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TRANSCRIPT
1/18/2018
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Management Evaluation Webcast
• 2018 Tool Changes
• 2017 ME Review
Nancy Erickson, MS, RDProgram Area Lead (PAL) for Management Evaluations and
Annual Reviews
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Go to michigan.gov/wicClick “WIC Providers”
ME Tools
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Active Record Review (White)
Page 1 InstructionsReflects the changes in the Record Review
Page numbers changed/moved
Page 2 Record ReviewAdded 6.2b “Previous NE reviewed at recert/evals? Note/Date Achieved”
Citation will be on hold this year –more training in this areaComplete Date Achieved and Note on the previous NE line
Previous NE Follow‐up Documentation
Cert/recert and I/CEVAL Appointments – (See Exhibit 5.07A, NE Documentation Grid). Documentation of NE must include: a. Follow up of previous WIC nutrition education at Recert and I/CEVAL (NE Pop‐up screen:
Note, Date Achieved. Documentation of behavior change is encouraged. See Policies 5.03, NE at Cert/Recert and 5.04, NE at I/CEVAL.)
Required Elements, per policy: Note and Date AchievedBoth edit‐able
Change Date Achieved to follow‐up date (wichealth.org auto‐populates this to lesson completion date; this can be changed.) (Think of that column as Follow‐up Date.)
Click Notes and add additional notes to Note section. Do not delete Notes already there.
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NE Documentation• Policy 5.07, A.3: Cert/recert and I/CEVAL Appointments – (See Exhibit 5.07A, NE Documentation Grid). Documentation of NE must include:
a.
b. NE provided: Date, topic(s), method, provider, initials, evaluation, and client’s selected behavior change. Document in Notes if client selects an alternate behavior change that is not listed in MI‐WIC. Best practice: Documentation of client’s stage and any additional notes is encouraged.
• Required Elements, per policy: Date, topic(s), method, provider, initials, evaluation, and client’s selected behavior change
Follow‐up after wichealth.org lesson completion• Policy 5.07, A.5: Interim Nutrition Education documentation of requirements
a. Internet (wichealth.org) lesson completion is automatically recorded in MI‐WIC for all enrolled family members. When Internet education is reviewed with the client following the lesson, the initials and evaluation of the staff answering the questions must be entered. Notes addressing client questions are encouraged.
• Required Elements, per policy: Initials and Evaluation• Initials field edit‐able
• Evaluation field only edit‐able day of lesson completion
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Active Record Review
Page 3 Single Certifier ReviewThis review was removed. We will be looking at your audits ‐ See Admin Tool
WIC/CSFP Dual Participation removed
Page 4 Roles ReportRevised to reflect MI‐WIC Policy 1.07
Document who has roles, and are required credentials or degree met
Page 5 Formula Approval Review4.3a ‐ Changed wording and added “or at any appointment when appropriate”
Class III records designated as high risk moved to 6.6a
Active Record Review
Page 6 High Risk Care PlanNE documentation changed from 6.6b to 6.2c
Pg 7 Moved the WIC Dual Participation Report here
Pg 8 Breastpump Monitoring Reports Added 2 newer Multiuser pumps: Endeare and Symphony
Changed to include Client ID of pump reviewing
Changed criteria to 20% of total pumps reviewed for a citation instead of 2.
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Certification/Observation (Blue)
Page 5 AnthropometricsChanged criteria “Through 23 mos” instead of “24 months” and
Adult height board/scale is “24 mos. and over” instead of “over 24 months”.
Page 10The CAR Tool reference has been removed and added MAR Tool
Page 11
Removed part of 4.3a “and document identified manual risks” duplicated previous questions under Risk Assessment
Changed 4.3a to 6.6a “For clients with Class III formulas…”
Certification/Observation
Page 12 Removed Best Practice item under 6.2d
Removed item re: close interaction on a positive note
Page 14Removed question on updating breastfeeding statistics
Page 15 Changed 7.2b to a ‐ Combined all classes of formulas
Page 17Print Docs ‐ Rearranged the order
Page 18Separation of Duties ‐ removed reference to benefit issuance.
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Nutrition Education (yellow)
Moved pages to keep observation pages together
Page 1 NE Lesson PlansRemoved “Summary” from required lesson plan contents
Moved wichealth.org questions from pg. 2 to pg. 1
Page 4 Breastfeeding Education and SupportAdded questions for Breastfeeding Peer: How do they refer to IBCLC, and What are their after‐hours availability
Page 6 High Risk CounselingDocumentation of NE changed from 6.6b to 6.2c
Moved questions regarding high risk records to Administration Tool
Administration (Salmon or Orange)
Page 2 Nutrition Ed Collaboration/WIC Agreementrequired now if using MSUE for Project Fresh
Page 2 Certification Timeframeschanged the set‐up of checking on the next appt.
Page 3 Removed redundant question for 5.2a.
Removed some questions regarding Waiting List
Combined questions on Policy Review
Page 4 Computer Security/MaintenanceChanged reference from SSO to MILogin
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Administration (Salmon or Orange)
Pg 7‐Staff3.1a regarding Training—Policy being revised
Compliance‐Removed question regarding Compliance Investigation Screen
Pg 8Changed questions on “Separation of Duties” (2nd 10.1b) to reflect latest policy
Pg 9Moved the High Risk Monitoring questions to this tool
Outreach (Pink)
Added space for Agency Name, Reviewer Name, and Date on top
Page 1 Removed word “written” material ‐ on‐line information
Removed “Are other referral source materials available?”
Page 2 Racial/Ethnic/DiscriminationUpdated link for Civil Rights Training module
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Project Fresh (Tan)
Reviewer to interview PF Coordinator
Removed some questions
Recordkeeping and Accountability –EBT (green)
No Changes!
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Management Evaluation ‐ Indicator Guide
Criterion
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Michigan WIC Indicator Guide
Documentation Required:
The most recent copy of the State issued Fair HearingFlyer and Rules of Local Agency Fair Hearing.
Fair Hearing records, if applicable.
WIC Indicator Guide
Observe that the Fair Hearing Flyer and the Rules of Local Agency Fair Hearing (MI-WIC Policy 1.04, Exhibit A, B) are available upon request. (a)
Ask Coordinator if any Fair Hearings have been held in the past 3 years; if so, verify that the documentation is on file and that it conforms to the policy requirements. (b)
If no Fair Hearings have been held, ask staff what are the actions to be taken if an applicant or client asks for a Fair Hearing. (b)
Ask Coordinator to state how they handle a request for Fair Hearing from staff/client. (b)
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Management Evaluation ‐Indicator Guide
Page 8 Indicator 3.1F) Lactation Consultant/(removed “Educator”)
Reflects requirement of IBCLC by 10/1/2017
Page 15 Indicator 4.3Removed reference to CAR Tool and replaced with MAR Tool
Page 42 Indicator 9.1 Requires collaboration agreement with MSUE for Project Fresh
MIWIC Reports for Management Evaluations (Purple)
Updated: Purpose column to explain report
Reviewed/Comments column Frequency of monitoring
Definition of Dates
Note: Single cert report updated with requirement
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Management Evaluation
USDA Management Evaluation Recommendation
Review of previous ME citations and if repeated
Reviewed at Exit Conference
Questions?
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Nancy Erickson, MS, RD
2017 Management Evaluation ReviewNot Mets and Recommendations
Nancy Erickson, MS, RD
January 25, 2018
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2017
106 Not Mets
Range 1‐13
Average 4.8
2016
113 Not Mets
Range 1‐10
Average 4.4
2015
115 Not Mets
Range 1‐10
Average 5.0
Management Evaluation Review-2017
1. 1.1 Fair Hearing Procedure
2. 1.2 Fair Hearing Notifying 11. 7.2 Food Package‐Appropriate
3 2.2 Civil Rights Training 12. 7.4 Returned Formula
4. 4.1 Services at No Cost 13. 8.1 Food Delivery System
5. 4.2 Verification of Eligibility 14. 11.1 ME Process
6. 4.4 Category based on Proof
7. 4.5 VOC
8. 5.2 Processing Standards
9. 5.3 Certification Periods
10. 5.5 Dual Enrollment
MET indicators‐ All 100%
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Not Met Indicators
Indicator 6.2 How Nutrition Education is Provided ‐17 errors
Overall: Met 23% (5)/ Not Met 77% (17)
A. Assessment ‐2 errorsNot identifying and exploring client concerns
Not providing NE that client was interested in
B. Reviewing previous Nutrition Ed ‐7 errorsNot providing clients opportunity to review previous education
Not documenting review of previous nutrition education
Not Met Indicators
Indicator 6.2 cont’d
C. Client Centered Nutrition Education ‐10 errorsNot documenting NE provided appropriately
Not addressing client concerns
Not summarizing concerns and how NE can help
Not affirming/supporting positive changes made
D. Nutrition Ed Plan ‐11 errorsNot developing plan with client (4)
Not documenting (5)
Not printing (4)
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Not Met Indicators
Indicator 6.6 Nutrition Counseling Services
Overall: Met 45% (10) / Not Met 55% (12)
A. Identify and Offer High Risk Services – 4 errorsNo documentation that HR services offered
B. Care Plan Documentation – 9 errorsIntervention Plan incomplete – Client’s desired outcomes, 1‐3 behavior changes, practical interventions, indicators to monitor and evaluate in Follow‐up
D. Monitoring High Risk and Class III Formula clients ‐2 errors
Not Met Indicators
Indicator 4.3 Nutritional Risk CriteriaOverall: Met (12) 55% / Not Met (10) 45%
A. Health and Diet Assessment (3)Not documenting known Qualifying Condition in MI‐WIC
B. Anthropometric Assessment (3)Procedures not followed
Not confirming, not weighed w/ dry diaper, using one leg, not measuring (asking ht.)
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Not Met Indicators
Indicator 4.3 cont’d
C. Hematological ‐7 errorsNot performing test according to procedures
Not performing re‐test according to policy
Not asking if there is a bleeding problem
Not recording on the Daily Hemoglobin Log
Not documenting Hemocue Quality Control Logs adequately
Not asking parent to monitor bandage for possible choking hazard
Not Met Indicators
Indicator 9.1 Maintain Complete records of Program Operations
Overall: Met 55% (12)/ Not Met 45% (10)
A. RecordsBreastpumps
Releases or receipts not signed and in record (9)
Annual Review – (1)
Homeless Facility Agreement not on file (1)
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Not Met Indicators
Indicator 5.1 Program Referral and AccessOverall: Met 73% (16)/ Not Met 27% (6)
A. Medicaid Referral ‐ 1 errorAll clients should be marked as Referred, Discussed, or Current
B. Health & Community Services – 5 errorsMIHP/Healthy Start or similar program not referred
MIWIC REFERRALS
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Not Met Indicators
Indicator 2.3 ConfidentialityMet 73% (16)/ Not Met 17% (6)
A. Names and addresses confidential (2)Not locking screens when leaving computer
Leaving schedules out in open
B. Privacy (5)Work area does not provide privacy
Not Met Indicators
Indicator 9.2 EBT Card Inventory, Security, Storage and Issuance
Overall: Met 77% (17)/ Not Met 23% (5)
A. Bridge Card Inventory – 4 errorsPhysical Inventory not completed monthly and documented
B. Issuance Logs – 1 errorMissing information on logs
Off‐site clinics missing logs, signature forms
C. Bridge Card Security – 1 errorNot limiting number of daily EBT cards
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Not Met Indicators
Indicator 6.4 Accurate and Up‐to‐date Nutrition Information
Overall: Met 77% (17)/ Not Met 23% (5)
B. Nutrition Ed Materials reviewed (5)• Exhibit 5.01c or equivalent not being used to review for appropriateness
Exhibit 5.01c
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Not Met Indicators
Indicator 5.4 Notification of Client Rights and Responsibilities
Overall: Met 77% (17)/ Not Met 23% (5)
C. Notices of Ineligibility, Short certs, and Termination of Cert ‐5 errorsNot providing Ineligible Notice (1)
Invalid reason (3)
Not providing short cert (1)
Not providing 15 days notice/benefits before end of cert (breastfeeding ended) (1)
Not Met Indicators
Indicator 7.3 Special FormulasOverall: Met 82% (18)/ Not Met 18% (4)
A. DocumentationQualifying condition did not meet requirement for formula
Incomplete Medical Documentation Forms
Food Package did not reflect MDF
Incorrect Expiration Dates
MDF not scanned
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Not Met Indicators
Indicator 6.1 Providing Nutrition Education
Overall: Met 82% (18)/ Not Met 18% (4)
A. Nutrition Ed ContactsRequired number of contacts not documented
Offered ‐ past appts, NE Plan ‐ wichealth.org
Received
Refused
Not Met Indicators
Indicator 6.3 Eligibility Explanation
Overall: Met 82% (18)/ Not Met 18% (4)
A. Verbally provide the Eligibility Explanation ‐4 errorsUse the NE Plan as a reminder
Include:What we provide: supplemental food, nutrition education, referrals and breastfeeding information and support
Food benefits are for the client
Encourage pregnant women to breastfeed or breastfeeding women to continue
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NE PLAN
NE PLAN/Eligibility Explanation
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Not Met Indicators
Indicator 6.5 Breastfeeding Promotion, Protection, and Support
Overall: Met 82% (18)/ Not Met 18% (4)
B. Staff Orientation ‐1 errorNo new staff orientation to breastfeeding developed
C. Ongoing Staff education ‐1 errorClerical staff not included/documented
D. Providing Breastfeeding education and Support‐ 2 errorsNo breastfeeding education or referral documented
No breastfeeding follow‐up where requested
Not Met Indicators
Indicator 3.1 Staff (3)Documenting trainings (2)
Credentials/degree missing for role (1)
Indicator 2.1 Civil Rights (3)Current non‐discrimination statement not on materials (1)
Unsafe work area and diaper changing area not available (2)
Indicator 10.1 Prevent, Detect and Document client or employee fraud and abuseSingle certifier documents not scanned and in‐adequate follow‐up on missing documents (2)
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Not Met Indicators
Indicator 7.1 Authorized Foods (2)Not reviewing food packages for new clients or when changed
Not asking if client has had problems with benefits/card
Indicator 5.6 Outreach (2)LA Clinic locations not available to clients
Outreach activities not documented
Indicator 12.1 Immunizations (2)No LA Immunization Policy
Pregnant women not informed of flu and Tdap vaccine
Management Evaluation Process
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1 2
3 4
5 6
Preparation
Report sent 45 days later
90 days Implementation
Management Evaluation
Corrective Plan of Action or CPA
Follow-up Review of CPA
Management Evaluation Process
Questions?
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Management Evaluation Program Area Lead (PAL)
Nancy Erickson, MS, RD, CLE
517‐335‐9562