West Virginia WIC Policy & Procedure 1.29 Effective Date: 6/18/2026

1.29 Quality Improvement Local Agency Responsibilities

POLICY:

Local Agency (LA) personnel play an important role in operational quality improvement to enhance workflow processes and data integrity that result in positive outcomes for WIC children, families and workforce.

Workflow is the logical order to accomplish efficient, streamlined service provision within a best practice model while continually assessing and prioritizing work tasks. Integrated workflow requirements align federal regulations, Nutrition Services Standards, state policy and procedures, and performance measures into everyday operations at all organizational levels.

The State Agency (SA) and Local Agencies acknowledge that quality improvement and federal standards require continual change and workflow adjustments. The LA assists the SA in carrying out continuous monitoring and improvement of workflow processes fairly and consistently.

The LA also assists the SA in entering and maintaining data for comprehensive applicant and participant records, federal reporting, and management evaluations.

Procedure: A. Local Agency Required Reports for Continual Quality Improvement 1. Weekly, designated LA staff will review the following reports within the Crossroads Computer System (XR), and conduct corrective actions to address participant needs: a. WV WIC Care Plan Missing Statement located at XR - Operations - Clinic (Policy 5.04) b. WV WIC-53 Missing Scanned Medical Doc located at XR - Operations - Clinic (Policy 4.09) c. WV Active Client with no Future Benefits located at XR - Operations d. WV Temporary Certification Report - Missing Documentation located at XR - Operations (Policy 2.08) 2. Weekly, LA designee will reach out to potentially eligible participants within three days of the date added to the spreadsheet that is shared with each LA designee, utilizing a Standard Operating Procedure: a. Local Agency Foster Detail Tracker Report (Policy 2.23) 1

West Virginia WIC Policy & Procedure 1.29 Effective Date: 6/18/2026

1.29 Quality Improvement Local Agency Responsibilities

3. Bi-weekly, the LA Director or designee will review the WV Separation of Duty Report Exceptions located at XR-Operations (Policy 1.18). The LA Director or designee will conduct corrective actions to ensure program integrity. 4. Monthly, designated LA staff will review the following reports within XR and conduct corrective actions to address program service requirements: a. WV Active Pregnant Women located at XR - Clinic for BFPC (Policy 5.20) b. WV Active Breastfeeding Women located at XR - Clinic for BFPC (Policy 5.20) c. Breast Pump Issuance Detail Report located at XR - Clinic for Breastfeeding Liaisons (Policy 5.20 and 5.21)

4. Every other month, designated LA staff will reach out to potentially eligible participants within 30 days of receiving the report, utilizing a Standard Operating Procedure: a. Medicaid List (2 reports) found on the Local Agency Google Drive in the Outreach Folder titled NonMatchKidsMONYEAR LA## and NonMatchPregMONYEAR

B. Local Agency Required Document Submission for Performance Measures 1. Monthly, LA staff will submit the following reports to the designated LA Liaison by the LA-outlined deadline to meet WIC grant performance measures, and report to the SA. a. Outreach Monthly Hour Reports by the 15th day of the month (Policy 7.01) b. Breastfeeding Monthly Hour Reports by the 15th day of the month (Policy 5.20) c. Vendor and Resource Listing (Policy 8.02, Attachment #1) by the 15th day of the month

2. Quarterly, designated LA staff will submit the following reports to meet WIC grant performance measures, and reporting to the SA: a. LA Staff Meeting Sign-in Sheets via Google Meet populated report or

11.01 Attachment #1 b. Breastfeeding, Farmers Market, Nutrition Education, Outreach and Vendor Annual Plan Action Templates by August 31, January 31, April 30, 2

West Virginia WIC Policy & Procedure 1.29 Effective Date: 6/18/2026

1.29 Quality Improvement Local Agency Responsibilities

and July 31. SA may allow specific liaison groups to be exempt from Annual Planning due to scope of work for the year. Nutrition and Breastfeeding will not be exempt.

3. Biannually, LA staff will submit the following reports to meet WIC grant performance measures, and reporting to the SA: a. Training tracking report to the Staff Development Specialist by April 1 and October 1 (Attachment #4 Policy 11.01).

4. Annually, LA Liaisons will submit an Annual Plan reporting to meet WIC grant performance measures, and reporting to the SA: a. Annual Plans by August 31 (Policy 5.11, 5.23, 7.10) b. Final Reports by October 31 (Policy 5.11, 5.23, 7.10)

C. Local Agency Required Document Submission for Memorandums of Understanding, Coordination of Services or Data Use Agreements 1. Monthly, LA staff will submit documents for record keeping to the designated LA Liaison in compliance with data use agreements, Memorandums of Understanding, or other required coordination of services: a. National Voter Registration Forms (Policy 1.20) 1. Each site will have a National Voter Registration Act (NVRA) Coordinator (Policy 1.20) b. Lead Screening Reporting (Policy 2.21) (if applicable to the LA)

D. Local Agency Required Document Submission for Program Management 1. Annually, designated LA staff will submit documents to designated SA staff for management evaluations and monitoring by September 30th: a. Internal Monitoring Reports (Policy 9.02) 2. Annually, designated LA staff will submit documents to designated SA staff by July 1st:

a. Security (Policy 1.26)

3. The Training Tracking Report must be submitted biannually to the Staff Development Specialist/Training Coordinator; this report will be due April 1st and October 1st.

a. Staff Training Records Training Tracking Report (Policy 11.01) 3

West Virginia WIC Policy & Procedure 1.29 Effective Date: 6/18/2026

1.29 Quality Improvement Local Agency Responsibilities

4. Within designated timeframes, LA staff will submit documents to designated SA staff: a. Policy Memo Acknowledgement within 14 working days following release of the memo b. New Employee Network Access-Director or a Director Designee will submit WV WIC Network Account Form within two (2) days prior to start date c. Departing Employee Network Access Deprovision within 24-48 hours or less after personnel leave. (Policy 1.26) d. The Inventory Form will be submitted to the State Agency for review no later than June 30 of the year in which the inventory is completed (Policy 6.15)

E. Local Agency Optional Reports for Continuous Quality Improvement 1. If directed by the Local Agency Director (LAD), LA staff will review the following reports within XR, and conduct corrective actions to address participant needs or ensure the most accurate data within records: a. Daily Appointment to be Rescheduled, located at XR - Appointments b. WV Nutr Ed Missed Appt located at XR - Appointments c. WV Families with no Future Appt located at XR - Appointments d. WV Family Alerts located at XR - Operations

F. Required Documents to be Maintained in XR

1. Various documents are submitted, reviewed, verified, and issued during the application, certification, or ongoing service provision process. Documents that must be scanned within the participant's XR record are: a. Income information if the applicant is over-income (Policy 2.09) b. Notification of Ineligibility (Policy 2.09) c. Self-Declaration Form (Policy 2.17) d. Foster Care, Kinship Care and/or Adoption Custody Documentation (Policy 2.07) e. Consent of Release of Information (Policy 1.03) 4

West Virginia WIC Policy & Procedure 1.29 Effective Date: 6/18/2026

1.29 Quality Improvement Local Agency Responsibilities

f. WIC-53 Exempt Formula and WIC Nutritionals Authorization Form (Policy 4.09) g. Participant Agreement, if completed via paper (Policy 2.10) h. Medical Documentation for Physical Presence Exemption (Policy 2.01) i. Medical Documentation for Hemoglobin Testing Exemption (Policy 2.13) 5