NUTRITION UNIT MONITORING TOOL MO-56 Nutrition Services: 400 points or 40% of Total Program Review Score A) District Nutrition Office Points Available for Each Section Score Based on Points available/Total Nutrition points available (400) Secondary Nutrition Education Provided Low Risk Secondary Nutrition Education High Risk Secondary Nutrition Education Breastfeeding Promotion and Support Breastfeeding Peer Counselor Program District Created Food Packages (999 Review) Nutrition Education Materials District Self Reviews “Nutrition”: Orientation Checklist Continuing Education: (% Meeting Standard) Competent Professional Authority (CPA) Nutrition Assistant (NA) Breastfeeding Peer Counselor (PC) 50 (25) (25) 20 20 15 15 15 5 20 12.5% 3.75% 5% 5% 3.75% 3.75% 1.25% 5% 160 B) (Clinic) Breastfeeding Chart Review Percentage for Documentation: Encouragement to Breastfeed Clinic Environment Supportive of Breastfeeding Breastfeeding Referral System in Place Breastfeeding Equipment 30 7.5% 30 C) (Clinic) - Clinic Observation Nutrition Education Observation (Certifications, low and high risk secondary nutrition education contacts) Anthropometric Equipment / Hematological Equipment Anthropometric Observation Hematological Observation 75 5 5 5 18.75% 1.25% 1.25% 1.25% 90 D) (Clinic) Food Package Formula Tracking Log & State Ordered Formula Tracking Log High Risk / Special Formulas/Medical Documentation 5 15 1.25% 3.75% 20 E) (Clinic) Record Review Record Review Summary - 100 Points Total per Chart. Highlighted Red OR Highlighted Black - Requires Corrective Action Training One clinic average <90% requires clinic specific training Two highlighted clinics <100% requires clinic specific training Three or more highlighted clinics <100% requires district-wide training 100 25%
OR District Total % from CSC data when available (Calculated from latest FFY total cumulative percentage) High Risk Secondary Nutrition Education Rate from Electronic Documentation. ____ % 90-100% 40 Points (S) 80-89% 20 Points (SN) 50-79% 15 Points (U) 0-49 % 0 Points (U) 25 Comments: Breastfeeding Promotion and Support: S SN U NA Possible Points Points Awarded BF (IV, V) Breastfeeding Promotion and Support Overall Rating: 20 Is the assigned District Breastfeeding Coordinator a full-time position? 4 Is the District Breastfeeding Coordinator a Certified Lactation Counselor (CLC) or International Board Certified Lactation Consultant (IBCLC)? 2 All staff interacting with WIC participants (CPAs, Nutrition Assistants, Peer Counselors, Clerical) receiving breastfeeding continuing education yearly? 5 Does the District have Breastfeeding Peer Counselors supporting prenatal and breastfeeding women? 2 Local agency: Appropriately manages an inventory of all breast pumps and kits? Has established appropriate policies and procedures for issuing pumps? 2 Has the local agency developed a breastfeeding resource list for prenatal and breastfeeding women? 1 BF (IV, V) Breastfeeding Promotion and Support Overall Rating: 20 Is the assigned District Breastfeeding Coordinator a full-time position? 4
Recommendation: When possible complete five (5) observations per clinic. At minimum complete 5 observations per District. Looking For: HEMOCUE Staff observed using universal precautions? Followed correct procedures for collecting hematological data? Hemoglobin was collected when required? MASIMO PRONTO Followed correct procedures for collecting measurement. If measurement was unable to be collected using non-invasive means; screening completed using Hemocue. Hemoglogin collected when required? Hemoglobin Observation / Universal Precautions Overall Rating: 5 Scoring is based on district summary: All observations conducted according to standards 5 Points (S) One (1) to two (2) observations with noted deficiencies 4 Points (SN) Three (3) to four (4) observations with noted deficiencies 3 Points (U) Five (5) or more observations with noted deficiencies 0 Points (U) Hemoglobin Observation / Universal Precautions: (S = Satisfactory, SN = Satisfactory Needs Improvement, U = Unsatisfactory and N/A = Not Applicable) Clinic District Average: Date Reviewer Rating: (S / SN / U / NA) Clinic Points Awarded: Comments: (Note additional observations under comments if the clinic was rated as unsatisfactory) N. Formula Tracking Log / State Ordered Formula Tracking Log: MO-77 S SN U NA Possible Points Points Awarded Formula Tracking Log book is required for all clinics. State Ordered Formula Tracking Log is required for all clinics that received state ordered formula within the required five (5) years plus current Formula Tracking Log / State Ordered Formula Tracking Log: Overall Rating: 5 Clinic scoring by the following criteria: Formula Tracking logged according to standards 5 Points (S) One (1) to two (2) criteria with noted deficiencies 4 Points (SN) Three (3) to four (4) criteria with noted deficiencies 3 Points (U) Five (5) or more criteria with noted deficiencies 0
documentation retention guidelines. Points (U) District points are assigned by averaging clinic scores according to the following. 4.5 – 5 average - 5 Points (S) 4.0 – 4.4 average - 4 points (SN) 3.0 – 3.9 average - 3 points (U) < 3.0 - 0 points (U) Recommendations for improving Formula Tracking Log. (Note findings under comments for each clinic) NUTRITION UNIT MONITORING TOOL Formula Tracking Log/State Ordered Formula Tracking Log MO-77, MO-78 7. State Ordered Formula Tracking Log available for review 8. Was the State Ordered Formula Tracking Log book completed according to guidelines? 9. 5 years plus current history available for review? Total Number of Findings: Comments: