WIC Management Evaluation Changes€¦ · WIC Management Evaluation ... Risk Assessment‐Removed duplicate item referring to the CAR Tool use ... 1.02 (Administration) Overview of

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WIC Management Evaluation Changes

4/28/16

• Presenter: Nancy Erickson, MS, RD

Active Record Review• Cover page‐

• Instructions are in order of pages

• Simplified wording to make easier to read

• Record Review (pg 2)• NE Plan Printed? Observations

• Breastfeeding Issues

Single Certifier Record Review pg 3

Single Cert has reference to Exhibit 9.03A which is the Single Certifier Audit Tool‐available on website with the ME ToolsME Consultant uses this tool to audit your Single Certifier Audit

WIC/CSFPCSFP ended for WIC eligible clients Feb ’14.

We will continue to monitor 2x/year

Ask your WIC Consultant for contact info

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Breastpump Monitoring Reports/Ineligibility/Short Certs

Pg 4 Deleted breastpumps not widely usedAmeda 1, Nurture III and pedal pumps

Ineligibility and Short Certs ReportObserving if these are provided

Possible Communication error MIWIC Release 7.0

EBT Card Security moved back to Recordkeeping & Accountability

Food Package/Formula Approval Review/HR Record

Removed Soy & 2% milk from formula Approval Review. Review appropriate food packages continues to be a part Record Review

and during Observation.

High Risk Record ReviewModified to make it more understandable.

Designed to identify possible gaps in the High Risk referral process.

NUTRITION EDUCATION

Lesson Plan content updated to Policy 5.01ERemoved “Staff qualified to present” and added “Summary”

Deleted “Are EBT benefits loaded without clinic visit?” Allowed with WIChealth.org

Moved Benefit Issuance question from previous page

Removed CPA observation on Breastfeeding Education and Support Page. Covered in certification observation. Changed MPR 6.5a to “d” to reflect the best indicator

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Nutrition Education continued

Interim Nutrition Education ContactUpdated indicator letters (Criterion) to reflect each item more accurately.

Removed last 6.2‐a duplication of above indicators.

Moved Benefit Issuance question to previous page

Nutrition CounselingRemoved reference to providing the High Risk client with a copy of NE Plan

–Not required in policy.

Certification /Observation

Removed two (2) observations overall – PG and CevalIncluded “Other” column if needed

Immunizations‐ Included the new requirement to inform pregnant women of Tdapvaccine in 3rd trimester

Breastfeeding Assessment‐Changed wording on 6.5d from CPA to Breastfeeding staff and addressing mothers concerns when breastfeeding status changes. Moved breastfeeding questions from USDA Mandate to this section and

moved general breastfeeding encouragement to USDA Mandate section.

Certification/Observation continued

Risk Assessment‐ Removed duplicate item referring to the CAR Tool use

Client Centered NE‐ Removed reference to Assessment Forms

USDA Mandated Info‐Moved Breastfeeding specific questions to Breastfeeding Assessment section and replaced with general encouragement to breastfeed

New Client Info‐Corrected Policy number

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OUTREACH

New Non‐discrimination statement 10/15 & Short Statement 12/15

Civil Rights Training‐ Staff with client interaction and supervisors

Removed: WIChealth.org and referrals questions from Client Interview

Q 14 Reworded nutrition education question to be open ended and get feedback from clients

Administration

Breastfeeding Promotion…

Six Steps to Achieve Breastfeeding Goals – Recommended

Annual Review‐Changed to correct wording “Corrective Plan of Action” (CPA)

Recordkeeping & Accountability

Inventory & Issuance section back to this Tool—from Record Review

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Project Fresh

Deleted reference to EBT Pilot.

Discontinued—no EBT for PF

Q #2 Wording changed from “when was the last time” to “How have staff been trained?”

POLICY UPDATEMDHHS WIC DIVISION

Go to Michigan.gov/WIC Click “WIC Providers”

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WIC E-Notice #2015–45: Recently Approved MI-WIC Policies

April 15, 2015

Dear WIC Coordinator:

The following revised policies have recently been approved by USDA and will be posted today on the Michigan Department of Health and Human Services WIC Division website at: www.mighigan.gov/wic. On the link, click on WIC Providers, MI-WIC Policy Manuals and Other Manuals, then Michigan MI-WIC Policy Manual.

1.01 (Administration) Use of Policy and Procedure Manual (Effective Date 04/15/15)Updated to reflect the current purpose and use of the MI-WIC Policy and Procedure Manual

1.02 (Administration) Overview of the WIC Program (Effective Date 04/15/15)Updated overview of the Michigan WIC Program

1.09 (Administration) Civil Rights (Effective Date 04/15/15)

Clarification of the short non-discrimination statement and staff civil rights training requirementPlease note that Policies 1.01 and 1.02 are replacements for old policies that were not previously converted to the MI-WIC format.

Policy Updates –May 2015

2.04 Income Eligibility30 days of pay stubs, if not adjunctively eligible

SSI enrollment is included as adjunctively eligible as all infants/children are Medicaid eligible

Clarified that for farm or self‐employment, use 1040 to verify income

Clarified that proof of income can be digital or paper documentation

2.05 Income Guidelines:Updated to 2015 Income Guidelines as published by USDA

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Policy Updates –September 2015

Revised Policy 5.06A High Risk Documentation GuidanceCorrection to the Guidance when ‘No Care Plan is Needed’

Document rationale in the Problem List

Policy Updates cont’d

6.03 ImmunizationFor women enrollees, WIC staff must offer immunization information appropriate for age

and status, especially in regards to pregnant women

WIC staff should be aware of immunization consideration for women for 1) Influenza vaccination in any trimester, and 2) pertussis vaccination (Tdap) recommended in the 3rd

trimester of every pregnancy

Additional information under Guidance regarding coordination of services

Additional links to immunization information and CDC vaccination schedules

Removed‐Reference to local agencies choosing to issue one month’s benefits to clients whose immunization status is delinquent

Policy Update cont’d

1.12 Public Health Disaster/Emergency Planning and CoordinationAdded guidance to local agencies for the procedure to follow in the event of a disruption of

potable water supply.

The following WIC policy is now obsolete:2.04C Guidelines for Growth Charts and Gestational Age Adjustment for LBW and VLBW

Infants

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2015 New Non‐Discrimination Statement

On October 14, 2015 USDA sent out the 2015 Non‐discrimination Statement.

The week of October 23, 2015, WIC E‐Notice #2015‐115: New Non‐Discrimination Statement was sent to all Coordinators.

If you have questions, please contact Cheryl Bernard, at [email protected] or call (517) 335‐9561.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, theUSDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited fromdiscriminating 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: [email protected].

This institution is an equal opportunity provider.

Please note, that all documents, pamphlets, websites, etc. should be updated as follows:

1. Websites, online applications and all IT systems/web pages must be updated by November 20, 2015.

2. Documents, pamphlets, brochures, etc. using Non-Discrimination Statement (NDS) language prior to 2013 must be updated by December 31, 2015.

3. Documents, pamphlets, brochures, etc. using 2013 NDS language should be updated when supplies are exhausted or by September 30, 2016.

4. All new printing must use the 2015 Non-Discrimination Statement.

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Civil Rights Training must be taken by all staff who have access to clients or supervise staff who do.

Food Packages

7.03 Food Package for Qualifying ConditionAllow authorization of Elecare Infant, Enfaport, Neocate Infant, and Similac PM 60/40 for

premature infants up to one year adjusted age.

New updated Special Food/Formula Request Form 11/1/15 with updated instructions

7.04 Maximum Food PackageIncrease in Cash Value Benefit from $10 to $11 for food packages for women

Added Table H to show the 1.5X BE Package for women Breastfeeding multiple infants less than 1 year old

: Revised Policies 9.01 ‐ Client Compliance, WIC Settlement Agreement, Michigan WIC Client Agreement ‐December 2015

Client Compliance Revision HighlightsState Agency determines uniform procedures and sanctions to be applied to cases of

program abuse by clients

Compliance letters must be sent or given to client notifying them of their sanction preferably same day or next business day.

9.01A New Definitions

9.01B Violation Types/Sanctions

2.18A WIC Client Agreement

WIC Settlement Agreement Form

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Policy and E‐Notice Updates – January 2016

The New “And Justice for All” posters in English and Spanish are now available on E‐forms, DCH‐0236.

IBP Food Package Changes Effective March 1, 2016All IBP‐powder formula food packages will default to one (1) can of formula. Tailor to clients

needs.

MIChild Conversion to Medicaid Expansion‐Effective Jan. 1, 2016

Policy and E‐Notice Updates – January 2016‐Current

WIC E‐Notice #2016‐54: Destruction of WIC Records 4/1/16

o Laboratory logs

o WIC Bridge (EBT) card inventory and issuance logs

o Project FRESH issuance inventory and issuance logs

o Compliance records (client and staff) if no restitution is owed or legal proceedings

o Quality Assurance and Monitoring, WIC Management Evaluation materials and responses

3 Years + 150 days

Summary

2015 ME Not Mets and Recommendations

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2015 ME Not Mets and Recommendations

2014137 Not Mets (NM)

1‐11 Range of NM

5.3 Average

2015

115 Not Mets

1‐10 Range of NM

5 Average

1. 1.1 Fair Hearing‐Procedure 11. 10.1 Program Abuse‐Detect, Prevent, Document

2. 1.2 Fair Hearing‐Notifying 12. 11.1 ME Process

3. 3.1 Staffing 13. 12.1 Immunization

4. 4.1 Services at No Cost

5. 4.4 Determines Category based on Proof

6. 4.5 VOC Provided

7. 5.2 Processing Standards

8. 5.6 Outreach

9. 7.2 Food Package‐Appropriate

10. 8.1 Food Benefits

MET Indicators!All 100%

Indicator 6.2 How Nutrition Education is Provided

Overall: MET 57% (19) Not Met 43% (14)

B. Not providing clients the opportunity to review previous education.

‐Both in observation and documentation

C. Not providing Client Centered nutrition education

‐What are the clients’ concerns?

D. Nutrition Education Plan

‐Develop the NE Plan with the client

‐Document the NE Plan at each cert and evaluation

appointment

Not Met Indicators

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Indicator 9.1 Maintain full and complete Records concerning program operations

Overall Met 58% (19) Not Met 42% (14)

A. Eight (8) of the 14 were issues with breastpump releases and/or receipts not signed and in the record.

Three (3) of the 14 did not have an Annual Review in place

Three (3) of the 14 did not have a Disaster Plan Policy in place

Not Met Indicators

Indicator 7.3 Special Formula and Food Packages

Overall: Met 58% (19) NOT MET 42% (14)

A. Food Package assignment did not match medical documentation (7 out of 14)

Qualifying Condition was not appropriate for the formula assigned (3 out of 14)

Expiration dates did not match the medical documentation (3 out of 14)

Risk not assigned at cert or Eval appointment (2 out of 14)

Not Met Indicators

Indicator 4.3 Nutritional Risk Criteria


A. Health and Diet Assessment

‐Not using the CAR Tool (6 out of 6)

B. Anthropometric Assessment

‐Calibration (3 out of 6)

‐Equipment (3/6)

‐Procedural Issues (3/6)

‐1 leg, sheet, not confirming, not measuring

‐Zero Balancing (2/6)

Not Met Indicators

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C. Hematological Assessment ‐ 4 Errors

‐Not performing re‐test according to policy

‐Not recording on the Daily Hemoglobin log

‐Not completing Hemocue Quality control logs

‐Not asking if there is a bleeding problem or asking parent to monitor children with bandages.

D. Assignment of Risk‐ 7 Errors

‐Risk Assignment not included for Special Formula clients (4)

‐Not all applicable/appropriate risk codes assigned (3)

Indicator 4.3 cont’d

Indicator 5.1 Program Referral and Access


B. Refer to health and community services, including MIHP/Healthy Start, etc

‐MIHP (or similar program) not documented for Pg, B, and Infants (7 of 9)

‐No referrals documented (2 of 9)

C. Provide New Clients with local resources for drug and other harmful substances

‐New clients, pregnant women and infants not

provided with local resources (4 out of 4)

‐See MIWIC Policy 6.02

Not Met Indicators

Indicator 6.6 Nutrition Counseling Services


A. Identify and offer High Risk services (4 Errors)

‐No Documentation that High Risk services were offered

B. Documenting Services (7 Errors)

‐NE Pop‐up screen was not completed (4 out of 7)

‐Documentation was not complete on Nutrition Care Plan (5 out of 7)

D. Monitoring High Risk and Class III formula clients (2 Errors)

‐Not monitoring to ensure referral to RD

E. Follow‐up Documentation (2 Errors)

‐Not documenting if/what follow‐up is planned

Not Met Indicators

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Indicator 9.2 EBT Card inventory, security, storage and issuance.


A. Bridge card Inventory (4 Errors)

‐Not performing a monthly physical inventory

C. Bridge card Security (2 Errors)

‐Bridge cards not kept in a locked storage area

Not Met Indicators

Indicator 5.4 Notification of Client Rights and Responsibilities


A. WIC Client Agreement (1 Error)

‐Not providing the WIC Client Agreement to read

B. Participant and benefit Abuse (2 Errors)

‐Not asking client at recertification if they are having any problems using their benefits

C. Notice of Ineligibility, mid‐cert terminations, and short cert notifications (3 errors)

‐Not providing written notice (2 out of 3)

‐Ineligibility/Short cert not valid (3 out of 3)

Not Met Indicators

Indicator 6.3 Eligibility Explanation


A. Not providing the client with their Eligibility Explanation

‐Must be verbal

‐Also on the NE Plan

‐Documentation required on Nutrition Education Screen

Not Met Indicators

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Indicator 7.4 Returned Formula


A. Securing and Monitoring Returned Formula (3 Errors)

‐Formula not secure (2 out of 3)

‐LA Policy not up to date (1 out of 3)

C. Accepts, Reissues or donates Formula according to Policy (3 Errors)

‐Returned Formula Logs not complete or accurate

Not Met Indicators

Indicator 6.5 Promote, Protects and Supports Breastfeeding


B. Breastfeeding Orientation for new employees (1 error)

‐Orientation checklist does not include breastfeeding promotion

D. Breastfeeding Education and Support (4 Errors)

‐Not documenting breastfeeding referrals or follow‐up for pregnant or breastfeeding women

Not Met Indicators

Indicator 2.3 Client Confidentiality

Overall: Met 87% NOT MET 13% (3)

B. Privacy for applicants and clients (3 Errors)

‐Not providing privacy in the front area where income and other confidential information is being collected.

Not Met Indicators

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“CPA” Corrective Plan of Action• After ME review, you will receive a CPA follow‐up form from Sheryl Darling at MDHHS/WIC

• [email protected]

• Complete Plan for each “Not Met” including training, observation, monitoring and record reviews.

• Save and return CPA by email to Sheryl or your LA Consultant for acceptance

Missy and Joan attended Anthrotraining in Dearborn and gave demo at staff meeting 10/14

LA completes

MDCH/WICApproves

LA keeps records & documents CPA steps

Management Evaluation Follow‐up• Implement your plan. Retain all materials to support your plan, i.e., meeting agenda/minutes, training documentation, observation forms with staff feedback noted, record reviews.

• Notify your LA Consultant or ME follow‐up Reviewer when your plan has been fully implemented for 90 days. Schedule follow‐up.

• Follow‐up reviewer will review all of your materials and documentation of your plan implementation and determine progress or completion of plan within 1 year of Exit Conference

• Receive Letter of Final Approval from LA Consultant

• Celebrate! (…and start planning for next ME)

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Develop Plan

Train

Monitor

Feedback

90 day Monitor Period

Follow‐up visit

&

Final approval

Management Evaluation Program Area Lead (PAL)

Nancy Erickson, MS, RD, CLE

[email protected]

517‐335‐9562