West Virginia WIC Policy & Procedure 9.02 Effective Date: 04/23/2012

9.02

Local Agency Internal Review

1 of 3 POLICY:

The Local Agency will perform an internal review of Local Agency operations to assure comprehension and compliance with Federal, State and local regulations, policies and guidelines.

PROCEDURE:

A. Frequency of Local Agency Internal Review

The Local Agency will perform the internal review of each Local Agency WIC clinic a minimum of one (1) time every two (2) fiscal years. If a local agency site is being monitored by the state agency, the requirement for an internal review will be waived for that two (2) year period.

B. Functional Areas of the Local Agency Internal Review

The review will consist of personnel interviews, observation and an examination of records, and computer reports as requested by the Monitor in the following areas:

• Evaluation of Management

• Eligibility and Certification

• Nutrition Education and Breastfeeding Promotion and Support

• Farmers Market Nutrition Program

• Individual and Group Counseling

• Caseload Management

• Civil Rights Compliance

• Food Package Tailoring

• Food Delivery Systems

West Virginia WIC Policy & Procedure 9.02 Effective Date: 04/23/2012

9.02

Local Agency Internal Review

2 of 3 C. Sample Size Determination for Internal Monitoring

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 twenty-five (25) participant records will be monitored; including a random sample of five (5) 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 fifteen (15) participant records will be monitored; including a random sample of three (3) 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 ten (10) participant records will be monitored; including a random sample of two (2) 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 seven (7) records to be reviewed in clinics that are classified as large, five (5) records to be reviewed in clinics that are classified as medium, and two (2) 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 internal monitoring, one of each WIC condition (pregnant, breastfeeding, 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.

West Virginia WIC Policy & Procedure 9.02 Effective Date: 04/23/2012

9.02

Local Agency Internal Review

3 of 3 D. Local Agency Internal Review Form

1. The Local Agency will use the State Agency’s Nutrition and Operations Monitoring Forms (see Attachment #3 and #4, 9.01).

2. When the Local Agency performs the Internal Reviews, both Attachment #3 and #4, 9.01 must be completed.

E. Completed Local Agency Internal Review

1. The completed review forms will be kept on file at the Local Agency for a minimum of three (3) years and one-hundred fifty (150) days (or until any litigation, audits, etc. are resolved) following the date of the evaluation, along with a written summary of procedures implemented and the expected date of corrective action plan for any problems identified.

2. A copy of the completed review and corrective action plan must be submitted to the State Agency.

REFERENCES:

1. Federal Regulations 246.11, Nutrition Education