West Virginia WIC

Policy & Procedure 9.01

Date: 04/23/2012 9.01 State Agency Review of Local Agency Program

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POLICY: The State Agency will evaluate and review each Local Agency to assure compliance with Federal, State and local regulations, policies and guidelines. PROCEDURE: A. Frequency of Local Agency Program Review The State Agency will perform the review of each Local Agency a minimum of one (1) time every two (2) fiscal years, and more frequently if deemed needed by the State Agency, at the State Agency’s discretion. B. Functional Areas of the Local Agency Review Financial management systems will be monitored separately per Policy and Procedure 6.17. Compliance with administrative and operations regulations will be monitored separately from compliance with clinical and nutrition related regulations policy and procedure. Reviews will consist of a scheduled interview with the Local Agency Director, to include a review of past performance, computer reports, current operation, and a review of any documents at the Local Agency Headquarters. In addition, monitoring reviews will consist of unannounced on-site visits to selected clinic sites (20% of sites under the Local Agency) to review any documents and files that may be stored there, observe procedures and the physical site, and interview employees on the site-level application of procedures and policy.

The following Operational areas will be reviewed: • Evaluation of Management • Security • Eligibility and Certification • Facility Evaluation • Caseload Management • Outreach • Civil Rights Compliance • Food Delivery Accountability Systems The following Clinical and Nutrition areas will be reviewed: • Eligibility and Certification • Nutrition Education and Breastfeeding Promotion and Support • Individual and Group Nutrition Education

West Virginia WIC

Policy & Procedure 9.01

Date: 04/23/2012 9.01 State Agency Review of Local Agency Program

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• Food Package Tailoring • Farmers’ Market Nutrition Program • Participant Services C. Written Notification 1. The State Agency will send written notification to the Local Agency Director a minimum of thirty (30) days in advance of a review to assure that appropriate personnel and records are available. If at all possible, nutrition and operations functional area reviews will occur at the same time. 2. Written notification will include a description of records or files that the Local Agency must have available for review. This may take the form of the monitoring tool(s) but additional documentation may be requested in the written notification. Written notification will include the name of the clinic(s) to be reviewed but will not include an announcement of the clinic on-site review dates, or the individual participant records that will be reviewed. D. On-Site Review of Local Agency Headquarters The State Agency will conduct a mandatory entrance interview with the Local Agency Director at the beginning of each Local Agency Review to discuss the upcoming clinic site reviews and any issues which the Local Agency may wish to share. The monitor will review documents that may be stored at the Local Agency Headquarters if not otherwise accessible, and discuss performance indicators and/or statistical reports at a Local Agency level with the Director. 1. The State Agency will use both 9.01 Attachment #1 for the nutrition portion of the review with the Local Agency Director and 9.01 Attachment #2 for the operations portion of the review with the Local Agency Director. E. On-Site Review of WIC Clinics

1. The State Agency will designate the WIC clinic(s) for the on-site review.

2. The number of WIC clinics to be reviewed will be twenty (20) percent of the total Local Agency WIC clinics. 3. The date of the on-site review of clinics will be unannounced, but within the timeline specified in the Crossroads tracking system as to when the review must be completed.

West Virginia WIC

Policy & Procedure 9.01

Date: 04/23/2012 9.01 State Agency Review of Local Agency Program

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4. The review will consist of observation of the physical site, personnel interviews, and observation of interviews or other direct observation of employees, review of documents, and review of individual participant files. 5. The number of individual participant records that will be examined will be based on the clinic being classified as large, medium, or small. The size classification will be determined based on the clinic’s active caseload in the most recent closed month. A clinic will be classified as large if the caseload is 1,500 and above; a clinic will be classified as medium if the caseload is between 501 and 1,499; and a clinic will be classified as small if the caseload is 500 and below. a. For clinics that are classified as large, a total of fifty (50) participant records will be monitored; including a random sample of ten (10) records for each WIC condition (pregnant, breastfeeding, postpartum, child, and infant). The random sample should include both low and high risk participants. b. For clinics that are classified as medium, a total of thirty (30) participant records will be monitored; including a random sample of six (6) records for each WIC condition. The random sample should include both low and high risk participants. c. For clinics that are classified as small, a total of twenty (20) participant records will be monitored; including a random sample of four (4) records for each WIC condition. The random sample should include both low and high risk participants. d. Special Formula Documentation will be monitored based on clinic size; with fourteen (14) records to be reviewed in clinics that are classified as large, ten (10) records to be reviewed in clinics that are classified as medium, and four (4) records to be reviewed in clinics that are classified as small. e. Five (5) termed records will be monitored for proper notification of terminations and denials for the past six (6) months which require advance written notice to the participant; regardless of clinic size classification. f. When observing certifications and sub-certifications for on-site monitoring, one of each WIC condition (pregnant, breastfeeding,

West Virginia WIC

Policy & Procedure 9.01

Date: 04/23/2012 9.01 State Agency Review of Local Agency Program

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postpartum, infant, and child) should be observed if possible. When observing a participant from each WIC condition is not possible; a minimum of one (1) woman, regardless of WIC condition (pregnant, postpartum, or breastfeeding), one (1) infant, and one (1) child must be observed. These categories or samples may be changed as new risk categories arise, or as the State Agency deems warranted in specific situations. F. Exit Interview The Local Agency Director has the option to have an exit interview with the State Agency Monitor to discuss preliminary review findings. The interview may be in person or by telephone. G. Local Agency External Review Form 1. The State Agency will use the State Agency’s Nutrition and Operations Monitoring Forms (see Attachment #3 and #4, 9.01). H. Local Agency Review Report The State Agency Monitor will submit a written report to the Local Agency Director within thirty (30) days of the last day all clinics in the Local Agency review are visited. The report will address the findings of the review. I. Action Plan 1. The Local Agency Director will submit a plan of corrective action to the State Agency within thirty (30) days of the receipt of the review report. The plan must include proposed corrective actions and target dates to correct the findings. 2. The State Agency will review the action plan and notify the Local Agency in writing of the approval or disapproval of the plan within fifteen (15) days of receipt of the corrective action plan.

West Virginia WIC

Policy & Procedure 9.01

Date: 04/23/2012 9.01 State Agency Review of Local Agency Program

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J. Follow-up Review The State Agency Monitor will examine the Local Agency compliance with the action plan during a follow-up review of the Local Agency should the State Agency determine that a follow- up review is necessary. REFERENCES: 1. Federal Regulations 246.19, Management Evaluation and Reviews. ATTACHMENTS: 1. Local Agency Monitoring-Entrance Interview Questions Nutrition Services 2. Local Agency Monitoring-Entrance Interview Questions Operations 3. Nutrition Monitoring Form Internal and External Monitoring Clinic Observation 4. Operations Monitoring Form Internal and External Monitoring Clinic Observation