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Section 1.18: Separation of Duties to Assure Program Integrity 04/2026 References: 7 CFR 246.4(a)(27), MOM Section 5.2, WIC Policy Memorandum #2016-5 Separation of Duties at WIC Local Agencies Policy: Controls and procedures must be in place to ensure Separation of Duties (SOD) during WIC certification. At a minimum, a single staff person may not determine both income eligibility and medical/nutrition risk for a participant. If only one person is available to determine both income and nutrition risk, a post review of the certification record must be completed by the WIC Coordinator or designee. Purpose: To ensure program integrity by involving two staff members in determining certification eligibility. Procedures Two WIC staff must be involved in each certification, and SOD must be auditable in each individual participant record. Local agencies must develop and maintain an SOD Plan describing how they will meet SOD requirements in all clinics. The plan must be approved by the State Agency and updated as necessary. Compliance will be reviewed by the WIC consultant during management evaluations. Refer to Exhibit 1-P: Two-Person SOD versus One-Staff Certifications for an overview of the SOD methods described below. Two-person SOD (preferred method) This is the preferred method of SOD and is recommended for use in nearly all situations, as it supports the highest level of program integrity. Two-person SOD requires: 1. Staff 1— must be Competent Professional Authority (CPA): Determines medical/nutrition risk and offers nutrition counseling. 2. Staff 2— does not need to be present during the certification: Verifies income or adjunct eligibility on the day of certification, or up to 21 days before.

S E C T I O N 1 . 1 8 : S E P A R A T I O N O F D U T I E S T O A S S U R E P R O G R A M I N T E G R I T Y 2 Note: Scanning or uploading verification documents may be necessary for later review. See Scanning/Uploading Verifying SOD Documentation below for details. Documenting two-person SOD During certification Participant Record- Income Page 1. Staff 1— The CPA determining medical/nutrition risk completes the certification after income or adjunctive eligibility has been verified and entered by a second staff. 2. Staff 2— The staff person verifying income or adjunct eligibility enters the verified information into the Income Page, while in Certification Mode, before the certification is finalized by the certifying CPA (steps 1 and 2 must happen on the same day). Outside certification (not in Certification Mode): SOD-Income Note 1. Staff 1— The CPA determining medical/nutrition risk documents the verified income in the income screen of the participant record during the certification. 2. Staff 2— The staff person verifying income or adjunct eligibility writes a SOD-Income Note detailing what they verified (e.g., “MA active” or HH size and total income). Document income eligibility up to 21 days before the certification or up to 14 days after the certification. Note: In the rare case where the original income verifier does not have access to the Information System, another staff person (other than the CPA determining nutrition/medical risk) may create the SOD-Income note, indicating who verified income. Discuss this with your State WIC Consultant for approval. Two-person SOD oversight The local agency coordinator or designee must review SOD reports quarterly to assess for missing SOD documentation. It is best practice to review SOD reports more frequently (e.g., bi- weekly or monthly) to maintain the highest level of program integrity. One-staff certifications One-staff certifications are an exception and should be avoided whenever possible. They occur when the certifying CPA determines both income eligibility and nutrition risk, and the agency lacks sufficient staff to complete the two-person SOD process for all certifications. See Guidance for examples of ways to implement two-person SOD in single staff clinics. Important: See Scanning/Uploading and Verifying SOD Documentation below for additional requirements. One-staff certification oversight The WIC Coordinator or designee must conduct, at a minimum, a bi-weekly post-review of all non-breastfeeding infant certification records and a sample of at least 20% of all other one- staff certification records. It is best practice to rotate staff coverage at clinics regularly using one-staff certifications.

S E C T I O N 1 . 1 8 : S E P A R A T I O N O F D U T I E S T O A S S U R E P R O G R A M I N T E G R I T Y 3 Post-review of one-staff certification records 1. Complete the post-review using Exhibit 1-Q: Local Agency Internal Chart Review for One-Staff Certifications. Retain these records for the next Management Evaluation (ME). Focus on key aspects of the certification process, including income, identity, residency, and nutritional risk. Prioritize records with one or more of the following characteristics: ▪ Transactions outside regular clinic hours ▪ Discrepancies between certification duration and benefits issued ▪ Infant records with no corresponding mother participant ▪ Missing or unreasonable height, weight, or blood test results ▪ Patterns of similar or repeated measurements (height, weight, blood) across multiple records. ▪ A high percentage of out-of-state transfers (VOCs) compared to other clinics during the same time 2. Document the completed post-review in a SOD-Review Note in the WIC information system. Documenting SOD for one-staff certifications Records identified through biweekly or quarterly SOD review: SOD-Review Note 1. Staff 1— The CPA completing the certification assesses income or adjunct eligibility and medical/nutrition risk at the time of the appointment and enters it into the participant record and scans/uploads required documents for post-review, as noted below. 2. Staff 2— The local agency coordinator or designee verifies scanned documents, completes a Post-Review of One-Staff Certification Records, and writes an SOD-Review note in the participant record, indicating the documents verified and that the Post Review is complete. Conduct a Post-Review of One-Staff Certification Records and complete a Quarterly SOD Review to identify and assess all known and potentially missed one-staff certifications. Scanning/uploading and verifying SOD documents If the agency has one-staff certifications, staff will need to scan/upload proofs into the participant record for later verification by a second person. Avoid scanning/uploading unnecessary documents. Adjunctively eligible participants: ▪ Certifier or designee: Scan/upload proof of identity for each participant certified (e.g., crib card, health benefits (insurance) card, photo ID, see: Exhibit 5-C: Identification Requirements by WIC Contact Type). ▪ Reviewer: Confirm active adjunctive eligibility (e.g., via phone/online system) and verify the scanned/uploaded ID in the participant record.

S E C T I O N 1 . 1 8 : S E P A R A T I O N O F D U T I E S T O A S S U R E P R O G R A M I N T E G R I T Y 4 Non-adjunctively eligible participants: ▪ Certifier or designee: Scan/upload the verified proof of income used for the certification (e.g., pay stub(s), W-2 forms, tax returns, written statement from the employer). ▪ Reviewer: Verify that the scanned/uploaded income document meets income guidelines and matches the income in the certification record. One-Staff Certifications: See Post-Review of One-Staff Certification Records for additional documentation requirements. Maintain scanned/uploaded proofs in the information system for review during Management Evaluation (ME). Delete scanned/uploaded proofs after SOD is completed and recorded. Ongoing local agency SOD oversight Local Agency WIC leadership is responsible for overseeing and monitoring SOD compliance and clinic and staff activities- refer to the Resources section for helpful reports. They must ensure: ▪ SOD procedures are implemented in all clinics. ▪ One-staff certification records are reviewed. ▪ The SOD plan submitted to the State Agency is up-to-date. Suspected fraud/abuse Deliberate efforts to defraud or abuse the Minnesota WIC Program shall be considered an act of employee misconduct. Report questionable certifications and benefit issuance to the state WIC consultant within one week of discovery. The State WIC Agency will investigate the issue accordingly. Guidance Two-person SOD in single-staff clinics Local agencies with one WIC staff on site should use the two-person SOD method. Examples of ways to implement two-person SOD in single-staff clinics include: ▪ A clerk, WIC Coordinator, or other designee verifies and documents adjunctive eligibility or pre-submitted income proofs up to 21 days before the certification. ▪ The certifying CPA connects with a second WIC staff person at a different location (via phone, messaging, or video) during the appointment. The second staff person verifies and documents income/adjunctive eligibility in real time. ▪ When one-staff certification occurs, the certifying CPA verifies income eligibility, scans the required information, and informs the WIC Coordinator or other designee. Within 14 days, the coordinator or designee reviews the scanned information, confirms participant eligibility, and writes an SOD note.

S E C T I O N 1 . 1 8 : S E P A R A T I O N O F D U T I E S T O A S S U R E P R O G R A M I N T E G R I T Y 5 Pending eligibility and presumptive eligibility For pending and presumptive eligibility, SOD is documented at two different times: 1. During the certification, and 2. When the participant provides proof of income (for pending eligibility) or proof of medical assistance enrollment (for presumptive eligibility). ▪ The staff person who verifies final income eligibility must be different from the one who determined nutrition risk at certification. ▪ Document income verification in an SOD-Income Note, following the same procedures used during certification, and include the name of the staff person who completed the verification. Resources The following Infoview reports can assist with Ongoing Local Agency SOD Oversight. Refer to the Infoview Report Template Reference for information on each report: ▪ “Certifications Completed by One Staff Person” ▪ “Daily Staff Productivity” ▪ “Benefits Issued & Certs Performed Outside of Information System Hours” Reference – Complete Listing of Hyperlinks WIC Policy Memorandum #2016-5 Separation of Duties at WIC Local Agencies (https://www.fns.usda.gov/wic/separation-duties) Exhibit 1-P: Two-Person SOD versus One Staff Certifications (https://www.health.state.mn.us/docs/people/wic/localagency/program/mom/exhbts/ex1/1p. pdf) Exhibit 1-Q Local Agency Internal Chart Review for One Staff Certification- Sample (https://www.health.state.mn.us/docs/people/wic/localagency/program/mom/exhbts/ex1/1q. docx) Exhibit 5-C: Identification Requirements by WIC Contact Type (https://www.health.state.mn.us/docs/people/wic/localagency/program/mom/exhbts/ex5/5c. pdf) Infoview Report Template Reference (https://www.health.state.mn.us/docs/people/wic/localagency/reports/infoview/reference.pdf) Minnesota Department of Health - WIC Program 625 Robert St N, PO BOX 64975, ST PAUL MN 55164-0975; 1-800-657-3942, health.wic@state.mn.us, www.health.state.mn.us. To obtain this information in a different format, call: 1-800-657-3942 This institution is an equal opportunity provider.