Organization and Management (OM) OM-6 Employee Fraud and Abuse

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Maine Center for Disease Control and Prevention WIC Nutrition Program

Effective: October 1, 2012

Policy No. OM-6 Revised: October 1, 2017 Employee Fraud and Abuse Authority 7 CFR §246.4(a)(26) 22 MRSA §255 and §1951 Policy 1. Employees participating in the Maine CDC WIC Nutrition Program shall have the same rights, responsibilities and obligations as any other WIC participant. 2. Employees shall not certify themselves, family members or close friends in the Maine CDC WIC Nutrition Program. 3. As participants in the Maine CDC WIC Nutrition Program, employees shall not make case file documentation notes or issue benefits (food instruments/ cash-value vouchers or eWIC cards) to themselves, family members or close friends. 4. Local Agencies must have routine clinic staffing patterns that ensure that two (2) staff people are involved in certification of each applicant and participant. 5. In the event that one person must complete the certification process alone, the Local Agency director or designee shall perform chart audits of all nonbreastfeeding infant records and at least 20% of children and women records certified. 6. All one staff member certification chart audits shall be available for review during the Local Agency Management Evaluation Review. Procedure 1. For any clinics that are operated by only one staff person, the Local Agency director shall have safeguards in place to prevent fraudulent activities, including but not limited to: 1.1. Rotate assigned staff members 1.2. Have adjunctive eligibility determination done by another staff member at the main site 1.3. Perform routine chart audits and create a log of findings (Appendix OM-16-A Separation of Duties File Review Form)

Organization and Management (OM) OM-6 Employee Fraud and Abuse

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1.3.1. Local Agency Director or designee other than the certifier must conduct a post-clinic file review of all nonbreastfeeding infant certification records and at least 20 percent of all other certification records within two (2) weeks of the certification. 1.3.2. Documentation of all file reviews must be maintained at the Local Agency for review during the State Agency Management Evaluation Review or upon request. 1.4. Conduct unscheduled site visits 2. Certifications done in clinics staffed with multiple WIC staff members must have documentation of more than one staff member performing certification duties of determining income eligibility and nutrition risk. 3. When WIC staff member(s) are program participants or have relatives/close friends enrolled in the program, local agency management staff shall conduct regular file audits to ensure WIC staff members are not actively documenting in the records or involved in any way with benefit issuance. 4. Any deliberate effort to defraud or abuse the Maine CDC WIC Nutrition Program (whether or not the employee is a WIC participant) including, but not limited to the following, shall be considered an act of employee misconduct: 4.1. Illegally taking WIC checks or eWIC cards 4.2. Certifying fictitious participants 4.3. Giving false/misleading information in order to become certified for WIC benefits 4.4. Theft of formula or other food 5. Suspected intentional fraud or abuse shall be investigated by the Local Agency with assistance from the State Agency and may require investigation through the DHHS Fraud Recovery Unit, Maine Office of the Attorney General and/or the local police department. 6. Action to be taken as a result of an investigation of fraud or abuse (whether or not the employee is a WIC participant), beyond sanctions applicable to WIC participants (see Policy OM-7, Participant Abuse for an explanation of the participant sanction system), shall depend on Local Agency personnel policy and procedures concerning employee misconduct. 7. The State Agency shall require that the Local Agency promptly remove any Local Agency employee suspected to be abusing the Maine CDC WIC Nutrition Program from WIC benefit issuing or processing responsibilities until the Local Agency investigation is completed.