Illinois WIC Program Management Evaluation Tool Form Date: September Part 2: Nutrition Services Section. Agency: Clinic site(s) being reviewed:

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1 Agency: Illinois WIC Program Management Evaluation Tool Form Date: September 2005 Clinic site(s) being reviewed: Monitoring Staff: Part 2: Nutrition Services Section Date(s) of M.E. Interaction with local agency: When conducting management evaluations of local WIC agencies, please use the following format: All questions and/or observations that have (CA) following them are considered to be contract requirements as required by Federal Regulation and WIC Policy. A contract requirement that is not met, should be addressed as a Corrective Actions. Corrective Actions require the agency to submit their corrective action plan, including implementation time frames, within 30 days of receipt of the state agency report. Their response must be dated and included in the last page of this management Evaluation Tool. All questions and/or observations that have an (R) following them, are considered Recommended Actions and are not contract requirements. However, they are important to identify to the agency because they relate to program quality assurance and achievement of certain contract requirements. Observations that result in a Recommended Action should be included within the cover letter to the agency with the completed Management Evaluation Tool attached. Recommended Actions are not to be included when filing this Tool. Illinois Department of Human Services Division of Community Health and Prevention Office of Family Health Bureau of Family Nutrition 535 W. Jefferson St., 3 rd Fl. Springfield, IL (phone) (fax)

2 Illinois WIC Program Management Evaluation Tool Nutrition Services Section The following is a summary of findings based on review of Local Agency Policies, Certification Observation, Nutrition Education and Non-Contract, Special Formula Documentation. Detailed worksheets used for each of these areas are available upon request from your Regional Nutritionist Consultant. CA: Corrective Actions are required by USDA Federal Requirements and require an action plan Recommended Actions are considered best practice and do not require an action plan. Date Local Agency Response Received: Local Agency Policies IL WIC PPM 1.6 Federal Regulations 7 CFR 246 CA Comments: Site only one Corrective Action for this question 1. Review local agency WIC policy and procedures manual for inclusion of the following a) Physician standing orders b) Referral procedures c) Proof of pregnancy procedures d) Certifying infants of WIC mothers procedures e) Scheduling mid-certification assessment for infants certified up to one year of age procedures f) Storage and distribution of infant formula supplies g) Deferral of blood work h) A policy that creates a positive clinic environment which endorses breastfeeding as the referred method of infant feeding. i) A plan to ensure women have access to breastfeeding promotion and support activities during the prenatal and postpartum periods. j) Clinic has a designated Breastfeeding Coordinator. k) Agency incorporates task appropriate: breastfeeding promotion and support training into orientation for new staff involved in direct contact. 1

3 Local Agency Policies Recommended Policies: 1. Immunization screening for infants and children procedures 2. High Risk procedures a. General b. Prenatal 3. Breast pump policy 4. Peer Counselor program policy (if applicable) 5. Special Formula Quality Assurance policy RA Comments: Total number of Corrective Actions for Local Agency Policies Section 2

4 Certification Observation Federal Regulations 7 CFR Corrective Actions Determination of Nutritional Risk: FR (e) 1. Height/length and weight is collected (referral data or on-site) and documented in client's file. 2. Referral measurements are not more than 60 days prior to certification date. NA 3. Hematological test is conducted reflective of category, time frames and documented. 4. Hematological tests from referral sources or deferred hematological tests are obtained within 90 days of the certification date. NA 5. Diet is assessed using currently accepted practices of FNS/IOM. 6. Pregnant/Breastfeeding/Postpartum participants are screened for drug and other harmful substance abuse. 7. CHP determined nutritional risk through an accurate nutritional assessment. 8. Nutritional risk is documented in client's file. 9. Nutrition education scheduled is appropriate to client's nutritional needs. 10. Referrals are made as necessary and appropriate. 11. Food package tailored to address client's nutritional needs. 12. Food packages are selected by CHP FR (b)(2)(iii) 13. Health, dietary assessment, plans for intervention/follow up are documented in chronological progress notes & kept in the client record. FR (e)(5) Certification Observation Recommended Actions: 1. It is strongly recommended that head circumference measurements be obtained on all infants up to 12 months of age and plotted on growth chart. (PPM 3.2) 2. It is recommended that blood pressure be obtained on all women and children over 3 years of age. (PPM 3.2) 3. Respect/consideration - staff and clients CA Comments: RA Comments: Total number of Corrective Actions for Certification Observation Section 3

5 Nutrition Education Federal Regulations 7 CFR Corrective Actions Nutrition Ed: General Requirements FR (a) 1. Nutrition education is a benefit of the program and is available at no cost to the participant. 2. Nutrition education is designed to be easily understood by participants. 3. Nutrition education is integrated into participant health care plans, delivery of supplemental foods and other program operations. 4. Nutrition education is made available to all participants. 5. Nutrition education is provided through the local agencies directly, or through arrangements made with other agencies. 6. During certification, local agency stresses the positive long-term benefits of nutrition education. 7. During certification, local agency encourages attendance and participation in nutrition education activities. 8. Individual participants are not denied supplemental foods for failure to attend or participant in nutrition education activities. 9. Information on drug and other harmful substance abuse information is provided to all pregnant, postpartum and breastfeeding women and to parents or caretakers of infants and children participating in WIC. Nutrition Ed.: Goals FR (b) & (e) 10. Nutrition education is designed to achieve the following goals: a. proper nutrition and good health with special emphasis on clients current category. b. Raise awareness about the dangers of using drugs and other harmful substances during pregnancy and while breastfeeding. c. Assist the individual who is at nutritional risk in achieving a positive change in food habits. d. All pregnant participants are encouraged to breastfeed unless contraindicated for health reasons. Nutrition Ed.: Participant Contacts FR (e) 11. Nutrition contacts are designed to meet different cultural and language needs of participants. 12. Nutrition education is appropriate to the individual participants' nutritional needs. 13. An appropriate number of nutrition education contacts is made available to all participants. CA Comments: 4

6 Nutrition Education Federal Regulations 7 CFR Corrective Actions 14. Nutrition education given or missed is documented: a. Class rosters of group education b. Case note of individual education 15. A care plan is developed for clients as determined by CHP and per client's request. 16. For group education attendance logs are NA on file and reflect: a. the name and title of presenter. b. name and category of clients and their signatures/initials 17. Other methods of secondary education (SSM, Web ed, ind. ed) are clearly documented? 18. Group education attendance logs are kept on file for 3 years? FR NA NA Civil Rights Requirements FR (a) 19. Nutrition education materials, which are developed locally AND identify/describe the WIC program, include the nondiscrimination statement. CA Comments: Total number of Corrective Actions for Nutrition Education Section 5

7 Non-Contract and Special Formula Issuance and Documentation Review Non-Contract and Special Formula Issuance and Documentation Review Federal Regulations 7 CFR Corrective Actions 1. Ready-to-feed (RTF) formula is only given to participants whose household has unsanitary or restricted water supply, poor refrigeration, person caring for infant has difficulty preparing or if the formula only comes in RTF form. 2. Medical documentation for non-contract and Special formula includes: a. Determination by a licensed health care professional authorized to write medical prescriptions under state law; b. Brand name of the WIC formula prescribed; c. Medical diagnosis warranting the issuance of the formula; d. Length of time that the formula is medically required by the participant; e. Signature or name of requesting health professional as defined in (a.). 3. If medical documentation is provided by the telephone: a. it is determined by the CHP; b. documented and kept in client's file; c. done only when necessary to prevent delay from client receiving needed formula; d. receive written documentation within 1-2 weeks; e. written documentation is kept in client's file with initial telephone documentation. Total number of Corrective Actions for Non-Contract and Special Formula Issuance and Documentation Review Section CA Comments: 6

8 Part 2 - Corrective Actions Local Agency: Agency Contact: Date of Response: Local Agency Policies Total # Corrective Actions Nutritionist *Agency Response Comment [H1]: Date of Response refers to the date a Local Agency submits the Corrective Action Plan to DHS/CSSC Certification Observation Total # Corrective Actions Nutritionist *Agency Response Nutrition Education Total # Corrective Actions Nutritionist *Agency Response Non-Contract and Special Formula Issuance and Documentation Review Total # Corrective Actions Nutritionist *Agency Response Total # Corrective Actions *Local agency must include a cover letter with their response and the response must include timeline for compliance with corrective action. Corrective Actions 7