12.017 - 1 Administrative Procedures Revised August 2019 XII. Administrative Procedures – Record Retention and Destruction PROCEDURE 12.017 Implementing Office: Community Health Administration (CHA) Created August 2019 Approved by: _______________________ LaQuandra S. Nesbitt MD, MPH; Agency Director Review by Legal Counsel: ____________________ Phillip Husband, Esq.; General Counsel Effective Date: 01/01/2020 I. Authority USDA II. Reason for the Policy CFR 246.25 (a) III. Applicability DC WIC State Agency and Local Agency Staff IV. Policy Statement This policy is meant to identify recordkeeping retention and destruction requirements for WIC records, which provide documentation of WIC program operations pertaining to fiscal operations, food delivery systems, food instrument issuance and redemption, equipment purchases and inventory, certification, nutrition education including breastfeeding promotion and support, civil rights and fair hearing procedures. Records must be destroyed in a manner that protects the confidentiality of WIC participants and vendors by the following methods: shredding, incineration. or landfill. WIC Local agencies must retain all WIC records for a minimum of three (3) years following the date of submission of the final expenditure report for the period to which the report pertains (usually covering an additional period of 150 days after the completed fiscal year) or until any litigation, claim, negotiation, audit or other action involving the records which was started before the end of the 3-year period has been resolved. V. Guidance Regarding Record Retention WIC RECORD RETENTION 1. Records, whether electronic or hard copy, that contain confidential client information must be stored in a secure manner. All records and reports that contain confidential client information shall be stored or kept in a locked area. Electronic records shall be kept under direct supervision at all times. See also Policy 3.001- DC CARES Management Information System, Appendix 3.001B - MIS CARES Confidentiality Agreement for New User ID Requests, and 12.019 - Confidentiality.

12.017 - 2 Administrative Procedures Revised August 2019 Note: There is no requirement for printing reports or records from the DC WIC data system except where necessary for documentation of compliance investigations. 2. The District of Columbia statutes require maintenance of medical records for a period longer than the WIC three-year guideline (see Record keeping requirements under the health regulations - D.C. MUN. REGS. tit. 22-B § 2030). Local Agencies that are affiliated with hospitals shall consult with the agency legal counsel and governing body for a decision regarding whether or not WIC participant charts are considered medical records. 3. The Local Agency must retain, as applicable, paper copies or electronic versions of the following records in accordance with this policy: a. Computer printouts or electronic reports for the District’s Management Information System (CARES) that serve as payment and/or source documents: • Check registers • Dual Issuance Report b. Other materials and information, which serves as source documents: • Audit documents • Civil rights complaints • Complaint information by and about the participant • Compliance investigation, sanction materials regarding client or employee compliance • Correspondence from State WIC office • Dual Participation materials such as paper reports or investigation materials • Equipment purchases and inventory • Fair hearing requests and documentation • Financial source documentation • Laboratory logs • Local Agency Plans Evaluations of Local Agency Plans • Local Agency Voter Registration Log Sheet • Monitoring reports, corrective action plan (CAP) and CAP approvals • News releases submitted to local media c. Program records: • Agency specific records, • Contracts, budgets and administrative records • Fair Hearing records d. Quality Assurance: • Records from quality assurance activities, • WIC State Agency Management Reviews • Local agency announced and unannounced Site visits e. Returned Formula Logs f. Staff credential verifications

12.017 - 3 Administrative Procedures Revised August 2019 4. During a federal or state management evaluation, participant records/files covering three (3) previous years plus 150 days for situations described above should be furnished upon request for inspection, auditing or copying purposes. If the items are not readily accessible due to being stored off-site based on space limitations, the Local Agency must present these records upon request within five (5) business days. 5. Complete participant files may require longer retention due to state statutes related to medical records. Refer to section 2, above. These include: • All materials used to assess, determine eligibility, or prove service offered, such as Physician documentation & referral, notarized documentation of income support, etc. • Certification Summary (if printed on a regular basis • Notification of Ineligibility and/or Termination • Rights and Responsibilities Participant Signature VI. Procedures for Record Destruction A. Prior to destruction of WIC records the local agency must determine that all agency audits and litigation pertaining to the information are completed for the period of these records. B. All records and printed reports containing client identifiers (e.g; names, addresses, phone numbers, and client IDs) must be destroyed in a manner that protects confidentiality. The approved methods to accomplish this are: a. Shredding (for records that are being recycled) b. Made Unreadable (for records that are being recycled) c. Incineration d. Landfill C. If instructed to do so by the State WIC office or FNS, the WIC Local Agency shall not destroy program records of historical interest, but shall forward such records to the State WIC office VI. Appendix N/A VII. Reference 3.001 – DC CARES Management Information System MIS 3.001B – MIS CARES Confidentiality Agreement for New User ID Requests 12.019 – Confidentiality