management evaluation webcast - mphi · 1/1/2017 · hearings are carried out as specified in wic...
TRANSCRIPT
1/13/2017
1
Management Evaluation Webcast
• 2017 Tool Changes• Michigan.gov/WIC/
• WIC Providers/Management Evaluation Tools
• 2016 ME Review
Go to Michigan.gov/WIC Click “WIC Providers”
ME Tools
1/13/2017
2
Management Evaluation Webcast
• 2017 Tool Changes
• 2016 ME Review
Nancy Erickson, MS, RDProgram Area Lead (PAL) for Management Evaluations and
Annual Reviews
Active Record Review (White)
Page 1 InstructionsSimplified/reduced wordiness
Acronyms: O‐Observation, I‐Interview, S‐System, D‐Document
Page order changed
Page 2 Record ReviewNutrition Ed‐order changed
10.1b omitted “and benefits issued by”
Page 3 Single Certifier ReviewPolicy to change on Single Certifier
WIC/CSFP Dual Participation‐Genesee & Focus:HOPE Counties Only
1/13/2017
3
Active Record Review
Page 5 Compliance ReportReview changed from 24 mos. to 12 mos.
Page 6 Formula Approval Review4.3d changed to 4.3a‐‐All known qualifying conditions included in risk assessment and Class III records designated as high risk
Page 7 High Risk Care PlanRemoved additional criterion for Follow‐up – already included under Intervention Plan
Added Criterion 6.6b for Care Plan Frozen? Policy 5.06
Corrected what NE documentation (NE pop‐up) required for
Care Plan
Certification/Observation (Blue)
Page 1Under Instructions (top left): Acronyms defined and used along far left side
Page 24.2a (bottom of page) Combined question if ID is checked for Authorized Person and Proxies
Page 5Changed from “Accurately determine and record weeks gestation…” to “Are completed weeks gestation recorded for all children…”
Page 9 Added flu vaccine for pregnant women according to Policy 6.03
Certification/Observation
Page 10 Removed 4.3d from risk assessment
Page 11 Client Centered NE‐‐removed reference to CAR Tool in 6.2
Page 13Added “(including new infants)” for list of local resources for drug and other harmful substances
Page 16Food Guide ‐Changed “Infant Food Insert” to “Infant Formula Insert”
Page 17
Print Docs‐ Changed Breastfeeding “Forms” to “Release/Receipt”
1/13/2017
4
Nutrition Education (yellow)
Page 2 WIChealth.orgRemoved questions related to marketing and offering wichealth.org‐No MPR
Page 3 Client Interview‐(Self‐Directed EDU) Removed closed ended questions
Benefit Issuance‐ Combined questions if Personal Recognition or ID checked
Page 4 Nutrition Ed MaterialsWording on grade level 4‐8th grade from Policy 5.01
Nutrition Education
Page 7 High Risk Counseling Observe‐Removed additional reference to follow‐up and added Freezing Care Plan
Changed MPR for Intervention Plan from 6.2b to the correct 6.6b
Page 8 High Risk MonitoringThis was included both here and the Administration Tool. Removed from the Administration tool and combined the language.
Administration (Orange)
Page 2 Added Homeless Facility Agreement (Policy 2.22 11/16)
Page 5 Transfer—added …certification information “or VOC”
Page 7Dual Enrollment‐Removed reference to an archived webcast on compliance
Page 10High Risk Monitoring—Moved to Nutrition Education Tool to
reduce duplication.
1/13/2017
5
Outreach (Pink)
Page 1 Referrals—Question on providing clients with local resources for drugs and other harmful substances Removed. Same as Certification/Observation.
Page 2 Racial/Ethnic/DiscriminationChanged name of Civil Rights office to current
Updated link for Civil Rights Training module
Page 3 Civil Rights InterviewRemoved questions that were checked during observation ie Client Agreement, Voter Registration, and Breastfeeding education
Outreach
Page 4 Q8 Removed “Please describe any problems you have had when you used your WIC EBT card in a store.” And replaced with: “What is your shopping experience for WIC foods?”
Page 5 question #11 Re‐worded to be more open‐ended
Recordkeeping and Accountability ‐EBT
Page 1Added: Who monitors Benefit over‐issuance and Re‐Issuance reports?
Removed question re: Issuing proxy separate EBT card
Removed: How often are clinics/files/charts purged for obsolete records and forms?
1/13/2017
6
Project Fresh
• Page 1 • Added wichealth.org column
• Page 2 • Q#5 Removed Video & Food Demonstration
• Added “(State issued powerpt)” next to “Handout” & MSUE led class
Management Evaluation –Pre‐Visit or Indicator Guide
Criterion
This indicator may be met by:
a. The WIC Program makes available the Fair Hearing rules of procedure uponrequest. (7 CFR 246.9(h), MI-WIC Policy 1.04)
a. The WIC Program ensures that all Fair Hearing requests (verbal or inwriting) by applicants or clients are honored within stated timeframes. FairHearings are carried out as specified in WIC Policy and documentationrelated to the Fair Hearing is recorded in the MI-WIC System and maintainedat the WIC Program for three years and 150 days after the close of the fiscalperiod. (7 CFR 246.9(k), 246.25, MI-WIC Policy 1.04)
1/13/2017
7
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
Evaluation Questions:
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)
Management Evaluation ‐Indicator Guide
Page 8 Indicator 3.1On g) made it more of a generic statement on maintaining separation of duties.
Page 11 Lactation Consultant/EducatorRemoved the word “OR”
Currently you must have a CLS, CLE, CLC on staff
By 10/1/2017 you will need someone who is IBCLC
Page 16 Indicator 4.3Removed 4.3d Criterion –this is already included in 4.3a
Evaluation Questions were moved around
Page 29 Indicator 6.2Under Assessment, Removed reference to the Health Hx and Client
Assessment Reference (CAR) ToolThis was already included in Indicator 4.3
1/13/2017
8
Management Evaluation ‐Indicator Guide
Page 33 Indicator 6.4Reinforcements/materials wording changed to correspond to Policy wording
Page 37 Indicator 7.2 Clarified by including under Evaluation Questions: “client’s needs (includes assigning 2% milk pkgs, soy milk, allergies, etc.).”
Page 48 Indicator 10.1Single Certifier language change…
Page 50 Indicator 12.1 Added Criterion “e”Local agencies shall provide information to women enrollees, especially pregnant women, to receive the Influenza vaccine and in their 3rd trimester, the Pertussis Vaccine (Tdap) for every pregnancy. (MI‐WIC Policy 6.03)
MIWIC Reports for Management Evaluations (Purple)
Changed a few addresses to correct names
Moved reports under correct section
Removed: Guidance under Hgb Daily summary report re: HR infants monitored at I Eval
Added: Benefit over Issuance Report to EBT
LA Directory to Admin section
Note: Single cert report will need updating when released in MIWIC
Management Evaluation
USDA Management Evaluation Recommendation
Review of previous ME citations and if repeated
Reviewed at Exit Conference
1/13/2017
9
Questions?
Nancy Erickson, MS, RD
2016 Management Evaluation ReviewNot Mets and Recommendations
Nancy Erickson, MS, RD
January 26, 2017
1/13/2017
10
2016
113 Not Mets
Range 1‐10
Average 4.4
2015
115 Not Mets
Range 1‐10
Average 5.0
2014
137 Not Mets
Range 1‐11
Average 5.3
Management Evaluation Review-2016
2016
1. 1.1 Fair Hearing Procedure 11. 5.6 Outreach
2. 1.2 Fair Hearing Notifying 12. 7.2 Food Package‐Appropriate
3. 2.1 Ensuring Non‐Discrimination 13. 7.4 Returned Formula
4. 2.2 Civil Rights Training 14. 11.1 ME Process
5. 4.1 Services at No Cost
6. 4.2 Verification of Eligibility
7. 4.4 Category based on Proof
8. 4.5 VOC
9. 5.2 Processing Standards
10. 5.5 Dual Enrollment
MET indicators‐ All 100%
Not Met Indicators
Indicator 4.3 Nutritional Risk CriteriaOverall: Met (6) 23% / Not Met (20) 77%
A. Health and Diet AssessmentNot using the CAR Tool (6 out of 6)
B. Anthropometric AssessmentProcedures not followed
Not confirming, 2 people not involved in length, no disposable paper, using one leg
EquipmentMeasurement boards inaccurate, Calibration not done annually
1/13/2017
11
Not Met Indicators
Indicator 4.3 cont’d
C. Hematological ‐7 errorsNot performing re‐test according to policy
Not asking if there is a bleeding problem
Not recording on the Daily Hemoglobin Log
Not completing Hemocue Quality Control Logs
D. Assignment of Risk – 8 errors
‐ Not all applicable risk codes assigned (6)
‐ Risk assignment not included for Special Formula clients (3)
Not Met Indicators
Indicator 6.2 How Nutrition Education is Provided ‐14 errors
Overall: Met 46% (12)/ Not Met 54% (14)
A. Assessment ‐6 errorsNot identifying and exploring client concerns
Self‐Directed Nutrition Ed‐not able to choose
Not asking about previous NE
B. Reviewing previous Nutrition Ed ‐6 errorsNot providing clients opportunity to review previous education
Not Met Indicators
Indicator 6.2 cont’d
C. Client Centered Nutrition Education ‐9 errorsNot addressing client concerns
Not summarizing concerns and how NE can help
Not affirming/supporting positive changes made
Not documenting NE provided
D. Nutrition Ed Plan ‐7 errorsNot developing plan with client (6)
Not documenting (2)
E. Providing information on Dangers of using Drugs ‐2 errors
1/13/2017
12
Not Met Indicators
Indicator 6.6 Nutrition Counseling Services
Overall: Met 46% (21) / Not Met 54% (14)
A. Identify and Offer High Risk Services – 5 errorsNo documentation that HR services offered
B. Care Plan Documentation – 9 errorsIntervention Plan incomplete – Client’s desired outcomes, 1‐3 behavior changes, practical interventions
Follow‐up
Documentation in NE pop‐up
D. Monitoring High Risk and Class III Formula clients ‐1 error
E. Follow‐up Documentation ‐4 errorsNot documenting if or what follow‐up is planned
Not Met Indicators
Indicator 5.1 Program Referral and AccessOverall: Met 64% (21)/ Not Met 35% (11)
A. Medicaid Referral ‐3 errorsAll clients should be marked as Referred, Discussed, or Current
B. Health & Community Services – 4 errorsMIHP/Healthy Start or similar program not referred (3)
Other services‐Lead, Family Planning, immunizations
MIWIC REFERRALS
1/13/2017
13
Check the Discussed and Referred first and save, thenCheck the Current referrals and save a 2nd time.
Workaround
Not Met Indicators
Indicator 5.1 cont’d
C. Provide New Clients with local resources for drug and other harmful substances– 6 errors
New Clients: pregnant women and infants not provided with list of local resources
See MIWIC Policy 6.02
Not Met Indicators
Indicator 6.1 –Providing Nutrition Education
Overall: Met 69% (18)/ Not Met 31% (8)
A. Nutrition Ed ContactsRequired number of contacts not documented
Offered‐past appts, NE Plan‐wichealth.org
Received
Refused
NE pop‐up not documented
1/13/2017
14
Not Met Indicators
Indicator 5.4 Notification of Client Rights and Responsibilities
Overall: Met 69% (18)/ Not Met 31% (8)
A. WIC Client Agreement ‐1 errorNot using current Agreement
C. Notice of Ineligibility ‐7 errorsNot providing Ineligible Notice (6)
Not documenting reason (2)
D. Voter Registration ‐1 errorDeclination form not being used
Not Met Indicators
Indicator 7.3 Special FormulasOverall: Met 73% (25)/ Not Met 27% (7)
A. DocumentationIncomplete Medical Documentation Forms
Food Package did not reflect MDF
Incorrect Expiration Dates
MDF not scanned
Not Met Indicators
Indicator 9.1 Maintain Complete records of Program Operations
Overall: Met 77% (20)/ Not Met 23% (6)
A. RecordsBreastpumps
Releases or receipts not signed and in record (5)
Overdue pumps not monitored
Annual Review ‐3 errors
1/13/2017
15
Not Met Indicators
Indicator 6.5 Breastfeeding Promotion, Protection, and Support
Overall: Met 81% (21)/ Not Met 19% (5)
B. Staff Orientation ‐1 errorNo new staff orientation to breastfeeding developed
D. Providing Breastfeeding education and Support‐ 4 errorsNo breastfeeding education or referral documented
No breastfeeding follow‐up where requested
Not Met Indicators
Indicator 6.3 Eligibility Explanation
Overall: Met 85% (22)/ Not Met 15% (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
Not Met Indicators
Indicator 9.2 EBT Card Inventory, Security, Storage and Issuance
Overall: Met 85% (22)/ Not Met 15% (4)
A. Bridge Card Inventory – 3 errorsPhysical Inventory not completed Monthly and documented
B. Issuance Logs – 2 errorsMissing information on logs
C. Bridge Card Security – 1 errorNot limiting access to Bulk EBT card supply
1/13/2017
16
Not Met Indicators
Indicator 7.1 Authorized Foods
Overall: Met 88% (23)/ Not Met 12% (3)
A. Provide WIC Food Guide – 3 errorsNot educating on the new Food Guide
Not educating on new food package when category changes
B. Notify client of Food Guide changes‐ 2 errorsNot making clients aware of new items/selections in Food Guide
Not Met Indicators
Indicator 10.1 Prevent, Detect and Document client or employee fraud and abuse
Overall: Met 88% (23)/ Not Met 12% (3)
B. Implement Controls to prevent and detect employee fraud and abuse ‐3 errorsRequired documents not scanned on Single Certified clients
Required number of records not audited for Single Certified clients
1/13/2017
17
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?
Management Evaluation Program Area Lead (PAL)
Nancy Erickson, MS, RD, CLE
517‐335‐9562