drawer, change the number in the computer to match the red number in the drawer. This will void any checks between the original number and the new inputted number. Alert the state office of these check numbers if the checks are circulating in the community.

Note: It is recommended to contact the state office for assistance on this procedure.

A.

330 - Assistance to Participants/Replacement of Checks

1. When a local agency requests state agency assistance due to participant hardship, the liaison will help the local agency to identify available food resources (ex: formula supplies, food closets.)

2. No replacement checks may be issued unless the Program Chief authorizes such issuance under exceptional circumstances. Evaluating exceptional circumstances shall include, but not be limited to, consideration of the following factors:

a. There is documented hardship to the participant.

b. There is corroborative evidence that the loss was the result of unavoidable catastrophe or forcible crime, and evidence that the receiver(s) of the checks took reasonable precautions to safeguard the checks.

c. Bank records have been reviewed to see if originals were redeemed.

d. Liaison and local have investigated whether participant (or agent) redeemed originals.

e. Any possible theft was reported to police.

f. The payee has not received previous replacement.

g. The payee signs a witnessed statement giving details of loss, and stating the payee:

• Did not authorize anyone to receive or redeem the checks.

• Did not receive any benefit therefrom.

• Is willing to appear in court to give evidence regarding the loss.

• Is making the statement for the purpose of obtaining replacement check(s).

• Understands that making a false and misleading statement or misrepresenting, concealing or withholding facts to obtain replacement of WIC checks may result in prosecution, disqualification from WIC and/or repaying the State

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h. There is sufficient time to notify vendors not to accept the originals.

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-10- 340 - Vendor Matters

The integrity of the Program and its effectiveness in improving nutrition depend heavily upon the adherence to proper food selection and redemption practices by both participants and vendors. Participants who obtained nonallowed items and vendors who charge improper prices, furthermore, deny limited Program resources to others who might benefit from them.

The state agency assumes primary responsibility for monitoring of vendors. Local agencies, however, are in a position to obtain information about vendor practices from participants which can be helpful to the state agency in monitoring.

In addition, local agencies have primary responsibility for ensuring that participants understand their responsibilities and adhere to Program rules.

Information about these matters obtained by the state or locals, then, must be exchanged and followed up on vigorously.

WIC shoppers can shop at any WIC authorized store in RI.

341 - Participant or Local Agency Complaints or Comments Regarding Vendors

A. Any complaints received at the state office regarding a vendor shall be transmitted to the Food Benefits Unit. The Food Benefits Unit shall assess the merits of the complaint and plan follow-up with the vendor monitoring staff.

B. Any complaint regarding a vendor received by a local agency shall be routed to the Community Health Liaison. Complete a Vendor Question/Complaint Form (Appendix) with full details, including how to contact the complainant. You may call direct in addition to sending the form.

Obtain as much of the following as possible:

1. Date, what occurred, store staff involved.

2. Checks involved, if any

3. Signed statement by complainant (i.e., ask complainant to sign completed form.)

C. If a complaint is verified on location, the vendor and WIC representative will immediately develop a plan of correction. All occurrences shall be noted on a Vendor Contact Record form.

D. The Community Health Liaison will contact local agency staff to inform them of any action or corrective plan developed as a result of a participant or local agency complaint regarding a vendor. The local agency shall inform the participant of that action or corrective plan. Information regarding compliance investigations will not be shared.

E. Failure to comply with the plan of correction may result in a warning letter or a termination.

F. A pattern of complaints may also be considered by the state agency as grounds for a warning letter,

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Possibly Contaminated Foods

If a participant should complain that she/he had purchased some food which was thought to be contaminated, refer that person to the Food Protection Office in the Department of Health. Advise participant that a sample of the contaminated food should be taken/sent to that office along with the complaint. Perishable items should be kept refrigerated.

Div. of Food Protection and Sanitation Rhode Island Department of Health Cannon Building Three Capitol Hill Room 203 Providence, Rhode Island 02908 222-2749

Department rules require that a complainant sign a statement that they are not taking legal action against the manufacturer.

Vendor Inventory Requirement:

A. The Rhode Island Department of Health WIC Program maintains minimum inventory requirements:

1. Authorized WIC vendors shall stock WIC allowed foods according to the WIC Allowed Foods List.

2. For each food group, the vendor shall maintain a minimum inventory according to the WIC Vendor Minimum Inventory Requirements. (WIC-39).

3. For most items, stores are only required to carry two varieties or brands.

B. Local staff may transmit questions regarding store inventories to the State office using the Vendor Question/Complaint Form.

342 - Vendor Reports on Participants Choosing Non-WIC Foods

A. When a vendor notices that a participant has chosen nonallowable food items to purchase with WIC checks he should:

(1) Ask a participant to exchange nonallowable food items for foods listed on the WIC Allowed Foods list.

(2) Write down the participant's name, date of selecting wrong foods, WIC participant ID number and local agency, as well as the types of nonallowable food items selected.

(3) Call the Rhode Island Department of Health WIC Program and relate the incident as it occurred.

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(4) Note whether participant was insistent and/or disruptive or abusive.

B. At this point the Rhode Island Department of Health WIC staff liaison person for the local agency in question will:

(1) Call the local agency and report the incident as told by the vendor, naming the participant and types of food that the participant had incorrectly chosen.

(2) File a report on the incident at the Rhode Island Department of Health.

C. The local agency will then:

(1) Flag the chart of the participant in question, with recount of the incident.

(2) At the next check pickup the participant will be referred to the nutritionist or nurse for an education session that covers the following information:

(a) What occurred, and where, in a tone such that the participant is given the benefit of the doubt. (For instance: It was reported that you tried to purchase such and such with your WIC checks; since these are not allowable WIC foods, we feel that perhaps you did not get the appropriate education concerning the list--or, perhaps you lost your list ... here is another one...).

(b) Go over the list category by category naming allowed items.

(c) Then tell why each food was chosen and why it is important for the participant to purchase it.

(d) If the participant has been disruptive or abusive, warn the participant that the vendor may refuse to serve him/her.

(e) Ask if the participant has any questions and answer them.

D. The state liaison should then do a follow-up call with the local agency to see what occurred, and so record on the same report originated earlier.

E. A determination will be made of the participant's intention and the severity of any actual Program violation. The local agency will take appropriate additional measures (warning letter, disqualification) if warranted.

Approved Vendors

A. Periodic listings of currently active WIC approved vendors and vendors removed from participation will be provided to local agencies at least four times per year. The lists are to be used only to inform participants of which stores may accept WIC checks for the current period.

B. Please note stores deleted. Question a sample of participants to ascertain use of non-authorized

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C. WIC shoppers can shop at any WIC authorized store in RI.

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-1-

SECTION 400

PROGRAM BENEFITS

(Goals – IV, Operations - 4)

Rhode Island WIC Program

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SECTION 410 - 2 -

410 - Health Care Support

Participant Health Care Status

A. Health Care Inquiry

At least during the process of certification or recertification, the local agency WIC staff shall inquire as to the type, extent, and adequacy of health care services received or needed by each participant in the family. The participant shall then be encouraged to continue or obtain such care, whichever is appropriate. Both the general benefits of regular health care and the relationship of the nutritional risk to health care can be explained. Informational materials might also be helpful and reinforcing.

B. Services Offered

Optional sources offering the needed health care services should be described. These might include the local agency's required health services, private sources, or other agencies' programs and clinics.

C. Documentation and Follow-up

Health care related factors, services received or needed, and referrals made should be documented in the participant's WIC record. When there is significant severity of the health problem, high degree of risk, and questions about the participant's ability to follow through, the local agency staff should develop a plan to follow-up with subsequent inquiry and encouragement.

D. Coordination With Health Care (See also Outreach - Section 510)

To the maximum extent feasible, WIC records and procedures should lend themselves to coordination with the recipient's health care program and should be family-centered. Each agency should develop policies and procedures that foster such coordination.

Whenever possible, visits for WIC procedures should be combined with visits for health care and other local agency programs. Medical data needed for WIC certification should be shared between health services and the WIC Program. This sharing may be accomplished through using a combined WIC/health record, or transfer of data.

E. Breastfeeding Promotion and Support

Any training related to nutrition education and counseling provided to State and Local Staff will include Breastfeeding as part of the subject matter. Food benefits will be provided only on a face-to-face distribution in coordination with nutrition and

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-4- 411 – WIC Breastfeeding Peer Counselor Program

The WIC Breastfeeding Peer Counselor Program is designed to enable specially trained breastfeeding mothers, who are either current or former WIC clients, to help other WIC participants initiate and succeed at breastfeeding their children. The WIC Breastfeeding Peer Counselors have breastfed their own children, have participated in the WIC Program, believe in the fundamental importance of breastfeeding as the primary nutrition source for most infants, and have completed an in-depth training to become a Peer Counselor. Ideally, they are also culturally similar to and speak the same language as the WIC participants they support. The primary responsibilities of the Peer Counselor are to establish relationships with prenatal WIC participants by talking with them about the benefits of breastfeeding and helping prenatal and breastfeeding women overcome common barriers to breastfeeding. The Breastfeeding Peer Counselors prepare prenatal participants for their breastfeeding experience by educating them on how to get breastfeeding off to a good start and what to expect in the early weeks. They maintain their relationship with WIC moms for the entire breastfeeding experience, from the first few days after WIC moms deliver their babies to the days when they are weaning. They provide consistent and non-judgmental support, help moms overcome common breastfeeding problems, and help WIC moms access the breastfeeding services they need. The effectiveness of the WIC Breastfeeding Peer Counselor Program highly depends on the successful integration of the WIC Breastfeeding Peer Counselor and the Peer Counselor Program into the local WIC agency. Strong leadership around breastfeeding issues, supportive staff and program supervision and monitoring, appropriate compensation, excellent teamwork between staff members and Peer Counselors, inclusion of the Peer Counselor in staff meetings and staff development opportunities, appropriate breastfeeding training for all staff members, effective Peer Counselor program policy development and implementation, and open communication between the Agency Coordinator, Breastfeeding Coordinator, WIC staff members and the Breastfeeding Peer Counselor are all integral components in facilitating program success.

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-1-

420 - Supplemental Foods

Participant Education In Obtaining Supplemental Foods

A. Explain to the participant or the caretaker of the participant the selected food package, procedure for using WIC checks and procedure for obtaining WIC checks throughout the certification period.

B. Provide the participant or caretaker with an appointment to return for WIC checks and other appropriate activities (i.e. nutrition education, immunizations, health care visit, etc.).

C. WIC Information and Rules are on the WIC ID folder and Eligibility Form (WIC-5) at each cert./recert. Ensure that the participant understands the rules for how to use the checks at the store and the penalties for violating the rules. Topics to be reviewed include:

1. Shop only in a store authorized to accept WIC checks. The local agency will provide you with this information. Such stores must be only a retail grocer or food store, or registered pharmacy, located in Rhode Island. Checks may not be redeemed through a home delivery retailer.

2. Children cannot use WIC checks; only the authorized persons on the I.D. folder may.

3. At the store choose the allowed foods listed on the WIC check. Use your WIC Allowed Foods list to pick the correct products.

4. At the checkout counter separate WIC foods from the rest of your grocery items and tell the cashier you have WIC checks.

5. Present your WIC Identification Folder to the cashier before signing the check(s). (The alternate shopper must present the Identification Folder if he/she purchases the WIC foods.)

6. After the cashier has totaled the cost of the WIC foods and entered the cost in ink on the WIC check(s), sign the check. Participants must not sign checks without the cost entered in ink.

7. Date check was used must be written on the check at checkout.

8. There is no refund if all foods listed on the WIC check(s) are not purchased.

9. WIC checks or unused WIC foods may not be sold or exchanged for cash, or credit.

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-2- WIC foods may only be exchanged for equivalent WIC allowed items (ex: cereal for cereal). Report any unused WIC foods to the WIC nutritionist. Such sale or exchange is an abuse of the Program and may result in a suspension from the Program.

10. Use checks within the dates printed on the checks.

11. Return any checks not used to your local agency at your next check pickup time.

12. Serious or repeated violation of the rules is grounds for termination from the Program.

D. Because of the large amount of information given to participants at certification, Program complexity, and other factors, this information should be periodically reinforced at later appointments (nutrition, check pick up) and through other means.

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-3- General Guidelines

The following food package tailoring guidelines have been developed in conjunction with Section 246.10 of the WIC Federal Regulations which specify that:

246.10(b)(2)iii "...a competent professional authority to prescribe types of supplemental foods in quantities appropriate for each participant, taking into consideration the participant's age and dietary needs,... not to exceed the maximum quantities specified (in the regulations).."

246.10(b)(2)i "... this does not mean that a local agency must provide each participant with a food from each food group."

These guidelines shall be applied uniformly statewide. Local Agencies will be periodically monitored to ensure compliance with the following standards:

1. Food packages prescribed shall meet the individual nutrient needs of each participant.

2. Food packages are to be prescribed and changed only by the competent professional authority responsible for the participant's nutritional care. (No changes may be made without the nutritionist's or nurse's prescription.)

3. Reasons for all special (any nonstandard) food package changes or tailoring must be amply documented in the participant's record.

4. In the event that a person's special dietary needs cannot be met by the food packages listed, contact the State WIC Nutritionist for guidance.

5. Prescription of, and changes in, food packages shall reflect changing individual nutrient needs and food consumption patterns. Foods not needed may be tailored out of the package or quantities can be reduced to reflect need. Food packages may not be tailored for cost reasons.

6. Ready-to-feed formula may be used only if the competent professional authority determines and documents that one of the following conditions exists: a. Little or no cold storage exists (in this case, powdered formula, prepared a bottle at a time, may be the package prescription of choice). b. The mother, or guardian, cannot understand how to properly mix the formula and may dilute it improperly. c. Contaminated or restricted water supply. Requires documentation. d. Infant/Child is better able to thrive using the ready to use form of the formula e. Only available form of product. f. Sufficient medical documentation for an at risk participant.

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-4- 7. When tailoring the milk portion of the food package, please use the following guidelines in conjunction with maximum allowable quantities:

a. Milk and formula may be mixed in the same prescription but the amounts are dependant on the participants intake. b. Cheese may be substituted at a rate of one pound per three quarts fluid milk. One pound is the maximum amount which may be substituted for all categories except for fully Breastfeeding women, who may receive 2 pounds.

c. Evaporated milk may be substituted at a rate of one can (12 oz.) per one quart fluid milk.

d. Non-fat dry milk may be substituted at a rate of one pound per five quarts fluid milk.

Example: A child 3 years of age may have a food package that contains a maximum of 16 quarts milk, or equivalent, and wants 1 pound cheese, so the package would contain

13 quarts milk

13 qts and 1 lb. cheese x 3 qts./# =

3 qts 16 qts equivalent

8. Calcium fortified juice is available for use with women who do not consume milk and/or cheese. Custom food packages specifying “calcium fortified orange juice” should only be issued to women who receive no WIC cheese or milk. Calcium fortified juice is not available for infants or children.

9. Tailoring of the food package should occur at the following times:

a. At certification and recertification for all participants. b. For infants, changes that should be made at 6 and 12 months of age will need to be adjusted by the nutritionist. c. When a woman is recertified as a nonbreastfeeding postpartum woman (changes include decreasing milk and juice allowances), when a non-breastfeeding postpartum woman begins to breastfeed, or when a breastfeeding woman discontinues breastfeeding but is less than six months postpartum. e. At any time that a physician documents need for a change with a valid medical condition. f. At the request of a participant. g. At the nutritionist's discretion.

10. The number of checks (amounts of foods) given should generally reflect the period of use and be appropriate for each participant. If a participant is late in picking up checks, the local agency should evaluate the reason for the lateness and use discretion in determining when to prorate checks. In

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-5- deciding the appropriateness of prorating, the agency should take into account such factors as the following:

a. The participant's age and dietary needs;

b. That there is evidence of abuse or misuse of checks or supplemental foods, related to late pickup;

c. That late pickup is habitual;

d. That there is not good cause for the lateness;

e. That the participant cannot reasonably utilize the full amount of WIC foods;

f. Whether prorating would create a hardship for the participant.

11. A participant who picks up late should be counseled about the importance of receiving WIC checks at the appointed time and warned that if late pickup of checks continues, a partial package will be issued. Counseling and warnings should be documented in the participant record.

The local agency shall establish guidelines and procedures for warning and counseling and for referral of a participant to a Competent Professional Authority when there is a high risk that late pickup may be associated with abuse, misuse or misdirection of supplemental foods. The CPA shall evaluate the circumstances and only authorize the issuance of such checks as can be reasonably utilized by the participant. The CPA may, after notice to the participant, stipulate a prorating plan to take effect under specified condition(s) at a future recurrence, without again seeing the participant.

The RI WEBS computer system will automatically prorate unless overridden by the system administrator.

12. The recommended food package options for children 1-2 years of age, and 2-3 years of age are based on average nutrient needs at these ages. Care should be taken to adjust these amounts accordingly with the individual growth needs of each child, while not exceeding the Maximum Quantities Authorized for Children (see next section).

13. Packages for Participants with Qualifying Medical Conditions (see Section VII) may contain formula and supplemental foods as long as documented on WIC-23A/B by Health Care Provider.

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Maximum Quantities Authorized per Month

When tailoring food packages to meet individual needs, the maximum amounts of food, per category of participant, must be kept in mind. These maximum quantities may not be exceeded, although tailoring lesser quantities is allowable. Refer to Food Package Options Section of this guide.

I. Infants – Fully Formula fed

0 - 3 months

31 cans Iron fortified infant formula concentrate or 8 lbs. Iron fortified powdered infant formula or 25 cans Iron fortified infant formula ready-to-feed

4 – 5 months

34 cans Iron fortified infant formula concentrate or lbs Iron fortified powdered infant formula or 28 cans Iron fortified infant formula ready-to-feed

6 - 12 Months 24 cans Iron fortified infant formula concentrate lbs Iron fortified powdered infant formula 20 cans Iron fortified ready-to-feed formula

plus 24 oz. Infant cereal 128 oz. Baby food fruits & vegetables II. Breastfed Infants

For partially breastfeeding infants, formula may be issued to the participant in amounts up to one can less than the full package.

The State Agency will track the number of breastfeeding infants receiving a full formula package on a monthly basis. Infant checks found to be in violation of the policy will be prorated in future months as restitution for exceeding program benefits.

Note: Infants are eligible to receive infant cereal at age 6 months. It is recommended at this time for the breastfed infant to improve iron status. Up to 92 oz. fluid juice may be added if the infant can drink from a cup. Adult juice is used to encourage use of a cup in feeding

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-7- to reduce possibility of nursing bottle syndrome. 24 oz. Infant cereal 92 oz. Fluid juice

III. Children: 1 - 5 years of age

16 qts.

Fluid milk, or its equivalent (See # 7 in Tailoring Guide) 1 doz.

Eggs 128 fl oz.

Juice 36 oz.

Cereal 1 lb./64 oz canned

beans or peas Or 1-18 oz. jar

Peanut butter $6 in cash value vouchers Fruit & vegetable

2 lbs.

Whole wheat bread

IV. Pregnant and Partially Breastfeeding Women (up to 1 year postpartum)

22 qts.

Fluid milk or its equivalent 1 doz.

Eggs 144 fl. oz.

Juice 36 oz.

Cereal 1 lb./64 oz canned

beans or peas Or 1-18 oz. jar

Peanut butter 1lb.

Whole wheat bread+ $10.00

Cash Value Voucher for fruits and Vegetables

V. Fully breastfeeding (up to 1 year postpartum)

24 qts.

Fluid milk or its equivalent

2 doz.

Eggs

144 fl. oz.

Juice

36 oz.

Cereal

1 lb.

Cheese

$10 in cash value vouchers Fruit & vegetables

1 lb.

Whole wheat bread

30oz canned

Fish

1lb./64oz canned

beans or peas AND

1-18oz jar

Peanut butter

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$10.00

Cash Value Voucher for fruits and Vegetables

VI. Postpartum Women

16 qts.

Fluid milk or its equivalent 1 doz.

Eggs 96 fl. oz.

Juice 36 oz.

Cereal

$8 in cash value vouchers Fruit & vegetables

1#/64 oz canned

beans or peas

Or

1-18oz jar

Peanut butter

$10.00

Cash Value Voucher for fruits and Vegetables

Note: Whole wheat bread is not permitted to be tailored into the food package for postpartum women. Also, the milk and juice amounts have been decreased to reflect changing nutrient needs.

VI. Infants with Special Needs

8 lbs. Powdered special formula-specified or 25 cans (32 oz.) infant formula R-T-F

plus, if need is indicated, a maximum of

128 oz Infant fruits and vegetables 24 oz. Infant cereal

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VII. Women and Children with Special Needs

31 cans

Iron fortified infant formula concentrate or

8 lbs.

Powdered special formula (specified) or 25 cans (32 oz.) Iron fortified infant formula R-T-F

plus, if need is indicated, a maximum of

Any foods based on category and approved by the medical provider

Any participant over the age of two on a food package III formula may receive whole milk.

Note: A WIC Prescription Formula Form documenting need for formula is necessary to prescribe this package, and should be present in the participant's chart.

Note: The Rhode Island WIC Program follows the American Academy of Pediatrics June 1988 recommendation that iron-fortified formula should be provided to non-breastfed infants in the WIC Program through the first year of life.

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-10-

Issuance of Formulas

Rev 06/07

Contract Formulas

1. Standard Contract Formulas

MEAD JOHNSON ENFAMIL PREMIUM 12.5 OZ POWDER MEAD JOHNSON ENFAMIL PREMIUM 13 OZ CONC.

MEAD JOHNSON PROSOBEE 12.9 OZ POWDER MEAD JOHNSON PROSOBEE 13 OZ CONC.

2. Non-Standard Contract Formulas

MEAD JOHNSON ENFAMIL PREMIUM 32 OZ. RTU MEAD JOHNSON ENFAMIL PREMIUM 4 -8 OZ. RTU MEAD JOHNSON PROSOBEE 32 OZ. RTU MEAD JOHNSON PROSOBEE 4-8 OZ. RTU MEAD JOHNSON ENFAMIL GENTLEASE 12.4 OZ POWDER MEAD JOHNSON ENFAMIL GENTLEASE 32 OZ RTU MEAD JOHNSON ENFAMIL A.R. 12.9 OZ POWDER MEAD JOHNSON ENFAMIL A.R. 32 OZ RTU

Non-Contract Formulas

1. Non-Contract Formulas (milk and soy-based)

Milk-based formula produced by a company other than Mead Johnson

Soy-based formula produced by a company other than Mead Johnson

2. Special Non-Contract Formulas

Nutramigen, Alimentum, Pregestimil, Ensure, Pediasure Other special metabolic formulas

CONTRACT FORMULAS

Mead Johnson Enfamil premium and Mead Johnson Prosobee are the contract formulas issued by WIC in Rhode Island. This is because the WIC Program has a contract with Mead Johnson to

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-11- receive a rebate for each can of Mead Johnson Enfamil Premium or Mead Johnson Prosobee. Formula-fed participants will be issued a contract milk-based or soy-based infant formula (Mead Johnson Enfamil Premium or Mead Johnson Prosobee. The WIC Program receives a rebate for all forms of Mead Johnson Enfamil Premium or Mead Johnson Prosobee, concentrate, ready-to-feed; therefore, all forms are considered contract brands.

Mead Johnson Enfamil Premium or Mead Johnson Prosobee in 13 oz. concentrate or powdered cans are considered the standard contract formulas. Ready-to-feed cans are considered non-standard contract formulas since documentation is needed to justify the issuance of ready-to-feed formula even if it is the contract brand.

Procedures:

Level 1 Standard Contract Formulas

Formula fed participants shall be issued WIC checks for Mead Johnson Enfamil Premium or Mead Johnson Prosobee in 13 oz. concentrate or powdered cans unless a documented reason exists for a non-standard contract formula or a formula not covered by the Mead Johnson contract.

Level 2 Non-Standard Contract Formulas

A. Ready-to-feed Mead Johnson Enfamil Premium or Mead Johns Prosobee may be issued only if the competent professional authority (CPA) determines and documents that one of the following conditions exist:

1. Little or no cold storage exists (in this case, powdered formula prepared a bottle at a time may be the prescription of choice).

2. Contaminated or restricted water supply.

3. The mother or guardian cannot understand how to properly mix the formula and may dilute it improperly.

4. Appropriate medical rationale is documented for an at-risk participant.

When authorizing ready-to-feed formula for any woman, infant, or child use the WIC Prescription Form. The WIC Prescription Form can be completed by the local agency CPA for ready-to-feed formula. One copy of the WIC Prescription Form should be kept in the participant's chart. One copy of the WIC Prescription Form should be sent to the State WIC Office.

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B. Mead Johnson Enfamil Premium or Mead Johnson Prosobee issued to Women or children is also considered non-standard since physician documentation is needed prior to issuance. As with other non-standard contract formulas, the participant's physician must complete a WIC Prescription Form prior to issuance. One copy of the Prescription Form should be kept in the participant's file and one copy should be sent to the Sate WIC Office.

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Non-contract milk-based or soy-based brands of formula are available, but will only be issued if a physician documents that a trial of the contract brand of formula would put the infant at risk because of a medical condition or if intolerance has been established after the infant has been tried on both the contract milk-based and soy-based formula. The majority of participants with these medical conditions will require a special formula such as Nutramigen or Pregestimil rather than a non- contract milk-based or soy-based formula.

Any infants receiving a non-contract brand of formula will reduce the total amount of rebate funds, thereby reducing the number of additional WIC participants that can be served. All major brands of commercially-produced milk-based or soy-based formulas are nutritionally equivalent and because of the Infant Formula Act there are minimal differences among the brands. True intolerance to milk based or soy-based formulas are actually quite rare. Infants may have symptoms that are related to food intake but other factors such as improper formula preparation, storage techniques, and feeding techniques must be considered.

B. If a parent or guardian reports that the infant is intolerant to both the contract milk-based and soy-based formula, determine whether the symptoms are due to a true intolerance or other factors. The symptoms of formula intolerance are similar to symptoms caused by improper formula dilution, preparation, and storage or poor infant feeding techniques. Therefore, make sure the parents are following the guidelines discussed below before switching to another infant formula. Use the guidelines below to screen for formula intolerance. Documentation of the results of the screening, counseling, and referrals must be documented. This may be documented in the participant's progress notes.

1. If the infant has been sick or had a fever during the past week or longer, ask the parent/caretaker if the infant had the intolerance symptoms before becoming ill.

2. If the infant has been taking medication during the past week or longer, ask if the infant was experiencing the symptoms before he/she started taking the medication.

Some medicines will make the infant experience symptoms similar to formula intolerance, but the symptoms will subside once the medication is discontinued.

3. Make sure the baby is not being overfed.

Review the signs of a full baby with the parent/caretaker. These include the following:

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-the baby will close his/her mouth. -the baby will stop sucking the bottle or breast. -the baby will want to play instead of eat.

Stress the importance of not overfeeding the infant. Explain that this could cause symptoms similar to formula intolerance. Review appropriate amounts of formula to feed baby.

4. Make sure that the hole in the nipple is not too large.

If the parent/caretaker has enlarged the nipple, then the formula may be flowing too readily and may cause the infant to spit up or choke. Also make sure that the nipple is appropriate for the age of the infant and for the liquid that is being fed. Different nipples are available for water, formula and juice.

5. Make sure the infant is being burped properly and at the correct intervals.

Newborns (birth to 6 weeks) need to be burped after every ounce of formula. Infants older than six weeks old need to be burped after every 2 ounces of formula. The infant can be burped by holding him on the parent’s shoulder, on the lap, or across the lap while gently patting his back. The baby should be well supported.

6. Make sure the infant is held during the feeding so his head is a little higher than the rest of his body.

This makes the feeding easier and more comfortable for the baby, and he is less likely to spit up the formula later. Infants should not be fed in infant seats or swings and bottles should never be propped up. Propping the bottle could cause choking, earache, or nursing bottle mouth (tooth decay).

7. Make sure the formula is diluted properly.

If not, counsel parent/caretaker about the correct method of mixing formula.

If symptoms are mild and a result of improper formula preparation or feeding techniques or other factors discovered during your screening for intolerance, provide appropriate counseling and continue to issue Mead Johnson Enfamil Premium or Mead Johnson Prosobee. Remember that both milk-based (Mead Johnson Enfamil Premium) and soy-based formula (Mead Johnson Prosobee) are available as contract brands. Document the results of your evaluation, your counseling, and referral in a progress note. Continue to issue checks for the contract brand of formula.

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If the infant is not gaining weight, if the symptoms are severe, or if the symptoms appear to be a true intolerance to the contracted formulas refer the parent or guardian to the infant's physician for a medical evaluation and for further guidance on issuing formula. Document the results of the formula intolerance evaluation and your referral in the participant's progress note.

C. If the parent refuses the contract formula (Mead Johnson Enfamil Premium or Mead Johnson Prosobee) and there is no documented medical reason to prescribe a special prescription formula explain as diplomatically as possible that Mead Johnson Enfamil Premium or Med Johnson Prosobee are the standard formulas that WIC supplies. Point out how necessary it is to stretch WIC monies to serve as many WIC participants as possible. If the parent wants another brand, s/he will have to purchase it on her own. Offer the parent the complete set of checks and encourage trying the standard contract brand. If WIC formulas are still refused, issue checks for baby food and cereal only (if appropriate for age) and tell the parent that WIC will be happy to provide Mead Johnson Enfamil Premium or Mead Johnson Prosobee at any time that the parent changes her/his mind. Keep a log of those who refuse to use the contract brand of formula. Continue to provide nutrition education and support. Refusal to accept this food item should be treated just like refusal to accept any other food item. It does not affect other Program benefits.

D. If the conditions above are met for the issuance of a non-contract formula, then use the WIC Prescription Form to document the need for the non-contract brand of formula.

1. Completed WIC Prescription Forms (WIC-23) must be received from the participant's physician before issuing any non-contract brand of formula.

The local agency may complete the form to document a telephone conversation with the participant's physician in order to expedite the formula issuance. However, a WIC Prescription Form must subsequently be obtained from the physician.

2. The WIC Prescription Form (WIC-23) must be kept in the participant's WIC chart. The State WIC Agency may at any time request a copy of the WIC-23 for review and tracking of non-contract formula usage.

Physician requests containing sufficient justification and documentation will be approved by the local agency CPA. Requests containing insufficient reasons or lacking supporting documentation need to be discussed further with the ordering physician.

3. Intolerances are usually transient and warrant only temporary use of a non-contract formula. Medical literature supports the view that rechallenging infants after 1-2

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-16- months is an acceptable procedure.

To prevent unnecessary issuance of non-contract formulas, infants should be retried on Mead Johnson Enfamil Premium or Mead Johnson Prosobee in 1-2 months or when symptoms subside, whichever comes first. If symptoms of intolerance are so severe or a medical condition exists which would make a rechallenge inappropriate, continue issuing the non-contract formula for the length of time specified by the physician on the WIC Prescription Form. Under no circumstances should a prescription for a non-contract formula, even if for a diagnosed medical condition, be continued from one certification to the next without determining the need for continued issuance.

Parents/caretakers of infants who will be rechallenged within 1-2 months of issuance should be informed of the retrial when any non-contract formula is authorized. Prescription formula logs should be used to track the length of issuance appropriate for the infant and the date for retrial on Mead Johnson Enfamil Premium or Mead Johnson Prosobee should be noted. This will help to ensure that non-contract formulas are continued no longer than the period of time prescribed by the physician and those infants appropriate for a retrial of the contract formula are retried within 1-2 months.

If there is sufficient reason not to retry an infant on Mead Johnson Enfamil Premium or Mead Johnson Prosobee, then the reason must be documented in RIWEBS in the participant's progress note.

4. The State WIC Office will monitor rates of issuance for non-contract formulas. Tracking these rates will allow the State Agency to identify possible overuse of non-contract prescription formulas. The State WIC Office will provide technical assistance to local agencies and physicians with high issuance rates. ** Addendum – as a result of overuse of partially hydrolyzed formulas (such as Nutramigen and Alimentum) without first trialing contract formulas such as MJ Gentlease and Enfamil AR, the State WIC office has instituted an access code approval for all partially hydrolyzed formulas. CPA will need to get State WIC office prior approval before vouchers for these formulas can be issued. Furthermore, CPA are required to utilize the “Formula Intolerance screening tool” to assess appropriateness of partially hydrolyzed formulas.

5. When a physician requests a return to standard contract formula, a WIC-23 must be completed by the physician and returned to the local agency as documentation that the participant no longer requires the specialized formula / medical food. If a WIC-23 is not received, a phone call must be made to the physician’s office as documentation.

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-17- Documentation of this phone call must be added to RIWEBS.

APPROVAL OF NON-CONTRACT STANDARD FORMULA PRESCRIPTIONS

Please be sure to contact the participant’s physician regarding any questionable prescriptions for clarity. State nutrition staff may be contacted if further questions remain after speaking with the participant’s physician. The following list includes common examples of medical rationale being reported on prescription forms and the appropriate action to be taken by nutrition staff:

• Vomiting  Taste issues/over feeding/occasional vomiting NOT APPROVED  GI disorder/frequent vomiting/weight loss  CALL DOCTOR FOR CLARIFICATION

Note: Frequent vomiting can occur if formula is not gradually introduced.

Confirm/encourage gradual introduction of Good Start for better outcome.

• Diarrhea Softer stools can be expected NOT APPROVED  Weight Loss/Dehydration/Blood CALL DOCTOR FOR CLARIFICATION

• Refusal of formula Taste, cold turkey formula introduction NOT APPROVED Note: Infant should attempt new formula for at least 1 week before alternate formula is issued. Assess for/encourage gradual introduction.

• Fussy/Gassy/Colic – NOT APPROVED Note: Determine age of infant, if infant has entered an age related colicky stage; a formula change may not have been the leading cause. The colic may have still presented itself on the previous formula. Assess for/encourage gradual introduction.

• Intolerance  CALL DOCTOR FOR CLARIFICATION

• Only formula that works CALL DOCTOR FOR CLARIFICATION

If the prescription is clear in the validity of medical rationale, local agency nutrition staff does not HAVE to call the doctor or the State Office.

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-18- The State Office will be performing regular QA on the issuance of non-contract standard formulas through RI Webs. This will help reveal any trends in formula use for specific areas and for appropriateness of issuance.

Level 4 and 5 Special Non-Contract Formulas

Special formulas are formulas designed to meet the special nutritional needs of infants, children, and women. Special formulas require a written physician's prescription prior to issuance.

Special non-contract formulas include specialized nutritional formulations such as Nutramigen, Pediasure, Pregestimil, Ensure.

Procedures:

A. The name of the particular Level 4 formula prescribed will be printed on the participant's checks. A WIC Prescription Form (WIC-23) must be completed by the patient's physician prior to issuance of the prescription formula. One copy of the WIC Prescription Form should be kept in the patient's chart.

B. Level 5 Special non-contract formulas or other speciality formulas require prior approval of the State WIC Nutrition Coordinator and will require the use of a WIC Prescription Form. (See information on WIC Prescription above.) Some Level 5 formulas are direct purchased from the manufacturer / distributor by the State WIC Office. A WIC Prescription Form must be completed by the patient’s physician prior to issuance of the prescription formula. One copy of the WIC Prescription Form should be kept in the patient’s chart and one copy should be sent to the State WIC Office. The Nutritionist should then call the State WIC Nutrition Coordinator for an access code to issue the formula.

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-19- Need for Prescription Formula Safeguards

It is important that those participants on prescription formulas receive the correct formula. The following procedures should be followed to ensure that each participant receives checks coded for the correct formula:

A. Those requiring a special prescription should have a valid medical justification for ordering the formula. B. RIWEBS will require the accurate dates the formula is approved for, the nutritionist needs to verify these dates when entering into the system. C. The Local Agency should notify a parent when the prescription for a non-contract formula, medical food or exempt formula is due to be renewed. D. The participant should have a follow up appointment to review diet and tolerance E. The client should review the checks to ensure the correct formula is issued.

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-20- Guidelines for Preparing Formula

Ready To Use Formula - No mixing is required. Feed to baby as is.

Concentrate Formula - Mix equal amounts of formula and clean water.

Powdered Formula - Mix 1 level scoop of powder for every 2 ounces of clean water used to make the bottle. If you are making an 8 ounce bottle, you would mix 4 level scoops of formula with 8 ounces of water.

8. Make sure the formula is kept at the correct temperature.

Recommend that the refrigerator temperature be checked to make sure it is between 35 and 40 degrees Fahrenheit. Caution against allowing the formula to remain unrefrigerated for more than 30 minutes before feeding to the infant. When away from refrigeration for a long period of time, recommend using powdered formula or keeping the formula on ice.

9. Make sure the formula is prepared in a sanitary manner as directed by physician or clinic staff.

Review the following steps for preparing formula with the parent/caretaker.

Aseptic Method a. Wash bottles, nipples, disc seals and caps with hot, soapy water and a bottle brush. Be sure water is able to get through the nipple hole. Rinse well. b. Place bottles, nipples, disc seals, caps and tongs in a large pan. Add approximately five inches of water and boil 5-10 minutes with the lid on. Remove bottle supplies from sterilizer with tongs and place on clean cloth or paper towel. c. Boil the water to be used in mixing the powdered or concentrated formulas for 5 minutes. Cool. d. Mix formula with the boiled and cooled water according to the label on the can. e. Using tongs, place nipples (upside down) disc seals and caps on the filled bottles.

Terminal Method a. Wash bottles, nipples, disc seals and caps with hot, soapy water and a bottle brush. Be sure water is able to get through the nipple hole. Rinse well. b. Mix the concentrated or powdered formula with water according to the label on the can. c. Put nipples in bottle, upside down, with disc seals covering top. Screw top on loosely. d. Put bottles in a rack or on a towel in a big pot. Add 2-3 inches of water.

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Single Bottle Method (recommended if bottle supply is limited) a. Wash a one-quart jar or container with lid in hot, soapy water. Rinse well with boiling water. b. Boil the water to be used in mixing powdered or concentrated formula for 5 minutes (boil enough to make a day's supply of formula). Cool. c. In the clean container, mix the formula with the boiled and cooled water according to the label on the can. d. For each feeding, wash bottle, nipple, cap and tongs with hot, soapy water and a bottle brush. Be sure water is able to get through the nipple hole. Rinse well. e. Place bottles, nipple, cap and tongs in large pan. Add five inches of water and boil 5-10 minutes with the lid on. Remove the bottle supplies with the tongs and place on a clean cloth or paper towel. f. Fill the bottle for one feeding from the mixed formula stored in the refrigerator.

10. The sterilization of water and bottles should be continued until the infant is 4-6 months of age. After that time, preparation using safe tap water and proper washing techniques should be adequate.

11. Formula should be stored in the refrigerator and used within 24 hours. Formula that is left after 24 hours should be thrown away.

12. Caution the parent/caretaker to always throw away formula left in the infant's bottle after a feeding. It should not be used later. Formula that has come in contact with baby's mouth should not be resterilized.

13. Make sure the parent/caretaker is following these guidelines when introducing new foods into the infant's diet.

- Introduce one new food at a time. - Try each new food for 5-7 days before trying another food. - Check for reactions such as diarrhea, skin rashes, wheezing, and

colic (some of the same symptoms are caused by milk intolerance). - If the infant dislikes a food, try it again a few weeks later.

14. If there is a family history of cow's milk allergy, refer to physician for evaluation of need for a soy-based formula. If the baby develops intolerance symptoms with the soy-based formula, a referral to physician for medical evaluation should be made.

15. If there has been recent emotional upset in the family, explain to the parent/caretaker that this

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SECTION 430

Index

Sections:

Pages: Index

1 Introduction

2 Nutrition Education Goals

2-3 Local agency Responsibilities

3 Frequency of Nutrition Education

3-4 HIV and AIDS Information

5 General Points

5

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Introduction

The purpose of nutrition education in the WIC process is to ensure that participants understand the importance of nutrition during the stages of pregnancy and early childhood. The quality of nutrition that expecting mothers, nursing mothers, and infants receive largely determines the overall health and future development of each child. Poor nutrition during these important years of development can result in an abundance of future health complications. These crucial years are also the time that a child develops eating habits that, in many cases, will last their entire lives. It is for these reasons that it is crucial that during each nutrition education contact you strive to make a lasting impression and provide the most practical and valuable information possible to every single participant.

A. Local Agency Responsibilities: There are certain regulations that all WIC offices must adhere to. Each office must: 1. Provide quality nutrition education at no cost to each participant or guardian. 2. Integrate nutrition education into, participant health care plans, the delivery of supplemental foods, and other Program operations. 3. Develop and implement an annual Nutrition Education Plan that is consistent with the nutrition education portion of the State Plan, and Federal Regulations.

B. Nutrition Education Goals: The goal in any WIC counseling session is to identify any and all nutritional pitfalls that participants may be experiencing. To accomplish this, the techniques and strategies of VENA should be utilized. These strategies illustrate employ specific psychological devices that encourage participants to look within themselves to discover their own individual nutritional and medical risks. This will in turn empower participants to further address these shortcomings in a positive non judgmental setting, rather than be told by a nutritionist all of the things that they are doing “wrong” which only causes participants to become defensive and disenfranchised. Because of the potential for confusion and difficulty when counseling it is important to remember three key parts of the VENA strategy. 1. Always keep eye contact with the participant: When meeting with any participant and discussing their current nutritional standings it is important to remain engaged in the conversation. Although it is important to transcribe the details of the meeting in the general notes section of the participants file it should not be done while meeting with the participant.

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2. Make the environment comfortable: It is important to be mindful that many participants are nervous and anxious when meeting with nutritionists. To help curb those fears it is important to create a comfortable atmosphere devoid of any obstacles, such as desks, between you and the participant.

3. Be understanding: There is a great amount of pressure put on women and mothers to eat only certain foods and to look a certain way. Because of this it is important to keep all meetings judgment free. People respond better to friendly honest advice and will usually not get their back up when instructions are given.

4. Be clear and concise: When meeting with participants remember that they are neither nutritionists nor WIC employees. This means they do not understand technical jargon. When explaining medical conditions and testing use easy to understand words and analogies to illustrate your point. The same reasoning applies to the explanation of WIC benefits. Never assume that the participant will understand the process, always fully explain every facet of the WIC supplemental foods package in clear over illustrated terms. This will not only help the participant to avoid issues with following instructions but will help the local and State offices by reducing the amount of participant confusion and complaints.

C. Frequency of Nutrition Education Contacts: 1. For Participants during Pregnancy or Certified for 6 Months When scheduling nutrition education appointments for participants that are either pregnant or certified for a full six month period, try to schedule one appointment every three months or at least two appointments over the six month period. During these contacts discuss the following with the participant: (a) At the first nutrition education Contact explain: • What WIC provides and why they qualify for WIC benefits • WIC procedure: who the food is for, who can use the checks… • The supplemental nature of WIC benefits • What’s their current nutritional standing • What, if any, are their nutritional risks • The importance of regular physician checkups • Counseling on breastfeeding if applicable • The importance of STD testing and the risk of transmission to their child • The detrimental effects of drugs, alcohol, and tobacco • Create obtainable nutrition goals for themselves and their child

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(b) At the Second Nutrition Education Contact (SNEC): SNECs Provided by CPA’s only

(1) Routine nutrition education contact: Participants should be encouraged to attend group information sessions which can count as a SNEC. Otherwise they can schedule a SNEC on an individual basis. This secondary contact is the time in which individual goals should be discussed and adjusted as necessary.

OR

(2) High risk nutrition education contact: All participants designated as high risk, according to local agency criteria, will receive a high risk care plan outlined in the SOAP notes section of RIWEBS. It will include a plan designed by the local agency nutritionist. Each high risk participant will receive a minimum of one follow-up visit. However, an individualized care plan can be provided to any non-high risk participant at his/her request. 2. Extended Certifications 1 year certifications Breastfeeding mothers and infants are considered extended certifications and should be seen once every 2-3 months but not less than 4 times in one year. These appointments should be scheduled at a convenient time for the participant to assure attendance and can be scheduled at the initial nutrition education contact. As with all contact with the participant these nutritional consultations should be noted in the participant’s progress notes.

NOTE**For infants and women on extended certifications, at least one follow-up contact must be an individual appointment; which should include a height/length and weight measurement, assessment and blood work (as indicated). For a mother who is providing “some breastfeeding”, she will no longer receive a food package after the infant turns 6 months of age, but she will still be considered active on the program and is eligible to receive nutrition education and referrals as needed. For this mother, nutritionists should document nutrition education contacts in the mothers chart at 9 months and 12 months postpartum, respectively. Additional nutrition education visits may be conducted at the nutritionists’ discretion.

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D. HIV and AIDS Information and Referral It is extremely important to impress upon participants the risks and dangers of HIV, AIDS, and other STD’s during pregnancy, birth, and breastfeeding. During the first nutritional consultation advise all participants to get tested for STD’s. If a mother is HIV positive strongly advise that she not breastfeed and refer her to the appropriate health care and supportive services. Due to the dangers of the transmission of HIV from mothers to children, every local WIC agency must have HIV and STD educational brochures available for participants, and must provide adequate training and reference information for their staff.

E. General Points

1. Individual participants cannot be denied supplemental foods for failure to attend or participate in nutrition education activities. Documentation of each nutrition education contact must be included in the participant's record, indicating receipt or refusal of the nutrition education. Not every participant will be willing to participate. Encourage all participants to take an interest in the nutritional well being of their child but don’t force information on those that are not willing, it’s counterproductive.

2. The type and content of the nutrition education visit must be documented in the general notes section for each participant. This will provide a reference for you, or any other nutritionist, to use during future nutrition education contacts.

4. Nutrition education contacts shall be the designed to meet the different language and cultural needs of all Program participants and should be implemented in a way that all participants, no matter their education level, will understand and benefit from the contact.

5. When Farmer’s Market Checks are distributed to a WIC participant, nutrition education regarding fresh produce must be provided, including but not limited to vegetable description, recipes, and nutritional information regarding different types of vegetables.

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SECTION 500

OUTREACH AND COORDINATION

(Goals – V, Operations – 5)

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SECTION 500

OUTREACH AND COORDINATION

(Goals - V)

510 - Outreach

Local agencies have a crucial responsibility for the outreach effort in their respective areas. Each agency has some valuable unique local relationships with referral and service sources. The local agency should seek methods of cooperating with these resources in order to both maintain its caseload and to reach a greater proportion of high risk individuals.

Local Agency Outreach Plan

A. In order to assess the local outreach needs, the local agency should monitor its caseload in terms of the total number served and the proportion of high priority participants enrolled.

B. State and locally developed outreach materials can be provided for dissemination through the outreach network. It is particularly helpful to increase dissemination of multilingual outreach materials.

C. When contacts are arranged on the local level, the state agency can provide written or audiovisual materials and, as much as possible, state agency staff to assist in public presentations.

D. All public information materials must bear the nondiscrimination statement (Sec. 8l0, H.).

E. A written plan should be developed and present in the state and local agencies which contains at least:

1. The assessment of outreach sources in the area, noting the potential of high risk clients of each. Describe the relationship and contacts with each.

2. Attach copies of outreach materials about the Program which will be provided to these agencies.

3. Identification of staff and other agency resources available to conduct outreach activities.

4. Steps which can be taken to publicize the availability of the Program.

5. Plans to coordinate services with other programs.

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SECTION 500 - 3 - 6. Steps which will be taken to reach potentially eligible pregnant women, or high risk children, with emphasis on early intervention and on reaching migrants, if appropriate.

7. Steps the agency will take to ensure that pregnant women and infants receive an appointment promptly.

8. Measures the agency can take to fill available openings, in addition to the usual schedule of certification contacts (ex: "Open House" and "Health Fairs", special certification days, additional staff or clinic hours).

9. A log or other record of outreach activities and results.

10. The agency should list in its outreach plan those local organizations that have contact with sizable numbers of potential WIC applicants. Local contacts may also supplement state activities. Primary emphasis should be given to those organizations serving potentially high priority persons or underserved groups in the population. Contacts with such sources can be established through direct initiation by the WIC Program, or affiliated health agency, or through attendance at local professional or civic gatherings.

11. Local health care providers should be contacted (by mail or visit) to provide information about the Program at least once yearly. These efforts will be most productive when combined with a demonstrated interest in coordination of care and cooperation.

12. Local offices of financial aid programs should be contacted yearly to secure referrals. Through such contacts, changes in the availability of openings, waiting list requirements, and referral procedures can be communicated.

13. The agency, at least once a year, should mail outreach materials to local health and social service agencies in the area, including any shelters for homeless women and children in the area. WIC posters and outreach pads should be displayed and maintained in at least three area locations. Locations may include local grocery stores, churches, resale shops, laundromats, day care centers, etc. State printed flyers are available in bulk. Agencies can ask grocers and pharmacies to place a flyer in shopping bags.

14. Local media should be contacted in an effort to obtain news and/or feature publicity. Such publicity can focus both on the nutritional benefits of the WIC Program, and the services offered by the local agency. Such media efforts often provide far more detail about eligibility requirements, agency hours, and application procedures than do features in broader statewide media. The agency should issue radio public service announcements to local radio stations each year and issue at least one press release to a local newspaper.

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520 - COORDINATION

Related to their economic and health status, WIC participants are likely to be in need of additional services provided by other health or human resource programs. Coordination between WIC and other programs can reinforce the effectiveness of the WIC benefits. The health status and quality of life can be enhanced. Coordination of services and referrals can provide additional support and encouragement to participants to begin, or continue, to receive a broad range of health related services. Expensive duplication of services can also be minimized, and frustration and discouragement avoided. In order to assure service to those most in need WIC must be accessible to all those in need. Part of that involves cooperation with other helping agencies serving the same population. The intent is to ensure referral between programs and facilitate application for several programs at once. This will avoid duplication of effort on both the agency and client side.

Health Services

Local agencies should establish effective procedures for referral of appropriate agency clients to the WIC Program. WIC is intended to be an adjunct to needed health care. WIC procedures should be designed to reinforce health care visits. Local agencies should be careful to avoid procedures which encourage participants to choose between health and WIC visits because of physical or chronological separation of services.

Whenever possible, WIC and health care visits should be combined. WIC and other agency health care staff should encourage participants to make maximum use of services. Patient care recommendations should be mutually agreed upon where there is a relationship (ex: WIC food package, desirable weight and diet recommendations).

When participants receive health care from a private provider, WIC staff should be aware of the provider's identity. Participant utilization of health care should be encouraged and inquired about. Constructive and cooperative relationships between the local agency and other health providers are recommended. Informal agreements concerning referrals, coordination of care, and communication of questions or concerns are potentially effective.

Medical Assistance and RIte Care

During certification, special effort should be made to identify potential Medical Assistance and RIte Care recipients, to give them information on Medical Assistance and to make referrals where appropriate. A pregnant woman, as soon as pregnancy is confirmed, can be considered for Medical Assistance. If possible, have the person call for an application on the spot (See Appendix for information). All pregnant women

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SECTION 500 - 5 - who have no health insurance should be referred to RIte Care for assistance.

Family and Child Services

In some instances, it may become apparent that the participant lacks the capacity to effectively obtain or utilize the WIC food benefits. Referrals to, or discussions with, family or child service or homemaker help agencies should be explored. When it is known that the Department of Children, Youth and Families is providing services to a participant family, appropriate use of WIC food benefits should be carefully monitored. Direct contact with other agencies without the client's participation, however, should be carefully evaluated for its implications on confidentiality requirements.

Economic Aid Programs

Local agencies are required by regulation to have available informational materials describing such programs as RI Works, Medical Assistance/ Rite Care, Child Support Enforcement and FSP and to coordinate with other programs, such as Fuel Aid. Specific addresses and telephone numbers of such programs should be offered to WIC participants or applicants who appear to be eligible for these programs (See Appendix for information).

Protective Services for Children

WIC local agency staff may be in a situation where they have reasonable cause to know or suspect (observation, complaints received) that a child (WIC participants and non-participants as well) is being abused or neglected. Under Rhode Island law, all complaints, suspicions or knowledge however received (mail, telephone, or in person) must be immediately telephoned to the Child Abuse and Neglect Tracking System (CANTS) at Department of Children, Youth and Families (DCYF). The telephone number of the DCYF Division of Protective Services, CANTS, is: 1-800-RI-CHILD. The WIC staff person (all levels of staff) who receives the information will record all of the appropriate information and telephone CANTS at DCYF about the situation. Refer to the WIC brochure "WIC - Child Abuse and the Law" for detailed information regarding WIC personnel responsibilities under the law.

Any person making a report required by the law is immune from any liability.

Abused and/or neglected child means a child whose physical or mental health or welfare is harmed or threatened with harm by his parent or other person responsible for his welfare.

Drug and Other Harmful Substance Abuse Counseling Services

During certification, effort should be made by questioning to determine if the applicant is taking any drugs or alcohol or other substances which could be harmful to the health of the applicant or her fetus. If such use is evident, WIC staff should refer the applicant to appropriate counseling services, if available, by giving the

Rhode Island WIC Program

Procedure Manual Sec. 500

SECTION 500 - 6 - applicant a list of such services. A list has been distributed to local agencies by the State agency and should be kept and made available to WIC adult participants and applicants. The local agency annual nutrition education plan should include a plan to coordinate services with local drug and other harmful substance abuse counseling and treatment services.

Breastfeeding Promotion Programs

Applicants will be referred to appropriate local breastfeeding support programs. A list of such services has been distributed to local agencies and should be kept for reference.

Other Special Services or Programs

If parents / guardians give permission, the WIC Program will share medical / nutritional / demographic information with the KIDSNET Program. Kidnset is the RI Dept of Health’s information system that tracks the provision of public health program services to children. WIC information will be disclosed to the lead screening, home visiting, and Early Intervention programs using permission obtained from the WIC – 5 WIC Eligibility Agreement. WIC information disclosed to Head Start and Lead Centers will require parental / guardian authorization documented on the WIC – 101 Third Party Authorization to Release Information form. This information will be restricted to coordinate care, assuring preventive health services are provided and for quality assurance. ( WIC – 101)

Participants may sometimes reveal specific health or social problems or needs during discussions with WIC staff. In such cases, WIC staff should explore the availability of resources within the programs of the local agency. Additionally, other known local programs or agencies providing health or social services can be referred to. Local programs such as food assistance agencies, nutrition education services like EFNEP, teen pregnancy programs, parenting and family stress intervention services and shelters for homeless women and children should be considered. Additional information about available services can be obtained from:

United Way 211 Department of Human Services - 462-1000 WIC State Agency Info Line - 401-222-5960

Documentation

Referrals discussed or made should be documented in the appropriate section of the participant folder in RI WEBS.

Rhode Island WIC Program

Procedure Manual Sec. 500

SECTION 500 - 7 - Financial Aid Programs / SNAP Programs

Refer WIC Applicant to Family Resource Counselors, or directly to RI Works, SNAP, Child Support Enforcement. See WIC Brochure WIC -44

Rhode Island WIC Program

Procedure Manual Sec. 600

SECTION 600

-1-

SECTION 600

FINANCIAL MANAGEMENT

Rhode Island WIC Program

Procedure Manual Sec. 600

SECTION 600

-2-

SECTION 600

FINANCIAL MANAGEMENT

(Goals - VI, Operations - 6)

610 - Reimbursement Claims

611 - Specified Allowable Nutrition Services and Administration (NSA)

Allowable NSA costs include the following:

A. The cost of nutrition education which meets the requirements of 246.11. During each fiscal year, the local agency shall use a minimum amount of 20% of the local agency's NSA expenditures for nutrition education and Breastfeeding Promotion. The local agency shall document the full amount of total NSA expenditures attributable to nutrition education and breastfeeding, including grant funds and other funds or values in its final closeout report for each fiscal year. If the local agency's reported nutrition education expenditures are less than the amount required to be spent, HEALTH may issue a claim for the difference. The local agency may request prior written permission from HEALTH to spend less than the required amounts for nutrition education and breastfeeding promotion and support if the local agency can document that a total of funds from other sources and Program funds will be expended at amounts equal to the required amount. Nutrition education costs are limited to activities which are distinct and separate efforts to help participants understand the importance of nutrition and breastfeeding promotion and support to health.

The cost of dietary assessments for the purpose of certification and the cost of prescribing and issuing supplemental foods shall not be applied to the one-sixth minimum amount required to be spent on nutrition education. Costs to be applied to the one-sixth minimum amount required to be spent on nutrition education may include, but need not be limited to:

(1) Salary and other costs for time spent on nutrition education consultations whether with an individual or group;

(2) The cost of procuring and producing nutrition education materials including handouts, flip charts, food models or other teaching aids and mailing nutrition education materials to participants;

(3) The cost of training nutrition educators, including costs related to conducting training sessions and purchasing and producing training materials;

(4) The cost of breastfeeding promotion and support, education and encouragement is an allowable nutrition education cost. Breastfeeding costs include the above categories and specific breastfeeding aids such as breast pumps, nursing bras,

Rhode Island WIC Program

Procedure Manual Sec. 600

SECTION 600

-3- and nursing pads, which directly support the initiation and continuation of breastfeeding, and salary and benefits expenses of peer counselors to assist women to continue with an initial decision to breastfeed.

B. The cost of Program certification procedures, including the following:

(1) Laboratory fees incurred for tests conducted to determine whether persons are at nutritional risk;

(2) Expendable medical supplies necessary to determine whether persons are at nutritional risk

(3) In connection with nutritional risk determinations, medical equipment used for taking anthropometric measurements, such as scales, measuring boards, and skin fold calipers; and for blood analysis to detect anemia.

(4) Salary and other costs for time spent on certification.

C. The cost of outreach services.

D. The cost of administering the food delivery system.

E. The cost of translators for materials and interpreters.

F. The cost of fair hearings including the cost of an independent medical assessment of the appellant, if necessary.

G. The cost of transporting rural participants to clinics when prior approval for using Program funds to provide transportation has been granted by the State agency and documentation that such service is considered essential to assure Program access has been filed at the state agency.

Additional part time sites will be considered whenever there is a request for such funds. Direct reimbursement to participants for transportation cost is not an allowable cost.

H. The cost of monitoring and reviewing Program operations.

I. Costs for auditing both Program Services and Administration costs and expenditures for food benefit redemptions. Food benefits values are determined by the State Agency based on actual redemptions (disregarding rebate credits) for months in which all issued FI's have been paid or expired and State Agency estimated redemption values for any month for which checks have been issued but not yet paid or expired. Figures are available upon request from the State Agency.

J. Training nutrition educators is an allowable nutrition education cost when it directly relates to the program. Periodic training such as in-service meetings, and professional

Rhode Island WIC Program

Procedure Manual Sec. 600

SECTION 600

-4- meetings and seminars for the nutrition professional including breastfeeding promotion and support, are a necessary and a justifiable expense.

6-12 - Costs allowable with approval. (Also see Property Management Standards Section 621) 9/97 The following costs are allowable only with the prior approval of HEALTH:

A. Capital expenditures over $500(per unit) must be approved by the Rhode Island Department of Health WIC Office. Capital expenditures exceeding $5,000 must also be approved by USDA/FNS.

1. Requests for approval of purchases of $500 or more up to $999, must be accompanied by three quotes, which can be obtained verbally but must be recorded at the time. If the local agency's preference is not the lowest price, the preference must be sufficiently justified in writing.

2. Purchases over $1,000 must go out to bid.

If an agency has formal policies which differ from this, it may request permission to follow its normal policies, instead, but may not necessarily be approved by RIDH.

B. Purchase of Medical Equipment

Any requests for purchasing medical equipment shall be submitted to the Rhode Island Department of Health WIC Program Office with all information regarding the items to be purchased, including manufacturer's and model numbers for approval.

C. ADP Expenditures

Any expenditures for automated information systems, except for those used in general management and payroll, including acquisition of automatic data processing hardware or software, whether by outright purchase, rental-purchase agreement or other method of acquisition, must receive prior approval of the state WIC agency and USDA/FNS, if funded in whole or in part with WIC administrative funds.

D. School Expenses

Local agencies may not use WIC administrative funds for college or graduate school tuition or expenses nor for college courses or training in the pursuit of a college or graduate school degree. However, the use of WIC funds for college courses or training in pursuit of a higher degree is not a justifiable expense. The latter is considered a personal career goal and does not necessarily provide any significant benefits to WIC participants. Reimbursement will only be made for any college course or training when approved in advance by the State Agency and USDA/FNS.

E. Travel - Local Agencies

Rhode Island WIC Program

Procedure Manual Sec. 600

SECTION 600

-5- All local agency travel requests over $100 requires prior approval from the State WIC Office in accordance with State Travel procedures, A-22.

Procedure:

1. Planning -

- Travel requests must be in writing and mailed or faxed to the Chief, Office of WIC Program as far in advance as possible to the date of travel, for approval or rejection from the State WIC Office.

2. Travel Advance -

- If necessary, a local agency employee may obtain a travel advance for conference fees and or registration if travel is approved; proper supporting documentation must be provided to the state agency.

3. Meal Allowance - in accordance with State Provisions

- Meal allowances for local agency WIC personnel who are planning to engage in state approved travel are as follows:

Per Diem: $30.00 per day

4. Lodging -

- Overnight accommodations will not be allowed within a 55 mile radius from workstation. Distance from home cannot be used in calculating the 55 mile radius.

5. Supporting Documentation -

- A copy of all supporting documentation must be submitted to the local agencys finance person who will then include everything with the local agencys monthly NSA expenditure report to the State WIC Office.

6. If you have any questions prior to travel, contact the State WIC Office Chief or Financial Person, to avoid delay or denial in initial approval or reimbursement.

* 613 - Submitted Reports

Local agencies are required to periodically complete and submit to the Rhode Island Department of Health several important reports as summarized below:

* Report

Submitted by

Rhode Island WIC Program

Procedure Manual Sec. 600

SECTION 600

-6-

WIC Actual Monthly

Within 30 days following Expenditure Report: (WIC-16A)

the end of the month

Staff Time for Nutrition Education

and Nutrition Services and Administration (16C)

Monthly Nutrition Services and Administration and Nutrition Education Expenditure Report (16B)

Monthly Nutrition Services and Administration and Nutrition Education Expenditure Report (16B)

* Annual Projected Budget

Prior to 15 September for next fiscal year

Local Agency Self-Assessment for Financial Mgt. October 1, each year (biannual)

Time Study Worksheet (Form WIC-16T)

Within 30 days after end of quarter

* Annual Breastfeeding Time Study (16BF)

October l, each year

* Annual Nutrition Services and

November 1 for prior Administration Expenditure Report (Closeout Report)

Fiscal year

Revised Budget-

as needed or requested by this office

Physical Inventory Report - Complete and submit at time expended with monthly expenditure report

Reports submitted incorrectly will be returned to the local agency for correction. The submission of incorrect reports could delay payment. Technical assistance is available upon request at the State WIC Office.

Local Agencies must submit reports on a timely basis. A delay in reporting interrupts the reimbursement and closeout process and could result in disallowance of charges.

Monthly Reporting of Expenditures - (Due 30 days after end of report month)

C. Staff Time for Nutrition Education and Nutrition Services and Administration

Rhode Island WIC Program

Procedure Manual Sec. 600

SECTION 600

-7- 1. General Procedures

(a) Employees whose salaries are covered at a total of 100 percent by other federal, state, or other grants will not be eligible for WIC salary support.

(b) Employees whose salaries are presently covered at a total of less than l00 percent by federal, state, or other grants may be eligible for WIC salary support. Also, any agency who files and is approved for a grant revision or adjustment to cover their salary at less than l00 percent may be eligible for WIC salary support.

(c) Such eligibility must be approved by the State agency prior to filing for coverage of salary.

(d) Each month, each employee conducting nutrition education activities or funded partially by WIC must complete a WIC-16C, Staff Time for Nutrition Education and Nutrition Services and Administration form and it must be signed by the employee and the executive director of the local agency.

(e) This form shall be completed and attached, on a monthly basis, to the Monthly Expenditure Report as filed by the local agency.

(f) The local agency is responsible for the accurate reporting and documentation of the employee's time. This method shall only cover activities specified as allowable administrative or programmatic costs as specified by USDA WIC regulations, or State WIC policies. Use of nutrition education resources charged to WIC may not be utilized for other than WIC participants if so doing would impede the certification of applicants, thereby effecting caseload, or jeopardize the quality of nutrition services provided to WIC participants.

(g) Allowable "In-Kind" costs include reimbursable administrative or nutrition education costs which are not paid for by any other federal grant.

2. Nutrition Education

Each staff member providing nutrition education shall maintain a daily record of time spent on nutrition education services performed for the local agency.

3. Nutrition Services and Administration

(a) The administration column must be completed for all personnel performing WIC related duties who are currently being charged only partially to the WIC Program except as noted under (e) below:

(b) The amount of time spent should be directly traceable to the amount charged on the Monthly Administrative and Program Services Expenditure Report for that employee.

Rhode Island WIC Program

Procedure Manual Sec. 600

SECTION 600

-8-

(c) It is the local agency's responsibility to ensure that these persons being charged to WIC are not being charged in excess of l00 percent of their salary.

(d) Employees being charged l00 percent to WIC are exempt from completing the Administration column.

(e) The local agency is exempt from this requirement if they utilize an acceptable formula when deriving partial costs per employee. It is the State agency's decision whether to allow the local agency formula. The justification for the formula should be maintained at the local agency for review.

B.1. Monthly and Nutrition Services and Administration Expenditure Report (WIC-16B)

(1) The purpose of this report is to provide documentation for the amount of dollars that WIC will reimburse you for the reporting month and for federal monitoring of staffing ratios. This report is inclusive of the data on the Nutrition Education Report. Such that this report is the total administrative dollar that the Rhode Island Department of Health will provide for reimbursement providing it is within your allocation level.

(2) Line I Personnel - It should be stated that for all charges, Personnel Fringe Benefits, Other Costs, there should be documentation to support the amount charged, e.g. payroll records, time cards, time sheets, purchase invoices, forms.

(3) Each employee's name, title, actual administrative expenditures being charged to WIC, administrative in-kind, hourly salary and number of hours worked should be listed.

(4) Line II Fringe Benefits - The actual amount being charged for Fringe Benefits should be listed on this line.

(5) Add line Ia plus line II. The total should be placed on line III. This is the total amount spent on Personnel and Fringe Benefits.

(6) Line IV Other Costs - This category should include any expense incurred during the reporting month for Other Costs previously listed in your annual budget. Some examples of this are: Travel, supplies, equipment, and nutrition education material. Once these direct costs have been listed they should be subtotaled on Line IV a. Any questions regarding allowable costs should be referred to the WIC Office. Line items combining more than one individual cost exceeding $500.00 on any monthly report or any change for such item(s) exceeding $500.00 on an annual closeout report should be supported by an attached itemized listing showing the vendor, total amount and portion charged to WIC. A WIC-17 Equipment Inventory Listing should be attached for each piece of equipment over $500.00.

Rhode Island WIC Program

Procedure Manual Sec. 600

SECTION 600

-9- (7) To derive the Actual Monthly WIC Administrative Expenditure, you should add line Ia, Actual Expenditure column, and line II, Fringe Benefits column, and line IV a, Actual column. These three costs will give you the total WIC Actual Monthly WIC Administrative Expenditure.

(8) The WIC office has added an encumbrance section. An encumbrance is an expense incurred in the form of purchase orders, requisitions, or invoices which are chargeable to an account and which a part of an account is reserved. The purchase ceases to be an encumbrance when paid, at which time it becomes an actual expense.

For example: If your agency ordered a scale in March then you would report this as an encumbrance on your March report. You must attach a copy of this purchase order to your monthly report when you submit it as an encumbrance to our office. When the scale comes in April and you pay for it in April, then you would report the scale as an actual expenditure under Other Costs and remove it from the encumbrance section. Capital expenditures will be allowable items which you can utilize as an encumbrance.

B.2. Monthly Nutrition Education Expenditure Report (16B)

(1) Once the nutrition education hours for each staff member are complete, the Coordinator should take the Monthly Nutrition Education Expenditure Report and fill in site name, month of report, list of names of all personnel who performed nutrition education and list the number of hours spent by each person. The number of hours spent should be obtained from the Staff Time for Nutrition Education Form.

(2) The Nutrition Education Coordinator shall also list any other costs that should be charged to nutrition education for the month, e.g. equipment, material printing, travel or telephone, on the Monthly Nutrition Education Expenditure Report.

(3) Once these data are complete, the Nutrition Education Coordinator should give the Monthly Nutrition Education Expenditure Report to the fiscal officer to complete.

(4) The fiscal officer should list the estimated annual NSA allocation at the top in the blank provided. This dollar amount should be multiplied by .l66 and this amount should be placed in appropriate block. The l/6 = dollar amount should then be divided by l2, and this figure placed in the last blank. This amount should be the minimum dollar spent on nutrition education providing you are spending at your monthly allocation level.

(5) Under the I, Personnel line item, all staff providing nutrition education should already be listed with the hours spent filled in. The fiscal officer should multiply the hours spent by the individual's hourly rate. This amount should be listed under Actual Monthly Nutrition Education or Nutrition Education inkind or a portion of the amount under each depending on the individual situation.

Rhode Island WIC Program

Procedure Manual Sec. 600

SECTION 600

-10- (6) The fiscal officer should fill in the actual amount being charged for fringe benefits to WIC for the personnel listed. This amount for Fringe Benefits should be placed on Line II under either Actual Monthly Nutrition Education or Nutrition Education In- kind depending on individual circumstances.

(7) The fiscal officer should then list any nutrition education purchases or other costs for the reporting month. This amount should be subtotaled on Line III a.

(8) Once these data are complete, the fiscal officer can derive the total dollars spent on nutrition education for the month: It is imperative to include the In-kind amount in deriving the total, since, even though WIC is not reimbursing the local agency for In- kind, the service is still being provided to WIC participants and can be credited to the l/6th nutrition education requirement.

(9) In deriving total nutrition education costs, add line III (Actual and In-kind) and NSA Actual and In-kind and place this dollar amount on the line TOTAL NUTRITION EDUCATION EXPENSES C. and D.

(10) Once these figures are computed, you may derive the total amount of dollars spent on nutrition education for that month by adding V C. and D.

(11) Before answering the questions concerning, "Is Nutrition Education at least l/6 NSA money?," you must complete the Monthly Expenditure Report.

(12) Adjustments from previously submitted reports included in the monthly expenditure total should be reported on the form 16A. The amount, reason and month being adjusted should be indicated. Additional justification or backup should be attached if required.

A. WIC Actual Monthly Expenditure Report (16A)

Once all amounts are derived you must bring all the totals to the front summary page WIC- 16A, WIC Actual Monthly Expenditure Report. Once signed, your agency should maintain a copy for at least three closed out fiscal years or until notified by our office for audit purposes; the following should be sent to our office by the end of the following month:

(1) Staff Time for Nutrition Education and Administrative and Program Services

(2) Monthly Nutrition Services and Administration Expenditure Report and Monthly Nutrition Education Expenditure Report

(3) WIC Actual Monthly Expenditure Report

Annual Projected Budget (16D) (Due September 15)

Submitted annually including the same components, annualized, as A-D, above, subject to review

Rhode Island WIC Program

Procedure Manual Sec. 600

SECTION 600

-11- and approval by RIDH. In addition, such revised budgets as deemed necessary by RIDH must be submitted subject to RIDH review and approval.

Annual Administrative Expenditure Report (16E) (Due November 1)

Submitted annually including the same components, annualized, as A-D, above, subject to review and approval by the RIDH. No claim for additional reimbursement may be submitted on the Closeout Report that has not previously been shown on appropriate Actual Monthly Expenditure Report(s). Any request for exception to this policy must be made in writing, no later than thirty (30) days following the end of the federal WIC fiscal year for which the claim is made. Any such request must include full documentation and justification to the satisfaction of the RIDH. Any approval of such request is at the sole discretion of RIDH.

614 - Quarterly Time Study Worksheet (Form WIC-16T) (added 11/05)

Local agency and state staff must complete the Time Study Worksheet (WIC-16T) to document the percentage of staff time charged by WIC staff.

A. Categories to be Reported

1. General Administration – The time generally considered to be related to program monitoring, fraud prevention, outreach, general oversight and food instrument accountability. General clerical and administrative support would be other areas that would qualify for this category.

2. Client Services – The time expended to deliver food and other client services and benefits. Included would be time spent on diet and health assessments, prescribing and issuing supplemental food, and screening for drug and other harmful substance use and making referrals to drug and other harmful substance abuse services and other health-related screening.

3. Nutrition Education – The time that WIC staff plan or conduct nutrition education and training or are involved in evaluating and monitoring of nutrition education.

4. Breastfeeding Promotion and Support – All time expended for promotion and support of breastfeeding. Peer Counselors and lactation consultants, as well as other staff time devoted to promotion of breastfeeding related activities, should be included in this category.

B. Procedure for Completing WIC Time Study Worksheet (Form WIC-16T)

1. Provide agency name and clinic site, name of staff person, job title, date, and % FTE, if part time employee.

2. Report on the form actual time spent in one of the following four administrative cost categories:

a. General Administration

Rhode Island WIC Program

Procedure Manual Sec. 600

SECTION 600

-12- b. Client Services c. Nutrition Education d. Breastfeeding Promotion and Support

3. Record time in the appropriate sub-category listed under each cost category. Indicate time in 30- minute intervals by putting an “X” or check mark in the box. Time must be documented for every day in the sample reporting month.

4. Signature of employee in the designated space upon form completion. 5. The time study must be conducted for one month per quarter of the grant year. Each local agency can choose the month to collect the data. The WIC-16T form must be completed for every day in the sample month. Forms are to be compiled by the WIC Coordinator and sent to the State WIC Office. Quarterly reports are due 30 days following the end of the report quarter (January 30th, April 30th, July 30th and October 30th). 6. Local Agency staff will utilize the WIC Local Agency Time Study Activity Descriptions/WIC 16- T Categories to be Reported form to ensure the appropriate cost category is selected for the various tasks.

7. Summary reports will be generated quarterly. Percentages for the four reporting categories will be calculated based on hours worked per category divided by total hours worked (net of leave time).

8. Other non-salary costs will be calculated by applying the agency percentage for each category to the total other costs reported for the year.

615 - Annual Breastfeeding Time Study (Form 16BF, Due October 1, each year)

Local agencies must calculate agency expenditures for breastfeeding activities by having local agency WIC nutritionists complete a two-week time study for allowable breastfeeding activities.

A. Examples of Allowable Breastfeeding Promotion and Support Expenditures

Although not exhaustive, the following list typifies allowable expenditures support of breastfeeding promotion and support:

1. Breastfeeding aids such as breast pumps, breastshells, nursing supplementers, nursing bras and nursing pads which directly support the initiation and continuation of breastfeeding;

2. Salary and benefit expenses of WIC staff delivering educational and direct client services related to breastfeeding;

3. Salary and benefit expenses of peer counselors and individuals hired to undertake home visits and other actions intended to assist women to continue with an initial decision to breastfeed;

4. Salary and benefit expenses of staff and non-WIC professionals to deliver/attend training on

Rhode Island WIC Program

Procedure Manual Sec. 600

SECTION 600

-13- breastfeeding promotion and support to be used for program purposes;

5. Costs to develop/procure educational materials, instructional curricula, etc., related to breastfeeding promotion and support;

6. Prorated costs of clinic space devoted to educational and training activities related to breastfeeding, including space and furniture set aside for nursing during clinic hours which would help provide an environment conducive to breastfeeding;

7. Salary and benefit expenses for WIC staff to participate in State and local planning committees dedicated to breastfeeding promotion;

8. Salary and benefit expenses and costs of materials, etc., utilized in the evaluation of breastfeeding initiatives (or contractual agreements entered into for this purpose);

9. Salary and benefit expenses for WIC staff to organize volunteers and community groups to support breastfeeding WIC participants;

10. Travel and related expenses incurred by WIC staff related to any of the above items; and

11. Costs of reimbursable agreements with other organizations, public or private, to undertake training and direct service delivery to WIC participants concerning breastfeeding promotion and support.

B. Procedure for Completing WIC Breastfeeding Time Study (Form 16BF)

1. List agency, signature of staff person, month of report, and staff person's hourly rate.

2. For each date listed as day worked, fill in columns "Total Hours Worked" and "Time Spent on Breastfeeding". Please refer to examples of allowable Breastfeeding and Support Activities.

3. Total the hours for each two-week column.

4. Signature of Supervisor must be on form and date of signature.

5. Report is due into the State WIC office October 1, each year.

Rhode Island WIC Program

Procedure Manual Sec. 600

SECTION 600

-14-

620 - Safeguards

621 PROPERTY MANAGEMENT STANDARDS

A. The Rhode Island Department of Health WIC Office requires that local agencies adhere to procedural requirements relating to the purchase of equipment with WIC monies.

B. Property records shall be maintained accurately, and shall include:

(1) A description of the property.

(2) Manufacturer's serial number, model number, stock number, or other identification number.

(3) Source of the property including grant or other agreement number.

(4) If property is to be used outside the WIC Program or scrapped, the Rhode Island Department of Health must be notified, prior to disposal, on a WIC-17.

(5) Acquisition date (or date received) and unit costs.

(6) a) Location, use and condition of the property and the date the information was reported.

b) All pertinent information on the transfer, replacement, or disposal of the property.

(7) Property owned by the Federal government must be marked to indicate Federal ownership.

(8) A physical inventory of property shall be taken and the results reconciled with the property records at least once a year.

(9) A control system shall be in effect to ensure adequate safeguards to prevent loss, damage, or theft of the property and shall ensure that it is used solely for authorized Program purposes. Any loss, damage, or theft of the property shall be investigated and fully documented. The agency shall promptly notify the Rhode Island Department of Health WIC Program Office.

(10) Adequate maintenance procedures shall be implemented to keep the property in good condition.

C. Title to Federally owned property remains vested in the Federal government.

D. Equipment Inventory

(1) Complete the Equipment Inventory Listing, WIC-l7, for each item or set of items purchased with WIC monies which costs equal or exceed $500.00. 9/97

Rhode Island WIC Program

Procedure Manual Sec. 600

SECTION 600

-15- (a) The local agency shall use the purchase requisition to obtain the necessary information to complete this form.

(b) The WIC-l7 shall be submitted to the Rhode Island Department of Health WIC Office as soon as any items purchased with WIC funds are received by the local agency.

(2) Each local agency shall submit annually an inventory listing Federally owned property in their custody to the Rhode Island Department of Health WIC Office.

(3) WIC equipment will be reviewed during on-site visits to ensure compliance with this policy.

(4) Equipment no longer needed or usable should be reported to the Rhode Island Department of Health WIC Program Office on a copy of the WIC-17 to facilitate transfer or disposal.

622 AUDITS/RETENTION OF RECORDS

Audits

A. In order to comply with Federal WIC Regulation 246.20, which mandates audits of State and local agencies, the State shall conduct or cause to be conducted, organization-wide audits in accordance with the provisions of 7 CFR 246.25 and Part 3016, "Audits of State and Local Governments." Other guidelines and documents to be followed will be:

(1) Compliance Supplement for Single Audits of State and Local Governments.

(2) OMB Circular A-133, "Audits of Institutions of Higher Education and Other Nonprofit Organizations.

(3) OMB Circular A-110 "Uniform Requirements for Grants to Universities, Hospitals and Other Nonprofit Organizations".

(4) Federal Management Circular, FMC-74-4, "Cost Principles Applicable to Grants and Contracts with State and Local Governments."

(5) WIC Program - State Conducted Audit Guide.

B. An audit shall be used to determine whether:

(1) Financial operations are properly conducted.

(2) The financial statements are presented fairly.

(3) The state and local agencies are complying with applicable laws, regulations, and administrative requirements that affect the expenditure of Federal funds.

Rhode Island WIC Program

Procedure Manual Sec. 600

SECTION 600

-16- (4) State and local agencies have established internal procedures to meet the financial management objectives of federally assisted programs.

(5) State and local agencies are providing accurate and reliable information to the Federal government.

C. The local agency shall have an independent annual audit conducted in accordance with 7CFR 3015 and A-110, and A-133 as appropriate.

D. Each local agency shall send a copy of all local agency sponsored audit reports covering any aspect of local Program related activities including, but not limited to, the complete A-110 and/or A-133 audit report and any related Management Letters, separate reports and local agency response and corrective plans.

(1) Such copies are due at the State WIC Agency no later than six months from the end of the fiscal year covered by the report. (2) The cost of these audits shall be considered a part of administrative and program services costs and may be funded from the local agency administrative and program services funds, as appropriate. For purposes of determining the Program's pro rata share of indirect costs associated with organization-wide audits, the value of food instrument redemptions shall be considered in the total dollar amount of the Program. Program service funds and food instrument values shall be listed separately (see Sec. 611, I, above).

Retention of Records

A. Program Records

Records shall include, but not be limited to, information pertaining to financial operations, food delivery systems, food instrument issuance and redemption, equipment purchases and inventory, certification, nutrition education, civil rights, and fair hearing procedures.

B. Subject to the requirements below, Program records shall be retained for the following "Retention Period":

A minimum of three (3) closed out federal fiscal years, plus the current operating fiscal year. This includes any record of any activities occurring in any part of the fiscal year.

(1) The Food and Nutrition Service or the Rhode Island Department of Health may, by written notice, require longer retention of any records necessary for resolution of an audit or any litigation, or for other purposes related to the administration of the Program. If FNS or the RIDH deems program records to be of historical interest, they may require the local agency to forward such records whenever the agency is disposing of them.

(2) Equipment inventory records - these records should be retained for the "Retention Period" following disposal of the property.

Rhode Island WIC Program

Procedure Manual Sec. 600

SECTION 600

-17-

(3) Fiscal Records - these records shall be obtained for at least the "Retention Period".

(4) Food Delivery System Records - check registers which bear the recipient's signature, voided checks, and the "End of Day" Check Transaction Logs shall be retained for at least the Retention Period. Check stubs shall be retained for three months from "last day to use" date plus the current month. Other food delivery records which are primarily managerial information, such as computer printouts, should be retained for as long as they are useful to the agency.

(5) Certification Records - all records which document the denial of eligibility, certification, or termination of participants and the supportive medical nutritional data used to make the certification decision should be retained for a minimum of the "Retention Period" and (for child participants) until the child turns 6 years old.

The Daily Caseload Report (from "End of Day" reports) and the Potential Dual Participation Report (from "Beginning of Day" reports) shall be retained for one year plus the current operating fiscal year.

Local agency developed forms, such as logs, intake sheets, etc., which are used for documentation or management need to be retained only if they are the source of documentation for decisions related to denial, certification, or termination of persons.

(6) Nutrition Education Records - records required by the state agency to document nutrition education expenditures, aggregate services, and individual services, need to be retained for the "Retention Period".

(7) Medical Records - medical records which contain any of the above data should be retained in accordance with the above WIC rules. In addition, local agency medical records policies may require that records be retained for longer periods of time whether or not they contain WIC certification or services information. (See Section 5 above)

(8) Notwithstanding the above, local agencies should also adhere to policies required by the agency

itself, its sponsoring body (city, hospital, etc.), or other funding sources (Department of Community Affairs, USPHS, etc.).

C. The Secretary of USDA, the Comptroller General of the United States, the state agency, or any of their duly authorized representatives, or designees, shall have access to any books, documents, papers and records (except medical case records of individuals unless that is the only source of certification data) of the State and local agencies and their contractors for the purpose of making surveys, audits, examinations, excerpts, and transcripts.

Rhode Island WIC Program

Procedure Manual Sec. 600

SECTION 600

-18-

623 CLAIMS AND PENALTIES

Claims

A. If the state agency determines through a review of the local agency's reports, program or financial analysis, monitoring, audit, or otherwise that any Program funds provided to a local agency for supplemental foods or administrative and program services purposes were, through local agency negligence or fraud, misused or otherwise diverted from Program purposes, a formal claim will be assessed the State agency against the Local agency. The local agency shall pay promptly to the State agency a sum equal to the amount of the administrative and program services funds or the value of supplemental foods or food instruments so misused or diverted.

B. If the state agency determines that any part of the Program funds received by a Local agency; or supplemental foods, either purchased or donated commodities; or food instruments were lost as a result of thefts, embezzlements or unexplained causes, the Local agency shall, on demand, pay a sum equal to the amount of the money or the value of the supplemental foods or food instruments so lost.

C. The local agency shall have full opportunity to submit evidence, explanation or information concerning alleged instances of noncompliance or diversion before a final determination is made in such cases.

Penalties.

In accordance with section 12(g) of the National School Lunch Act, whoever embezzles willfully misapplies, steals or obtains by fraud any funds, assets or property provided under Section 17 of the Child Nutrition Act of 1966, as amended, whether received directly or indirectly from USDA, or whoever receives, conceals or retains such funds, assets or property for his or her own interest, knowing such funds, assets or property have been embezzled, willfully misapplies, stolen, or obtained by fraud shall, if such funds, assets or property are of the value of $100 or more, be fined not more than $10,000 or imprisoned not more than five years, or both, or if such funds, assets or property are of a value of less than $100, shall be fined not more than $1,000 or imprisoned for not more than one year, or both.

624 RESTRICTIONS ON LOBBYING

Restrictions on Lobbying Common Rule:

The New Restrictions on Lobbying Common Rule was issued on 26 February 1990 by the OMB in response to Section 319 of Public Law 101-121. This new legislation was signed on 23 October 1989 and was effective 60 days later, on 23 December 1989.

The rule includes provisions which prohibit the use of appropriated Federal funds for the lobbying of the Executive or Legislative Branches of the Federal Government in connection with procurement and no procurement contracts, grants or loans. It also requires the reporting of payments made with non-appropriated

Rhode Island WIC Program

Procedure Manual Sec. 600

SECTION 600

-19- funds for lobbying purposes.

For the USDA, the Common Rule will be identified as 7 CFR 3018. Appendix A of the Common Rule contains the certification statement which must be filed by each recipient of a Federal grant, cooperative agreement, loan, or contract/subcontract (see Subpart A____110). Appendix B contains a specimen copy of the Lobbying Activities Disclosure Form (SF-LLL), which must be filed if non-appropriated funds are used for lobbying purposes.

625 WIC BREASTFEEDING PEER COUNSELOR PROGRAM FUNDING A. The State WIC Office reimburses the local WIC agency for Peer Counselor salaries, fringe benefits and employment expenses on a scale determined by the local agency in accordance with agency standards. The local agency WIC Coordinator must notify the State WIC Breastfeeding Coordinator of any salary, fringe benefit, and employment expense modifications affecting the Peer Counselor within one week of the change. B. The State WIC Office recommends a starting PC salary rate equivalent to or higher than a starting WIC clerk rate and routine pay raises in accordance with agency standards. C. To retain funding for the PC position, the local WIC agency must adhere to these program guidelines and submit required paperwork, including an internal PC job description and an internal Breastfeeding Peer Counselor Program description (see Paperwork section), to the State WIC Breastfeeding Coordinator. Ongoing state support of the PC Program also depends on the availability of adequate federal funding.

Revised April 2015

Rhode Island WIC Program: Policy & Procedure Manual Section 500 Outreach and Coordination or Nutrition Education ______________________________________________________________________________________________________

Policy: Local agency WIC programs shall complete an annual Nutrition Education and Outreach Plan and Quarterly Reports consistent with the state’s goals and objectives. ______________________________________________________________________________________________________ Procedure:

1) LA shall complete a Nutrition Education Plan (NEP) annually to coincide with the new fiscal year. Quarterly Reports evaluating the status and/or progress of the NEP shall be completed in January, April, July and October.

2) The Nutrition Education Plan shall contain the following components: a) Cover sheet with original signatures of the Local Agency Executive Director and/or CEO and the Local Agency WIC Coordinator b) Evaluation summary from the previous year for all objectives i) Use this page to discuss findings from the previous year’s plan. Restate your objectives under the appropriate section. In the discussion column, provide a brief explanation as to whether or not the expected objectives were met. Include any data/information which will help support the findings. This section is to reflect on the previous fiscal year only, and should not include new objectives and/or goals. c) New fiscal year objectives for all categories: i) Terminations ii) Prenatal WIC enrollment iii) Breastfeeding initiation iv) Breastfeeding duration v) Farmers Market redemption vi) Obesity prevention d) Participant survey summary results i) Describe the most profound issue(s) revealed by the participant survey results. The Participant Survey summary sheet must be completed for each individual site. e) Extension request i) Submit a request if unforeseen circumstances prevent submission of the NEP within a timely manner. This request must be received by October 1st and must include sufficient/adequate reasoning for not being able to meet the deadline, and a reasonable timeline for submitting the NEP. f) Certification Regarding Lobbying form (needs to be completed annually) and must be signed by Local Agency Executive Director and/or CEO.

Revised April 2015

3) Objectives shall include the following: i) Need: Must be completed for Objectives 3a, 3b and 5. Optional: You may add additional information to this section for Objectives 1, 2, & 4. ii) Goal: Template has been filled in with general statewide goals iii) Agency Baseline Data: This data is provided either monthly or quarterly by the state WIC office. Data should be added to the report as it becomes available and should be used to evaluate progress toward the current fiscal year’s objectives. Evaluation of progress toward these objectives should be discussed in the Quarterly Report. iv) RI State Comparison Data: Used to help evaluate local agency progress in comparison to statewide numbers for the same performance measure. v) Objectives: Evaluate previous FY data for each of the Objectives and determine a realistic goal for the new FY. vi) Action Steps: How will the LA achieve the established Objectives? What can the LA do beyond standard policy and procedure? Action steps should not include normal day to day procedures, such as “will explain the Farmer’s Market food guide”, “will schedule prenatal appointments within 10 days of request”; these procedures should be done on a daily basis, regardless of the Nutrition Education Plan. vii) Action Steps need to be formatted in a numbered/outline style rather than writing a general paragraph, so that each action step is easily identified. viii) Evaluation Plan: How will the LA evaluate whether the action steps are helping to achieve the established Objectives? The evaluation plan should be specific toward each objective and should not be the same for every objective.

4) Quarterly Reports shall be submitted to the State Office once per quarter: January, April, July and October. Quarterly Reports must include the following: a) Calculation of the “No Show” rate for the quarter and explanation as to the probable reason b) Outreach activities completed from the previous quarter; must be a minimum of 3 activities and should include dates and personnel completing the outreach c) Outreach activities planned for the current quarter; must be at least 3 activities planned. d) Nutrition Education Plan: Must include a review and an evaluation for all objectives from the most recent quarter. Include a discussion of LA’s progress toward objective, data analysis and policy changes required to help achieve objective. e) Nutrition Education activities completed from the previous quarter: i) In-service trainings and staff meetings ii) Professional continuing education activities iii) Civil Rights trainings – Required annually iv) WIC chart reviews: paper charts and electronic – A minimum of 3 participant electronic file reviews per WIC category (Prenatal, Breastfeeding, Postpartum, Infant and Child) for each LA CPA, Peer Counselor and Support Staff is required annually. v) Staff observations – A minimum of 1 observation per WIC category (Prenatal, Breastfeeding, Postpartum, Infant and Child) for each LA CPA, Peer Counselor and Support Staff is required annually.

Rhode Island WIC Program

Procedure Manual Section 700

SECTION 700

-1-

SECTION 700

MONITORING

2

MONITORING

(Goals - VII, Operations - 7)

Introduction

The state agency for the WIC Program is required by federal regulations to conduct biennial and continuing reviews of local agency WIC Programs. The state agency is required to establish evaluation and review procedures and to document the results of these procedures. In a broad sense, monitoring of local agencies is accomplished through both regular ongoing contacts and as needed. An annual or biennial local agency review, in addition, is conducted by the state agency in order to obtain an overall picture of local agency operations.

If a local agency is in compliance and citations are corrected and no conditions exist or are suspected to warrant State Agency return for annual evaluations (complaints, change in management, staffing etc..), Local Agencies will conduct "off-year" self- assessment management evaluations.

The purpose of each local agency review is to arrive at a comprehensive assessment of all aspects of the local agency WIC Program, including compliance with the requirements of federal regulations, the local agency agreement and state procedures.

710 - Local Agency Review

711 Procedures

A. Upon being contacted by the state agency, the local agency administrator and local WIC staff will mutually establish the time with the state staff for the team to conduct an on-site review.

An entrance letter is sent to the local agency with a copy of the review format which includes the prereview information form which should be completed before the evaluation site visit and given to the review staff. The letter describes the purpose, format and procedures to be followed.

B. At the established time, the review team will meet with the local agency staff to go over the areas covered in the review format and secure answers to the questions. Local agency staff members should be available to participate in discussions with the review team, to provide for observation of local agency procedures and review of local agency records, and to arrange participant interviews.

Local agency staff members will need to be available to assist the review as required. All local WIC records should be made available as requested by the review team.

C. The local agency review process is intended to be a way to identify both strengths and weaknesses of the WIC Program. Local agency staff should respond to the process in a

3 constructive, objective, and professional manner that will result in conclusions that are useful to the local agency. State and local staff will begin to identify local agency needs and deficiencies, and feasible corrections and improvements.

D. Any deficiencies corrected prior to the completion of the review should be brought to the attention of state review staff.

E. At the completion of the local agency review, a local agency administrator, above the level of the WIC Program, and other staff at the administrator's discretion will meet with the review team in an exit conference, to discuss a verbal summary of findings and recommendations.

F. Upon receipt of the written formal statement of review findings and recommendations by the WIC state agency, the local agency staff will review the findings and formulate the plan of correction.

G. Within thirty days of the receipt of the letter of the review findings, the local agency should submit to the state agency a written response to the findings, including plans of corrections and projected dates of implementation (and dates of corrections that have already been made).

H. The plan of correction must be signed by the Executive Director, or other management level administrator acceptable to the RIDH, to assure administrative review of WIC operations and agency commitment to the plan.

I. The state agency will accept the plan of correction or notify the local agency of needed revisions.

J. The local agency shall implement the plans of corrections according to the stated timetable. If it is unable to do so, the local agency must notify the state agency and submit a revised plan of corrections acceptable to the state agency.

712 Follow-up

Follow-up is conducted by state agency staff during regularly scheduled visits or such additional contacts as may be required. During these contacts staff review the implementation of correction plans.

713 Penalties

If the state agency determines that an acceptable plan of correction is not submitted within thirty days, or if corrective action is not completed according to the schedule established in the corrective action plan, the state agency may withhold administrative and program services funds through a reduction in the local agency funds allocation or by assessing a claim against the local agency.

714 Ongoing Monitoring

4 Periodic on-site visits are conducted by the state liaison, nutrition, and fiscal staff. Additional contacts may be conducted when deemed necessary by the state agency to ensure compliance. These contacts provide for ongoing monitoring. Any interim policies, procedures, and instructions issued by the state agency or USDA may also be discussed.

Additional sources of monitoring information include but are not limited to, records available at other locations (such as the state agency) and participant interviews.

720 - Local Agency Self Assessment

721 Additional Monitoring

The State agency shall require local agencies to establish management evaluation system (Self-Assessment) to review their operations and those of associated clinics or contractors. This process will occur on a biennial basis, using a State developed assessment tool or a local agency self assessment process approved by the State WIC Agency. (See Appendix 700 for Financial Self-Assessment Tool. Refer to Appendix 400 for Nutrition Education Plan Self- Assessment Tool).

In the event of changed or additional federal or state requirements, directives, guidance or so forth, such additional review activities as are needed to ensure local agency compliance shall be conducted.

730 - Participant Interviews Introduction

State staff interview a sample of participants at each local agency in order to obtain participant input into all aspects of the operations of the WIC Program.

Definition - "Participant" may refer to potential, active, or former participants, applicants or denied applicants.

731 Procedures

A. Local agency staff should assist state agency liaison staff in scheduling participant interviews and coordinating the interviews with other required participant visits.

B. A representative sample of foreign-speaking participants should be arranged, if possible, including arrangements for translation resources.

C. The interview is for Program improvement purposes and is, therefore, voluntary and not associated with Program eligibility. Local agencies should, however, seek to arrange for participant comfort and cooperation.

D. As appropriate, the state liaison will bring issues, complaints, or questions on behalf

5 of participants to local agency staff which should be responded to and followed up as appropriate.

732 Follow-up

A. The appropriate local agency person will be notified of any matters to be jointly evaluated and resolved, or plans made for resolution. Depending on the complexity of the issue, further follow-up may be required.

B. In the event of evident or possible health, social, or nutritional problems and needs local staff should work with the liaison to advise the participant of appropriate resources or of referral sources. Local agency resources should also be enlisted.

733 Related Local Agency Activities

The participant interview process is most efficient and effective when performed through the cooperation of the local agencies. Local agencies, then, will:

A. Assist in participant random selection and notification.

B. Confirm any scheduled appointments with the participants just before their visit.

C. As available, provide interview facilities which allow for comfort and privacy. Assist with language interpretation, if needed.

D. Follow-up with recommendations and solutions worked out with the liaison and the state agency.

E. Submit appropriate reports to the liaison as requested, if follow-up is extensive in scope or time.

734 WIC Breastfeeding Peer Counselor Program Evaluation A. The WIC Breastfeeding Peer Counseling Program will be evaluated for compliance with state and local WIC agency program guidelines during the biannual Management Evaluation Review using the Peer Counselor Program Management Evaluation Form, the Peer Counselor Program Chart Review Form and RI WEBS. Peer Counselor performance will also be evaluated using these methods in addition to the Breastfeeding Peer Counselor Competency Checklist. Program deficiencies will be identified during the exit interview and must be addressed with a correction plan. B. In addition to the biannual Management Evaluation Review, the State WIC Breastfeeding Coordinator may conduct periodic site visits to local WIC agencies to assess Peer Counselor Program effectiveness and provide technical assistance. The local agency WIC Coordinator or the State WIC Breastfeeding Coordinator may initiate a site visit.

6 C. State WIC staff may access client records in RI WEBS or utilize other Peer Counselor program paperwork at any time to evaluate the effectiveness of the Breastfeeding Peer Counselor Program. D. The State WIC Breastfeeding Coordinator will periodically calculate and evaluate Peer Counselor client contact rates using the WIC Breastfeeding Peer Counselor Monthly Summary and will provide follow-up technical assistance to the local WIC agency as needed to increase the frequency of monthly contacts. Client contact rates will be evaluated based on statewide averages for similar types of contacts rather than by a standardized quantity. E. The State WIC Breastfeeding Coordinator will provide technical assistance to local agencies as needed by either the local agency or the State WIC Office. Local agencies will notify the State WIC Breastfeeding Coordinator of developing program needs and changes.

Rhode Island WIC Program

Procedure Manual Sec. 800

SECTION 800

CIVIL RIGHTS AND APPEAL PROCEDURES

(Goals - VIII, Operations - 8)

Rhode Island WIC Program

Procedure Manual Sec. 800

Section 800

-2-

SECTION 800

CIVIL RIGHTS AND APPEAL PROCEDURES

(Goals - VIII, Operations - 8)

810 - Civil Rights

Local agency staff play key front line roles in ensuring the absence of discriminatory attitudes and practices in WIC. In compliance with the requirements of Title VI of the Civil Rights Act of l964, Section 504 of the Rehabilitation Act of l973, USDA Regulations 7 CFR 15, and Regulations for the Special Supplemental Food Program for Women, Infants and Children, the Governor's Executive Orders and the Department of Health's Affirmative Action Plan, discrimination in the Rhode Island WIC Program is prohibited.

811 Local Agency Practices

A. The local WIC agency must ensure that no person shall, on the grounds of race, color, national origin, age, sex, or handicap, be excluded from participation in, be denied the benefit of, or be otherwise subjected to discrimination under the WIC Program.

B. If there are physical barriers to the handicapped, the local agency should identify reasonable alternative means of access, alternative means for certification off-site, or referral to the nearest accessible facility.

C. Program information and guidelines should be made available to the public, especially applicants, participants, grassroots organizations, and minority groups.

D. The local agency must inform Program applicants and participants of the procedure for filing discrimination complaints (see Complaints below), and rights and responsibilities of participants and applicants.

E. The local agency must ensure that for those participants who are non-English speaking and limited English speaking, there is required Program information, other than certification forms, provided in the appropriate language, either orally or in writing. Also, all rights and responsibilities on the application form are read to the applicant in the appropriate language. Volunteer interpreters can be used instead of bilingual staff members. There must, however, be assurances of the reliability and availability, when needed, of the volunteers.

Rhode Island WIC Program

Procedure Manual Sec. 800

Section 800

-3- As appropriate, local agencies may request Spanish language versions of the WIC Power Point Orientation-Outreach presentation.

F. The local agency should be aware of, and utilize resources for providing Program information to the visually and hearing impaired.

G. Public Notification Materials - The local agency must display in a prominent place the poster "...and justice for all."

Required by FNS Memo 2015 “Nondiscrimination Statement for WIC Materials”

H. All Program materials for public information developed or distributed by the local agency must include the statement:

“The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal and, where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov. Individuals who are deaf, hard of hearing, or have speech disabilities and wish to file either an EEO or program complaint please contact USDA through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (in Spanish). Persons with disabilities who wish to file a program complaint, please see information above on how to contact us by mail directly or by email. If you require alternative means of communication for program information (e.g., Braille, large print, audiotape, etc.) please contact USDA's TARGET Center at (202) 720-2600 (voice and TDD).

If the material is too small to permit the full statement to be included, the material will, at

Rhode Island WIC Program

Procedure Manual Sec. 800

Section 800

-4- a minimum, include the statement, in print size no smaller than the text, that “USDA is an equal opportunity provider and employer.”

The statement should also be included on all notices that serve as notice of condition to continued eligibility and convey the intent of fairness in the processing of the action. The statement should be in a prominent place and in bold type print, if possible.

I. Local Agency Training - The local agency must provide specific training to employees in the principles of nondiscrimination, and agency and WIC civil rights policies, in order to assure absence of obvious or subtle discriminatory practices. Such training shall be provided through orientation for new employees, and, where no specific training has been provided, through in-service training to present employees.

Local agency staff must attend any civil rights training provided by, or under the auspices of, the state agency or the USDA.

J. Data Reporting - Racial/Ethnic data needed by FNS or the state agency to evaluate participation ratios must be collected and forwarded as required.

K. The local agency must assist the regular compliance review process and cooperate in any special compliance reviews. Findings and recommendations of the compliance review must be responded to and implemented as appropriate.

L. Information regarding vendor practices which might be discriminatory should be forwarded to the state agency via the most expeditious route. The first contact would usually be the state liaison.

812 Complaints

A. Any complaints of discrimination received by the state or local agency must be forwarded immediately.

1. Right to File - Any person alleging discrimination based on race, color, national origin, age, sex, or handicap has a right to file a complaint within l80 days of the alleged discriminatory action.

2. Forwarding Complaints - All complaints, written or verbal, based on race, color, national origin or age shall be accepted and forwarded to:

USDA Director, Office of Civil Rights

Rhode Island WIC Program

Procedure Manual Sec. 800

Section 800

-5- Room 326-W Whitten Building 1400 Independence Avenue, SW Washington, DC 20250-9410

A copy should also be sent to:

Regional Civil Rights Director Food and Nutrition Service, USDA Northeast Region 10 Causeway Street, Room 501 Boston, MA 02222-1063

All complaints based on sex or handicap shall be accepted by completing a Discrimination Complaint Form EEO-WIC (appendix). Keep a copy of the form in agency files and forward the original to:

Rhode Island State Equal Opportunity Office 289 Promenade Street Providence, RI 02908

It is necessary that the information be sufficient to determine the identity of the agency or individual toward which the complaint is directed, and to indicate the possibility of violation. Anonymous complaints may be handled just like any other complaint.

3. Verbal Complaint - In the event that a complainant makes an allegation verbally or through a telephone conversation and refuses, or is not inclined, to place such allegations in writing, the person to whom the allegations are made should write up the elements of the complaint for the complainant. Every effort will be made to have the complainant provide the following information:

(a) Name, address, and telephone number of the complainant or other means of contacting the complainant.

(b) The specific location and name of the entity delivering the service or benefit.

(c) The nature of the incident or action that led the complainant to feel discrimination was a factor or an example of the method of administration which is alleged to have a discriminatory effect on the public or potential or actual participants.

Rhode Island WIC Program

Procedure Manual Sec. 800

Section 800

-6- (d) The basis on which the complainant feels discrimination exists (race, color, national origin, age, sex, or handicap).

(e) The names, titles, and business addresses of persons who may have knowledge of a discriminatory action.

(f) The dates during which the alleged discriminatory actions occurred, or, if continuing, the duration of such actions.

RI STATE EQUAL OPPORTUNITY OFFICE

TELEPHONE 222-3090 TDD 277-3092

WIC PROGRAM GRIEVANCE PROCEDURE

The State Equal Opportunity Office will accept from WIC Program employees and applicants for WIC Program employment, WIC participants, potentially eligible persons and former participants complaints of discrimination that are based on sex and physical or mental handicap, related to WIC Program employees, the State Agency or WIC local agencies.

1. A complaint may be filed formally on the "Complaint of Discrimination Form" available through the state Equal Opportunity Office, within 180 days of the alleged incident of discrimination, unless it is an ongoing discrimination.

Verbal complaints shall be accepted and the person to whom the allegations are made shall write up the elements of the complaint for the complainant.

2. An Equal Opportunity Officer will be assigned to investigate the complaint. Complaints will usually be investigated within thirty days. There are exceptions, depending upon the number of witnesses and extent of cooperation.

3. The Executive Director or Chief Executive Officer (Respondent) will be notified of the alleged charge. When the RIDH is not the respondent, the Associate Director, Management and Support Services, RIDH, shall also be notified.

4. Upon the completion of the investigation, the State Equal Opportunity Office will make a determination as to probable cause, based on the summary of facts. Determinations are made as a result of meetings with the Administrator, Assistant Administrator and Investigating Officer. If there is no probable cause the concerned parties will be notified within five (5) days.

Rhode Island WIC Program

Procedure Manual Sec. 800

Section 800

-7-

5. When probable cause is not evident, the parties are so informed by the State Equal Opportunity Office.

6. When there is probable cause of discrimination, Administrator of the State Equal Opportunity Office will try to conciliate the complaint with concerned parties.

7. If an agreement between both parties is not reached, an amicable date for a formal hearing, within thirty (30) days of conciliation attempt, will be scheduled and a Hearing Officer will be assigned by the State Equal Opportunity Office.

8. The Hearing Officer is requested to make a decision within fifteen days of receipt of the hearing transcript. Within five days after the decision of the Hearing Officer, the State Equal Opportunity Office will then, by written notification, present the findings and recommended corrective action to both parties.

Implementation of the decision shall be within thirty (30) days. If the corrective action is not implemented within the specified time frame, the State Equal Opportunity Office will notify the Governor.

All complaints will remain confidential except to the extent necessary to conduct a review of the facts.

When the RIDH is not a party to the complaint, the RIDH shall be kept informed of the status of the complaint and any resolution, recommendation or action related to the complaint.

820 - Fair Hearing Procedures

821 Grounds for a Fair Hearing

An individual may request a Fair Hearing to appeal a State or local agency action which results in the individual's denial of participation, disqualification, termination from the Program, or the attempted recovery of the cash value of benefits issued to such individual.

822 Local Agency Responsibilities

A. Inform each WIC applicant of his/her right to a Fair Hearing during the initial contact with the local

Rhode Island WIC Program

Procedure Manual Sec. 800

Section 800

-8- agency.

B. Assure an applicant (or participant), against whom sanctions have been imposed, of unrestricted freedom to request a Fair Hearing.

C. Offer assistance to help the applicant prepare and submit the Fair Hearing Request.

D. Inform the applicant that he/she may request copies of any documents in his/her WIC record, in advance of the Fair Hearing.

E. Inform each applicant (or participant), against whom sanctions have been imposed, in writing, at the time the sanction is imposed, of the reason for the sanction, the right to a Fair Hearing, and how to request a Fair Hearing. This written information is contained in a separate form, "Fair Hearing Information," WIC-14, given to participants at the time of initial certification and at the time of denial, termination from the Program or other sanction.

823 Processing the Request

A. A request for a Fair Hearing must be made within sixty (60) days of the date of the notification of denial or termination of benefits or of other sanction imposed.

B. The request may be oral or written, but a formal written record of any request must be secured or prepared by the local agency on the "Request for Fair Hearing" form WIC-15.

C. Forward to the State agency any Fair Hearing Requests within two (2) days of their receipt.

D. Copies of appropriate documents or notes from the participant's record must also be sent to the state agency immediately.

E. The hearings will be held within three weeks from the date of receipt of request.

F. At least ten (10) days prior to the hearing, the applicant will receive written notice from the state agency as to the time, date, and site for hearing.

824 Assisting the Appellant

A reasonable attempt should be made to inform the applicant of what they might expect at a Fair Hearing, their responsibilities to present their case, the need to be on time, that any request to withdraw must be in writing (Appendix, Withdrawal of Appeal, WIC-15W), and other relevant, helpful information.

Rhode Island WIC Program

Procedure Manual Sec. 800

Section 800

-9-

830 - Mandatory No-smoking Policy

The Fiscal Year 1994 Agriculture, Rural Development, Food and Drug Administration, and Related Agencies Appropriations Act (Public Law 103-111) stipulates that each local WIC agency and/or WIC clinic must have an announced, posted public policy against smoking in any area where WIC Program functions are performed, in order to be eligible to receive WIC administrative funds.

This prohibition against smoking applies only during the times that the WIC Program is actually operating at a clinic site. For example, satellite operations where WIC services may only be offered once or twice a week, would not have to announce and implement the non-smoking policy for those time periods when the WIC Program is not operating.

Rhode Island WIC Program

Procedure Manual Sec. 800

SECTION 800

CIVIL RIGHTS AND APPEAL PROCEDURES

(Goals - VIII, Operations - 8)

Rhode Island WIC Program

Procedure Manual Sec. 800

Section 800

-2-

SECTION 800

CIVIL RIGHTS AND APPEAL PROCEDURES

(Goals - VIII, Operations - 8)

810 - Civil Rights

Local agency staff play key front line roles in ensuring the absence of discriminatory attitudes and practices in WIC. In compliance with the requirements of Title VI of the Civil Rights Act of l964, Section 504 of the Rehabilitation Act of l973, USDA Regulations 7 CFR 15, and Regulations for the Special Supplemental Food Program for Women, Infants and Children, the Governor's Executive Orders and the Department of Health's Affirmative Action Plan, discrimination in the Rhode Island WIC Program is prohibited.

811 Local Agency Practices

A. The local WIC agency must ensure that no person shall, on the grounds of race, color, national origin, age, sex, or handicap, be excluded from participation in, be denied the benefit of, or be otherwise subjected to discrimination under the WIC Program.

B. If there are physical barriers to the handicapped, the local agency should identify reasonable alternative means of access, alternative means for certification off-site, or referral to the nearest accessible facility.

C. Program information and guidelines should be made available to the public, especially applicants, participants, grassroots organizations, and minority groups.

D. The local agency must inform Program applicants and participants of the procedure for filing discrimination complaints (see Complaints below), and rights and responsibilities of participants and applicants.

E. The local agency must ensure that for those participants who are non-English speaking and limited English speaking, there is required Program information, other than certification forms, provided in the appropriate language, either orally or in writing. Also, all rights and responsibilities on the application form are read to the applicant in the appropriate language. Volunteer interpreters can be used instead of bilingual staff members. There must, however, be assurances of the reliability and availability, when needed, of the volunteers.

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-3- As appropriate, local agencies may request Spanish language versions of the WIC Power Point Orientation-Outreach presentation.

F. The local agency should be aware of,and utilize resources for providing Program information to the visually and hearing impaired.

G. Public Notification Materials - The local agency must display in a prominent place the poster "...and justice for all."

Required by FNS Memo 2015 “Nondiscrimination Statement for WIC Materials”

H. All Program materials for public information developed or distributed by the local agency must include the statement:

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov.

If the material is too small to permit the full statement to be included, the material will, at a minimum, include the statement, in print size no smaller than the text, that “USDA is an equal opportunity provider and employer.”

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-4- The statement should also be included on all notices that serve as notice of condition to continued eligibility and convey the intent of fairness in the processing of the action. The statement should be in a prominent place and in bold type print, if possible.

I. Local Agency Training - The local agency must provide specific training to employees in the principles of nondiscrimination, and agency and WIC civil rights policies, in order to assure absence of obvious or subtle discriminatory practices. Such training shall be provided through orientation for new employees, and, where no specific training has been provided, through in-service training to present employees.

Local agency staff must attend any civil rights training provided by, or under the auspices of, the state agency or the USDA.

J. Data Reporting - Racial/Ethnic data needed by FNS or the state agency to evaluate participation ratios must be collected and forwarded as required.

K. The local agency must assist the regular compliance review process and cooperate in any special compliance reviews. Findings and recommendations of the compliance review must be responded to and implemented as appropriate.

L. Information regarding vendor practices which might be discriminatory should be forwarded to the state agency via the most expeditious route. The first contact would usually be the state liaison.

WIC PROGRAM GRIEVANCE PROCEDURE

The State Equal Opportunity Office will accept from WIC Program employees and applicants for WIC Program employment, WIC participants, potentially eligible persons and former participants complaints of discrimination that are based on sex and physical or mental handicap, related to WIC Program employees, the State Agency or WIC local agencies.

1. A complaint may be filed formally on the "Complaint of Discrimination Form" available through the state Equal Opportunity Office, within 180 days of the alleged incident of discrimination, unless it is an ongoing discrimination.

Verbal complaints shall be accepted and the person to whom the allegations are made shall write up the elements of the complaint for the complainant.

2. An Equal Opportunity Officer will be assigned to investigate the complaint.

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-5- Complaints will usually be investigated within thirty days. There are exceptions, depending upon the number of witnesses and extent of cooperation.

3. The Executive Director or Chief Executive Officer (Respondent) will be notified of the alleged charge. When the RIDH is not the respondent, the Associate Director, Management and Support Services, RIDH, shall also be notified.

4. Upon the completion of the investigation, the State Equal Opportunity Office will make a determination as to probable cause, based on the summary of facts. Determinations are made as a result of meetings with the Administrator, Assistant Administrator and Investigating Officer. If there is no probable cause the concerned parties will be notified within five (5) days.

5. When probable cause is not evident, the parties are so informed by the State Equal Opportunity Office.

6. When there is probable cause of discrimination, Administrator of the State Equal Opportunity Office will try to conciliate the complaint with concerned parties.

7. If an agreement between both parties is not reached, an amicable date for a formal hearing, within thirty (30) days of conciliation attempt, will be scheduled and a Hearing Officer will be assigned by the State Equal Opportunity Office.

8. The Hearing Officer is requested to make a decision within fifteen days of receipt of the hearing transcript. Within five days after the decision of the Hearing Officer, the State Equal Opportunity Office will then, by written notification, present the findings and recommended corrective action to both parties.

Implementation of the decision shall be within thirty (30) days. If the corrective action is not implemented within the specified time frame, the State Equal Opportunity Office will notify the Governor.

All complaints will remain confidential except to the extent necessary to conduct a review of the facts.

When the RIDH is not a party to the complaint, the RIDH shall be kept informed of the status of the complaint and any resolution, recommendation or action related to the complaint.

820 - Fair Hearing Procedures

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821 Grounds for a Fair Hearing

An individual may request a Fair Hearing to appeal a State or local agency action which results in the individual's denial of participation, disqualification, termination from the Program, or the attempted recovery of the cash value of benefits issued to such individual.

822 Local Agency Responsibilities

A. Inform each WIC applicant of his/her right to a Fair Hearing during the initial contact with the local agency.

B. Assure an applicant (or participant), against whom sanctions have been imposed, of unrestricted freedom to request a Fair Hearing.

C. Offer assistance to help the applicant prepare and submit the Fair Hearing Request.

D. Inform the applicant that he/she may request copies of any documents in his/her WIC record, in advance of the Fair Hearing.

E. Inform each applicant (or participant), against whom sanctions have been imposed, in writing, at the time the sanction is imposed, of the reason for the sanction, the right to a Fair Hearing, and how to request a Fair Hearing. This written information is contained in a separate form, "Fair Hearing Information," WIC-14, given to participants at the time of initial certification and at the time of denial, termination from the Program or other sanction.

823 Processing the Request

A. A request for a Fair Hearing must be made within sixty (60) days of the date of the notification of denial or termination of benefits or of other sanction imposed.

B. The request may be oral or written, but a formal written record of any request must be secured or prepared by the local agency on the "Request for Fair Hearing" form WIC-15.

C. Forward to the State agency any Fair Hearing Requests within two (2) days of their receipt.

D. Copies of appropriate documents or notes from the participant's record must also be sent to the state agency immediately.

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-7- E. The hearings will be held within three weeks from the date of receipt of request.

F. At least ten (10) days prior to the hearing, the applicant will receive written notice from the state agency as to the time, date, and site for hearing.

824 Assisting the Appellant

A reasonable attempt should be made to inform the applicant of what they might expect at a Fair Hearing, their responsibilities to present their case, the need to be on time, that any request to withdraw must be in writing (Appendix, Withdrawal of Appeal, WIC-15W), and other relevant, helpful information.

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-8-

830 - Mandatory No-smoking Policy

The Fiscal Year 1994 Agriculture, Rural Development, Food and Drug Administration, and Related Agencies Appropriations Act (Public Law 103-111) stipulates that each local WIC agency and/or WIC clinic must have an announced, posted public policy against smoking in any area where WIC Program functions are performed, in order to be eligible to receive WIC administrative funds.

This prohibition against smoking applies only during the times that the WIC Program is actually operating at a clinic site. For example, satellite operations where WIC services may only be offered once or twice a week, would not have to announce and implement the non-smoking policy for those time periods when the WIC Program is not operating.

Rhode Island WIC Program Retail Vendor Policies

Operations Manual Section 3 Appendix

Revisions are italicized

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Policy V-1: APPLICANT VENDOR SELECTION AND AUTHORIZATION

GOAL

To ensure that only vendors which will be a benefit to the Rhode Island WIC Program are accepted and maintain their authorization.

PROCEDURE

A. Retail grocers, food stores (known as grocers), and registered pharmacies (known as pharmacies) located in the State of Rhode Island may request initial participation as authorized vendors in the WIC Program throughout the year. An application will only be accepted from a grocery or pharmacy owner, partner or corporate officer acceptable to WIC. Mobile stores and home food delivery companies are not eligible to be WIC vendors. Persons or entities may also apply up to thirty days before commencing operations of a grocery or pharmacy. B. A Vendor Application portal is available online for new and existing vendors. All required materials will be available at RIDOH website. a. Vendor Application b. WIC Price List c. WIC-Approved Foods list d. Vendor Minimum Inventor e. WIC Bulletins f. Vendor Policy

The applicant vendor returns the: a. Vendor Application signature page from Online Vendor Application Portal b. Price Surveys, c. Proof of ownership, d. Annual reconciliation or Quarterly reconciliation tax forms for last four quarters (T – 204 or T204CIG, both sides) e. Current copy of Health Department License, SNAP license and Permit to make sales f. Copy of a recent driver's license or other positive photo identification, and g. List names of stores, owner, partnership, manager, spouse, and clerk to WIC for review after completion by the vendor.

The establishment owner, partner or a corporate official (provided they have the authority to sign on behalf of the company) must sign the Vendor Application signature page. The applicant must provide evidence of ownership and/or control, satisfactory to the Rhode Island Department of Health (RIDOH) WIC Program, of the operations of the grocery or pharmacy at the location for which the application is being submitted.

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C. For the purposes of the RIDOH WIC Program the terms vendor, applicant or applicant vendor, except as described above, shall refer to the business and any person, firm, corporation, officer, owner or manager or any entity who/which has or has had a controlling or partnership interest in, or managerial control of the business with respect to the business' WIC vendor application or re- application for participation in the Program and in compliance with any Food And Nutrition Service (FNS) Program's rules, regulations or procedures.

D. If the vendor has withheld, misrepresented or falsified any information required by the application process, the application will be denied and/or any subsequent Vendor Agreement relating thereto will be immediately rendered null and void, upon discovery.

If the vendor has participated in any actions which are violations of Program rules, the application will be denied and/or any subsequent Vendor Agreement relating thereto will be immediately rendered null and void, upon discovery.

The vendor may not be accepted if it has been debarred or suspended from participating in any transactions involving federal funds or other assistance with grantees and sub grantees of federal funds under the terms of 7 CFR Part 3017. E. A vendor will not be accepted if it shows potential for risk (see Policy V-2). F. FNS and WIC Compliance (Applies to Programs’ Compliance in Rhode Island or in other states) 1. Unless needed to serve an area (Section S, below), a grocery vendor will not be approved unless the vendor is authorized by the Supplemental Nutrition Assistance Program (SNAP) under the current ownership. If the Vendor is disqualified from the SNAP as a result of disqualification from the WIC Program, the Vendor may not reapply until SNAP authorization is reinstated 2. (a) A vendor will not be approved if a vendor as a vendor owner, officer, partner, manager or individual: (i) Has not paid in full any fiscal claim, penalty, or fine owed to any USDA or other Federal or State Program or if the Vendor has not corrected any previous violation. (ii) Has committed or been convicted of any violation of or been found in violation of any of the laws and/or regulations, or rules of any USDA or other Federal or State Program, or the terms of any previous Vendor Participation Agreement.

The vendor will not be accepted for from one to six years from the time of the last violation committed, or from the time it was determined the violation had been committed, or prior to the end of any disqualification, sentence, or sanction imposed with respect to that violation; whichever last occurs.

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If the sanction was a civil money penalty, or fine or other monetary settlement imposed in lieu of a disqualification or agreed to as part of resolution of a charge of violation of USDA rules, the vendor may not be accepted during the period of time the monetary penalty or settlement is in lieu of, beginning with the date the sanction was imposed.

Re-applicant(s) must serve this time under the WIC Program before they can be re-approved as a WIC Vendor or such term as consistent with the nature of the act and penalties for a similar act as set forth in Policy V - 4. The RIDOH WIC PROGRAM may accept such a vendor if it deems vendor would be a special benefit to the Program and acceptance to be in the best interests of the Program, and impose an alternative penalty and/or special conditions of participation in lieu of denial of participation.

(iii) Is owned, in whole or in part, or is managed by any person who has committed or been convicted of any violation of or found in violation of the laws, regulations, or rules, of any above USDA Program in accordance with the above.

(iv) Employs any person who has committed or been convicted of any violation of, or found in violation of, any of the laws, regulations, or rules of any USDA Program in accordance with the above, whether such violations occurred in relation to that applicant store while the store was under previous ownership, or any other store where such person committed such violations unless such person is under on-site supervision of a superior during all hours of WIC related activity and is not allowed to take part in any WIC transactions.

(v) Has committed any violation of the laws, rules, or regulations of any USDA Program while under disqualification or other sanction by any USDA Program, or when not participating in such Program; in accordance with Policy V-4, Vendor Compliance.

(vi) Where there is evidence of an attempt to circumvent, or assist in a circumvention of, a period of disqualification from any USDA Program or a civil money penalty imposed for violations of the rules or regulations of any USDA Program in accordance with Policy V-4 or Program vendor selection and authorization rules and requirements.

(vii) Where there is likelihood that a former owner, who would not him/herself qualify, still retains direct or indirect ownership in, control over or interest in the business or its operations.

(b) Re-application/Re- approval of Vendor Agreement - When reliable evidence or likelihood exists of violations of the regulations, rules, or procedures of any USDA Program in accordance with (a), above or Policies V-2 or V-4, such evidence shall be grounds for denial of the WIC Vendor Agreement. The RIDOH WIC Program may deny vendor participation in the Program for a period in accordance with (a), above, or until such time as the vendor is no longer subject to, or under judicial,

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administrative penalties, sanctions and/or sanction reviews, or other punishment, whichever last occurs. Any of the conditions of (a) above, shall constitute a violation for purposes of re-approval of a vendor even when it has been served under any USDA Program but not under the WIC Program. Applicant(s) or re-applicant(s) must serve this time under the WIC Program before he/she can be re-approved as a WIC Vendor.

3. The RIDOH WIC Program may, at its option, enter into a conditional Vendor Participation Agreement when a vendor is pending judicial or administrative finding, decision, or applicant sanction for an alleged violation, or being readmitted following an allegation of violation, or for special authorization needs as provided for in section O below.

4. Each applicant vendor, including re-applications, will be reviewed for compliance with any current or previous WIC Agreement for the past three years from the date of application or from the termination of the most recent Agreement.

A vendor will not be accepted or renewed if it meets any of the following criteria:

(a) Is currently suspended or disqualified from any USDA Program for non- compliance, or is under threat of disqualification related to pending charges. This shall not be subject to administrative or judicial review under the WIC Program.

(b) Committed three violations of WIC Program rules such as would be grounds for a 90 day or less disqualification under the provisions of Policy V-4: Vendor Compliance.

(c) Committed two violations, and/or was issued two notices of violation, of a type described in Policy V-4: Vendor Compliance, as Violations and Sanction Types A, B, C, D, E, F; or committed serious, deliberate, or widespread violations described under I or J of that policy.

(d) Received two disqualifications during the preceding three years. Such vendors shall not be renewed or approved for participation for from one to three years from the date of termination of their current or most recent Agreement, in accordance with Policy V-4.

(e) Has been determined to be charging excessive prices, in accordance with Policy V- 10.

(f) If federal regulations for the WIC Program are adopted which change the maximum disqualification or standards for vendor authorization the RIDOH WIC Program may modify the terms of disqualification or non-approval for participation in accordance with the standards set forth in the new federal regulations.