MPR MPR/Indicator/Criteria Text Change Documentation required How to verify 2.1 The WIC Program ensures that no person, on the basis of race, color, national origin, sex, age or disability, is excluded from participation, denied benefits, or subjected to discrimination under the Program. (7 CFR 246.7, 246.8, 246.19(b)(2), Policy 1.03, 1.09, , 2.18, 9.02) Updated policy references MI-WIC 1.09, 9.02 Updated USDA statements Added non-English accommodations Materials updated to include revised statement. Translators and or translation services Review materials for non-discrimination statement Ask non-English speaker services 2.2 a. The WIC Program trains new staff during orientation using the Michigan WIC Civil Rights Web-based Training Module and retakes/reviews the Michigan WIC Civil Rights Training Module with all other staff once a year, and maintains records of the tests/reviews in MI-WIC Staff Training. (7 CFR 246.8(a), FNS Instruction 113-1, MI-WIC Policy 1.09) Reflects use of module instead of USDA WIC Civil Rights Training Record training results in MI-WIC Record of Civil Rights training module scores in MI-WIC Training for each staff member. Review record of Civil Rights training module scores in Training for each staff member. 2.3 The WIC Program restricts the use or disclosure of information obtained from program applicants and clients, and parents or caregivers of infant and child clients. (7 CFR 246.21(b), 246.26(d), FNS Instruction 800-1, MI-WIC Policy 1.03, 1.06, 2.18, 9.02) Updated policy reference 1.06. Signed Michigan WIC Employee Confidentiality and Compliance Agreement Signature Review of signed Michigan WIC Employee Confidentiality and Compliance Agreement Signature
3.1 The WIC Program has has adequate, trained, qualified staff to provide required certification, breastfeeding and nutrition services to adult clients, parents or caregivers of infant and child clients, and whenever possible to child clients and applicants. (7 CFR 246.2, 246.7(e), 246.10(b)(2)(iii), WIC Policy 1.11, 4.19, 6.07, Policy 1.07, 9.03, 7.01) c. The WIC Program has a WIC Coordinator who the required qualifications and carries out the duties as specified in WIC Policy. (MI-WIC Policy 1.07) d. The WIC Program has a WIC Breastfeeding Coordinator who the required qualifications and carries out the duties as specified in WIC Policy. (MI-WIC Policy 1.07) e. The WIC Program has designated a Nutrition Education Coordinator who meets the required qualifications and carries out the duties as specified in WIC Policy. (MI-WIC Policy 1.07) f. The WIC Program has appointed a Lactation Consultant/Educator who meets the required qualifications and carries out the duties as specified in WIC Policy. By 10/1/17, the expert must be an International Board Certified Lactation Consultant (IBCLC) or the agency has a MDCH/WIC Division approved Plan for these services. (MI-WIC Policy 1.07) g. The WIC Program has adequate staffing at each clinic to determine WIC eligibility and to issue benefits while maintaining separation of duties. (MI-WIC Policy 1.07, 9.03) h. The WIC Program has adequate staffing to offer RD counseling services in a timely manner Reflects new staffing Policy 1.07. Requires review of credentials for specified staff. Requires adequate staffing for WIC eligibility determination with separation of duties. Requires adequate staffing to allow NCRD to be scheduled within 30 days. Requires credentials for specified staff. Requires evidence of adequate staffing for WIC eligibility determination with separation of duties. Requires adequate staffing to allow NCRD to be scheduled within 30 days. Requires review of credentials for specified staff. Review of single certifier reports and monitoring, observation of staffing to ensure separation of duties. Review of schedule to ensure availability of NCRD appointments within 30 days.
7.3 a. The WIC Program CPA/RD approves and provides special dietary formula and food packages as indicated for clients with special dietary needs, based on complete medical documentation received for: •Standard infant (Class I) formulas after 1 year of age. •Soy beverage food package for children •Hypoallergenic infant (Class II) formulas. •Specialty formulas (Class III) •Other special food packages as indicated per policy. (7 CFR 246.10(c)(1), MI-WIC Policy 1.07, 7.03) Combined criteria a & b, updated policy reference 1.07 Record review and observation showing CPA/RD follows procedures for special food package authorization. Record review demonstrates compliance with special food package documentation and assignment. 7.4 a. The WIC Program designates a staff person to be responsible for securing and monitoring the appropriate distribution of returned formula to clients or eligible programs. (MI-WIC Policy 8.05) Included securing and monitoring the returned formula to person responsible for distribution. Noted change in formula inventory log 8.05A, 9/10/13 Completed LA “Returned Formula Policy” detailing responsibilities, security, inventory and issuance/donation. Use of revised inventory log. Review completed LA “Returned Formula Policy” detailing responsibilities, security, inventory and issuance/donation. Observe use of revised inventory log. 8.1 a. The WIC Program ensures that the client has access to no more than three complete months of food benefits at one time. (7 CFR 246.12(r)(7), MI-WIC Policy 8.01) Clarified that “client has access to no more than 3 complete months of benefits at a time, instead of issued at a time. Benefit issuance reviewed to ensure that client doesn’t have benefits extended beyond 3 complete months. Record review of benefit issuance.
Is the client measured without shoes on a disposable paper covered stadiometer? Use of disposable sheet covering measurement equipment Observation of measurement Is the client weighed wearing only light, indoor clothing, without shoes and the scale covered with disposable paper? Is measurement repeated until confirming measurements have been obtained? (Within 1/4 lb.) Please note that the individual should NOT be asked to step off the scale between measurements unless indicated by scale. Clarification of procedure: Allow individual to remain on scale during re-weigh unless indicated by scale Observation of measurement Laboratory: Does all staff wear gloves (optional: appropriate personal protective equipment -lab coat, gown, scrubs, apron) when collecting blood? Procedure change: Protective equipment is optional Observation of procedure. 12.1c Does the LA provide the recommended immunization schedule to clients who are not up to date or don’t have a documented record? Policy 6.03) Is the CDC Immunization website on the desktop to provide current recommendations and detailed information, if not suggest they do? Inclusion of policy statement in checklist Availability or knowledge of current schedule and immunization resources. Observation
6.3a Is the client the eligibility explanation? Example: You are being enrolled in WIC today because WIC’s services (food, nutrition education, referrals, breastfeeding support) can help you with your health concerns. WIC food benefits are supplemental and available while the client is enrolled. The food provided is for the client, not the family. (MI-WIC Policy 5.03) Revised policy Eligibility Explanation checked during cert/recert Observation 6.3a Does the CPA provide encouragement to all pregnant clients to breastfeed unless contraindicated for health reasons? (MI-WIC Policy 5.03) Observation 6.3a Does the CPA provide encouragement to all postpartum breastfeeding women to continue breastfeeding? (MI-WIC Policy 5.03 ) Observation 6.2b Does the CPA stress the positive long-term benefits of nutrition education and encourage the client to attend and participate in nutrition education activities? (MI-WIC Policy 5.03) Observation 6.2d Is the Authorized Person offered information on the dangers of using drugs and other harmful substances during pregnancy or parenting? (P.L. 100-690) (verbal preferred, also noted on Nutrition Education Plan) (MI-WIC Policy 5.03) Observation of education. Documentation in NOTES, if applicable. 6.6a Is a client determined to be at high-risk offered/scheduled with the RD for counseling? (MI-WIC Policy 5.06) NE Plan, RD refusal/non-WIC RD Observation, record review, compare with high risk reports 5.1a Is a woman or infant/child with no health insurance referred to Medicaid Outreach or DHS for Healthy Kids/Medicaid/Healthy Michigan Plan or MIChild enrollment? (MI-WIC Policy 6.02) Inclusion of Healthy Michigan Plan. Took out reference to Plan First. Documentation on Referral screen if not on MA Observation/record review for evidence of referral if not on MA.
4.3c Is a copy of the MDCH/WIC Laboratory Procedure Manual in the WIC Clinic or do staff know how to access from the MDCH/WIC website? (DCH-476, revised 11/21/2013) Revision date Copy or know where to find on website LA has copy or awareness of website. Is the hemoglobin analyzer cleaned each day it is used? Procedure changed to state clean daily when used. Observation Are microcuvettes dated when they are opened and the vial disposed of 90 days after opening, if unused? (If so, suggest ordering individually wrapped cuvettes) Suggestion for use of individually wrapped cuvettes Vial dated Observation, lab logs Are microcuvettes or control solutions used before their expiration date? Clarify procedure Vial dated, noted on Lab Log Lab logs Anthropometric Equipment (MI-WIC Policy 2.15) 4.3b Is a copy of the Anthropometric Measurement Procedures in the WIC Clinic or do staff know how to access from the MDCH/WIC website? (If not, suggest they do.) DCH - 0730, revised 3/12/13 Revision date Copy or know to find on website LA has copy or awareness of website. Record Review 5.1b Other referrals documented, if applicable? (MIHP/Healthy Start, NFP for I/PG, BE/BP, if available) Clarify that if MIHP… are available, referral is needed and should be documented Document on referral grid Review referrals grid 6.5e Breastfeeding referral/assistance, PG, BE/BP? (Breastfeeding screens, NE or referral) Clarified that if BF screens indicate assistance or referral this is sufficient Referral on BF screens or Referral grid Review BF screens 6.5e BF follow up documented (BF Contact and BF Aids and Notes)? PG, BE/IBE, BP/IBP, child if breastfed) Clarify that BF follow up is needed and must be documented as long as BF document on BF screens Review BF screens
Single Certifier Record Review: Does agency ever enroll using a single certifier? NO YES If yes, must 20% of records. Verify that 20% of clients certified by single certifier were reviewed by Coor. (Admin/reports/role reports/Single User Certification Report) Modified to document review Copies of reviews. Compare with Single Certifier Report Review copies of Audit reviews. Compare with Single Certifier Report 10.1b Is the agency performing routine audits of 20% of records certified by one staff member, as required? NA YES 9.1a Breastpump Inventory & Issuance Modified table and instructions Completed BP Agreements Review completed BP Agreements, inventory records and issuance reports 3.1a Role Report-Credential verification Modified and instructions License, RD, degree verification Review credentials, confirm meet requirements 7.3a Formula Approval Record Review Combined 7 a & b Med. Documentation forms, food package assignments Review MDF’s and food package assignments. High Risk Record Review No citation, note if high % of clients decline RD NE Pop-up: NE Plan, RD Refused, RD documented Review NE Pop-up Referrals Outreach materials for Medicaid/Healthy Kids/Healthy Michigan Plan Added Healthy Michigan Plan outreach materials Updated MA application and outreach materials available Copies of applications/outreach materials. Access to MA applications Civil Rights Civil Rights Training ONLY LMS module training.mihealth.org Clarified that ONLY LMS module is allowed Test results/score for each WIC staff member. Review training log, test results
Immunization Policy (MI-WIC Policy 6.03- A. 6-8) Only required if within a local health department. Local agency policy related to WIC/Immunization program collaboration, update of immunization records, appropriate information on specific childhood preventable diseases, benefits of immunization and CDC recommended immunization schedule will be provided. Nutrition Education Collaboration/WIC Agreement Only if Collaborative Program provides Nutrition Education. Does not include Project FRESH Education. (MI-WIC Policy 5.08 – specifying what activities will be performed, who to contact…) 3.1h Does the agency have NCRD appointments available within 30 days at each site? (MI-WIC Policy 5.06) Revised policy, requirement for available NCRD Schedule demonstrating NCRD appointments available within 30 days Review schedule 5.2a Is the agency in compliance with scheduling within the required timeframes? out from other questions for emphasis. Schedule demonstrating cert/pcert appointments available within 10/20 days as required Review schedule 5.2a Are pregnant applicants or clients, who do not keep their appointments, contacted to reschedule? (MI-WIC Policy 3.01) LA contact is required if client selected “do not mail” How? MI-WIC postcard (automatic) Autodialer/Text Message Agency follow up Other: Included “do not mail” scenario Note indicating client had been contacted Review note indicating client had been contacted
12.1 If a record is not found in MCIR, are efforts made to link WIC/MCIR record to client? If not, suggest they do. Included question to better correlate with MCIR LA policy/procedure Observe efforts to link WIC/MCIR records 9.1a Has the agency provided feedback, training and guidance to agency or sub-contractor staff regarding these annual reviews and findings? Policy 1.11 New Policy. Included expectation that annual reviews generate CPA for each site/contractor. CPA generated, evidence of training, discussion and implementation of Verify CPA generated, evidence of training, discussion and implementation of Plans. 11.1a Has the agency completed the Comprehensive Plan of Action from their previous WIC Management Evaluation/Annual review? (MI-WIC Policy 1.05, 1.11) New citation, inclusion of Annual Review CPA and status Verify CPA generated and steps completed documented Nutrition Education Policy 5.01-Nutrition Education One year cert changes 1 contact per quarter (all statuses) Breastfeeding –more occur earlier to meet client’s needs Follow up at cert/eval of previously received nutrition education New citations for revised policies. Follow up of NE documented on NE popup or ICP follow up screen Observe and review NE follow up documentation on NE popup or ICP follow up screens Recordkeeping and Accountability Record retention: Stored securely 10/1/2010-to date NOTE - All records can be destroyed E-Notice 2014-89 (4/18/14) Revised policy Observe that obsolete records are destroyed. Verify that no audits are outstanding. 3 months of benefits AVAILABLE Allow not more than 3 full months benefits to be on EBT card at a time. Replacement of WIC Bridge Card in clinic Clarified not more than 3 full months of benefits available to client at a time Benefit inquiry Review benefit inquiry to verify # months of benefits loaded at a time Project FRESH
When and how was training completed? What methods of education/training are used to educate clients? Are inventory/issuance records retained for the required period? (10/1/10-present) Clarified Project training and record retention Lesson plans for client education Inventory of stock and signature logs Review records and materials