CERTIFICATION WPPM #210-16 Subject: Maintaining Program Integrity Item: Separation of Duties Revised May 1, 2023 California WIC Policy and Procedure Manual Page 1 of 4 PURPOSE: To minimize fraud and maintain program integrity during the certification process. POLICY: I. Local agency (LA) staff must maintain separation of duties (SOD) during initial certifications and recertifications by using one of the following two methods at each site: A. The LA staff person who determines income eligibility cannot be the same staff person who completes the nutritional risk assessment for the participant. B. The LA staff person who determines eligibility for all certification criteria cannot be the same staff person who issues the WIC Card and food benefits for the participant. II. All certifications that do not achieve separation of duties must be completed by a competent professional authority (CPA). A. A staff person that has the authority to change an eligibility determination and not directly related to the certification must conduct a post review of certifications that did not achieve separation of duties, regardless of WPPM 1000-80 Alternate Procedure for Separation of Duties submission to CDPH/WIC. Refer to Procedures II and III below. PROCEDURES: I. LAs with two or more staff persons at a site must maintain SOD using either of the following two methods: A. Assign at least two staff persons when certifying/recertifying an applicant. 1. Staff person A must determine income eligibility during initial certification/recertification. Complete “Family Information” and “Individual Information” screens in the WIC Web Information System Exchange (WIC WISE). 2. Staff person B, the certifier, must be a CPA and determine if an applicant is at nutritional risk through a nutrition assessment. Complete all other certification screens starting with “Cert Action” in WIC WISE. 3. Either staff or any other staff may issue the WIC Card and appropriate food benefits. B. Assign one staff person to complete the certification/recertification and other staff to issue the WIC Card and food benefits. 1. Staff person A, the certifier, must be a CPA and determine eligibility for all certification criteria. Complete all certification screens in WIC WISE. 2. Other staff must issue the WIC Card and appropriate food benefits. C. Monitor for records that did not observe SOD and complete any necessary record reviews. Refer to the SOD Reports & Monitoring Guide for monitoring instructions.

CERTIFICATION WPPM #210-16 Subject: Maintaining Program Integrity Item: Separation of Duties

Revised California WIC Policy and Procedure Manual Page 2 of 4 May 1, 2023 II. LAs with only one staff person at a site must: A. Notify the CDPH/WIC Nutrition Consultant that the LA cannot meet the separation of duties requirement by completing and submitting the notification form WPPM 1000-80 Alternate Procedure for Separation of Duties. The notification is valid from submission date through the expiration of the contract. B. Complete the required record review. Refer to the SOD Reports & Monitoring User Guide for detailed instructions. 1. A staff person (an individual that has the authority to change an eligibility determination and not directly related to the certification) must conduct: a. A post review of certification records for all infants receiving any amount of formula. b. A post review of a 20 percent random sample of the remaining certification records. c. Post review must be completed within two weeks of the certification date. 2. Documentation of the review must be maintained on file for three years for review during program monitoring visits. 3. It is recommended that staff is rotated on a regular basis so that the same staff person is not the only one known to the participants. III. LAs with multiple staff at a site that have only one staff person perform all eligibility and certification functions. This scenario is not recommended by the United States Department of Agriculture. LAs that plan to use this scenario must: A. Notify the CDPH/WIC Nutrition Consultant that the LA expects to use this alternate procedure by completing and submitting the notification form WPPM 1000-80 Alternate Procedure for Separation of Duties. The notification is valid from submission date through the expiration of the contract. B. Ensure the staff person completing the certifications is a CPA. C. Complete the required record review. Refer to the SOD Reports & Monitoring User Guide for detailed instructions. 1. A staff person (an individual that has the authority to change an eligibility determination and not directly related to the certification) must conduct: a. A post review of certification records for all infants receiving any amount of formula. b. A post review of a 20 percent random sample of the remaining certification records. c. Post review must be completed within two weeks of the certification date.

CERTIFICATION WPPM #210-16 Subject: Maintaining Program Integrity Item: Separation of Duties

Revised California WIC Policy and Procedure Manual Page 3 of 4 May 1, 2023 2. The LA director or designee must conduct an additional review of 10 percent of certification records every six months. 3. Documentation of the review must be maintained on file for three years for review during program monitoring visits.

Example Procedures for Separation of Duties Method 1 Staff Person Staff Functions Person A Determines income eligibility: 1. Completes the “Family Information” which includes adding or verifying caretakers. 2. Completes “Income Information” screen and “Individual Information” screen in WIC WISE. 3. Completes Self Declaration Statement for any missing eligibility documents (if appropriate). 4. Issue the WIC Card, if applicable. 5. Places “Alerts” and/or “Notes” as needed. Person B (Competent Professional Authority) Determines medical or nutritional risk and completes certification/recertification: 1. Resumes certification/recertification process in WIC WISE at the “Cert Action” screen. 2. Completes nutrition assessment by completing “Breastfeeding” (if applicable), “Ht/Wt/Bloodwork”. “Health” & “Nutrition” screens. 3. Reviews and adds nutritional risk manually, if identified. 4. Provides nutrition education. 5. Completes “Care Plan”. 6. Documents Nutrition Education contact. 7. Provides and documents “Referrals” as needed. 8. Creates food package. 9. Completes any applicable forms including Rights & Responsibilities. 10. Schedules next appointment. 11. Places “Alerts” and/or “Notes” as needed. Person A or B or C Issue Food Benefits: 1. Issue the appropriate food benefits.

CERTIFICATION WPPM #210-16 Subject: Maintaining Program Integrity Item: Separation of Duties

Revised California WIC Policy and Procedure Manual Page 4 of 4 May 1, 2023 Example Procedures for Separation of Duties Method 2 Staff Person Staff Functions Person A (Competent Professional Authority) Determines program eligibility and completes certification/recertification 1. Completes the “Family Information” which includes adding or verifying caretakers. 2. Completes “Income Information” screen and “Individual Information” screen in WIC WISE. 3. Completes Self Declaration Statement for any missing eligibility documents (if appropriate). 4. Places “Alerts” and/or “Notes” as needed. 5. Completes the “Cert Action” screen. 6. Completes nutrition assessment by completing “Breastfeeding” (if applicable), “Ht/Wt/Bloodwork”. “Health” & “Nutrition” screens. 7. Reviews and adds nutritional risk manually, if identified. 8. Provides nutrition education. 9. Completes “Care Plan”. 10. Documents Nutrition Education contact. 11. Provides and documents “Referrals” as needed. 12. Creates food package. 13. Completes any applicable forms including Rights & Responsibilities. 14. Schedules next appointment. 15. Places “Alerts” and/or “Notes” as needed. Person B

Issue Food Benefits 1. Issues the WIC Card, if applicable. 2. Issues the appropriate food benefits.

AUTHORITY: WIC Policy Memorandum # 2016-5 CROSS REFERENCE: WPPM 140-10 WIC Services for Employees and Relatives WPPM 1000-70 Job Aid for Separation of Duties WPPM 1000-80 Alternate Procedure for Separation of Duties SOD Reports & Monitoring User Guide