Caseload Management/Scheduling |
|
Participation by Program Report (HSPR0702) for previous month
|
|
Clinic Schedule (HSPR0505) for days of review
|
-
Budget and Fiscal
|
|
Current Organizational Chart
|
|
“Summary Expenditure Documentation Forms” for the most recent completed fiscal reporting quarter
|
|
WIC Equipment Inventory List per policy manual
(required for all equipment ever purchased with WIC funds costing $100 or more)
|
NVRA (since last WIC ME) |
|
Copies of the Voter Registration Information (VRI) cards –for past two years
|
|
Weekly Transmittal forms –for past two years
|
Civil Rights (since last WIC ME) |
|
Civil Rights Complaint Forms (kept on file) and Complaint Log (dated annually & indicate “no complaints” if applicable)
|
|
Civil Rights Training Log/Records and Training material used
|
Program Integrity |
|
Pre-Visit Questionnaire (complete and submitted to IDHS RNC prior to Review)
|
|
BOD/EOD Reports (if requested)
|
|
“Potential Dual Participant” BOD reports with documentation of reconciliation
|
|
Cornerstone computer available for IDHS staff to use during time of WIC ME Review
|
VI. Local Agency Reports and Other Documents
|
|
Validation/Calibration documentation for Anthropometric & Biochemical equipment
|
|
Nutrition Education Plan, current and past year, including past Participant Survey results
|
|
Participation by Priority and Category Report (HSPR0107) past 3 months
|
|
WIC Education Summary Report (HSPR0108) past 3 months
|
|
Medically Prescribed Formula Report (HSPR0116) past 3 months
|
|
Breastfeeding Food Package Assignment Report (HSPR0120) past 3 months
|
|
Memorandum of Understanding (MOU) on file (if applicable)
|
|
WIC Farmers’ Market Monitoring Forms (if applicable)
|
|
Local Agency Letters of Department Approval (i.e. Approval for purchase per policy (PPM AD 3.1a), Disposal of WIC Equipment (PPM AD 3.1b), and Participant related research (PPM AD 8)) (if applicable)
|
-
Local Agency Procedures & Quality Assurance
|
|
| Local Agency Procedures -
Enhanced Outreach
-
Geographic Boundaries (if applicable)
-
Deferred Bloodwork Follow-up
-
Referrals
-
Communication to Medical Providers regarding abnormal values/health concerns
-
Immunization Screening and Documentation
-
Sample or donated formula (fair, equal distribution and safe disposal) (if applicable)
-
Breastfeeding Positive Clinic Environment
-
Breastfeeding Promotion and Support for BF and Postpartum Women
-
Breastpump Issuance Procedures
Other Required Items
-
Standing Orders for Hgb/Hct, updated annually
-
Public Announcement for No Smoking (signs posted/visible)
-
“And Justice For All” current USDA Posters (posted/visible in WIC clinic areas)
-
Outreach Log/File (identifies: activities, dates, & staff involved) – for past two years
-
Referral List, updated annually
|
|
Local Agency Quality Assurance /Self- Monitoring
-
Certification Observation Results (Self-Monitoring Worksheets per MCH Integrated Plan)
-
Program Operations Self-evaluation/Review, completed annually and kept on file
-
Medically Prescribed Formula Quality Assurance (Internal Chart/Records Reviews)
-
Breastfeeding Food Package Assignment (Internal QA Chart/Records Reviews)
|
|
Training Log/File(s):
-
Security Training (provide current Security Coordinator Report (HSPR0424) for review)
-
WIC job specific training for all staff (minimum annually, since last WIC ME)
-
Breastfeeding (training for staff at orientation and annually since last WIC ME)
-
Counseling Training List (staff trained on Counseling Skills – past 3 years)
-
Formula Authorization List (staff trained on Medically Prescribed Formulas – past 3 years)
|
VIII. Secondary Nutrition Education & Nutrition Education Materials
|
|
Group Education Attendance Sheets (HSPR0503) since last WIC ME (if applicable)
|
|
WIC Nutrition Education materials created by local agency and those from outside resources (non-IDHS)
|
|
Secondary Education utilized by agency on file for review (applicable per type of education offered)
-
Group Education Lesson Plans and Calendar (identifying group sessions offered)
-
Self–Study Modules
-
Internet Education Certificates (documentation accessible upon request)
-
Other Secondary Education utilized (i.e. displays, Shopping Matters, etc.)
|
Yüklə 95 Kb.