595.1 Policy 595 Program Integrity: Separation of Duties October 1, 2025 (Revised) POLICY

Local WIC programs shall have separate staff conduct the activities (duties) of determining participant income eligibility and risk determination. PURPOSE To ensure program integrity and prevent program abuse by assigning certification functions to more than one staff at the local level. RELEVANT REGULATIONS ASM 99-94—Separation of duties in WIC clinic operations 7 CFR 246.4(a)(26)—State plan: Conflicts of Interest WIC Policy Memorandum #2016-5—Separation of Duties at WIC Local Agencies OREGON WIC PPM REFERENCES

♦ 215—Local Program Monitoring and Review ♦ 510—WIC Cardholder Requirements ♦ 511—Food Benefit Issuance ♦ 596—Program Integrity: Acknowledgement of Employee Responsibilities ♦ 620—Certification and Issuing Benefits or eWIC Cards to Themselves, Co-workers, Relatives, or Friends DEFINITIONS Food benefits: The individual foods a participant receives as a WIC participant for a selected month. “Food Benefits” are specific amounts of WIC authorized foods or formulas or a fixed-dollar amount for participants to obtain WIC authorized fruits and vegetables. eWIC card: Magnetic stripe card used to purchase WIC authorized foods or formulas from a WIC family’s Electronic Benefit Account (EBA). Each card has a 16-digit Primary Account Number (PAN). Also referred to as a “food instrument”. Separation of Duties: A standard accountability and security practice to separate income eligibility determination and risk determination between more than one person when possible. PROCEDURE Separation of Duties 1.0 Local programs shall establish and maintain a standard system for separation of staff duties at the clinic level as a security feature to prevent program abuse, whenever possible.

Program Integrity: Separation of Duties, Continued 595.2 1.1. Assign income eligibility determination to one staff member and risk determination duties to different staff members. This avoids a single staff member doing all functions of the certification process. Example: The staff person at the front desk determines the participant’s income eligibility, residency, and identity and sets up the Cardholder Account. The Competent Professional Authority (CPA) assesses risk, assigns the food package and issues the eWIC benefits. 1.2. Separation of duties is not required when issuing benefits, including via the phone or text, if eligibility has already been completely determined using separation of duties, and if food benefits have already been issued at least once during a participant’s current certification. See  511—Food Benefit Issuance. Audit 2.0 Each local program will establish quality assurance standards and a regular monitoring system. This should include at a minimum: 2.1. The WIC coordinator or agency designee runs the Separation of Duties Audit report in the WIC data system and completes the audit review every two weeks. If the WIC coordinator chooses to have a designee complete the monitoring, that person needs to be in a lead or supervisory role (this could include Registered Dietitian Nutritionists (RDNs), Registered Nurses (RNs), or Training Supervisors). Note: WIC staff cannot audit themselves, therefore, if the coordinator or designee shows up on the report, the coordinator must assign an appropriate designee to complete the audit. 2.2. For participant records where the income determination and risk determination, including food package assignment, was performed by the same staff person, review all certifications for non-breastfeeding infants (IN) and at least 20% of the remaining certifications on the report. The audit can consist of reviewing information by completing actions such as the following: 2.3. Check for recent appointments and dates of certification. 2.4. Check to see if more than one person has had contact with the participant. • Validate adjunct income eligibility, identity and residency through Medicaid (Oregon Health Plan) portal. • Check that height and weight were taken on the date in question and measurements are within a reasonable range. • Check that the Medical Documentation Form (MDF) on file is signed by a healthcare provider outside of WIC. • Complete a “customer satisfaction” call to the participant to obtain feedback on services provided and verify there is a real individual attached to the participant record. 2.5. If verification cannot be completed by review of participant record or if there are compliance issues (e.g. frequent replacement cards, dual participation, etc.), then contact the participant with a “customer service” call to confirm benefits were issued to that participant.

Program Integrity: Separation of Duties, Continued 595.3 2.6. Write Yes or No in the “Valid Certification?” column on the report for each selected participant. 2.7. Contact the State Compliance and Civil Rights Coordinator with any concerns about compliance or potential fraud. 2.8. In clinics with multiple WIC staff, but where only one staff person performs all eligibility and certification functions, the WIC coordinator must audit an additional 10% of records every six months. 2.9. Retain copies of all reports for 3 years. 2.10. The state WIC program will review for compliance during the biennial WIC program review. See  215—Local Program Monitoring and Review. WIC staff who are also WIC participants 3.0 Local staff who are also WIC participants may not certify themselves. See  620— Certification and Issuing Benefits or eWIC Cards to Themselves, Co-workers, Relatives, or Friends. Certifying relatives, friends or coworkers 4.0 Refer to  620—Certification and Issuing Benefits or eWIC Cards to Themselves, Co-workers, Relatives, or Friends for guidelines on certification of relatives, friends or coworkers.

POLICY HISTORY Date * Major Revision, Minor revision 7/13/2018

10/01/2025 Minor Revision

The date located at the top of the policy is the implementation date unless an “effective date” is noted on the policy. Policies will become compliance findings 6 months from the implementation date. Release notes can be found in the corresponding document on the Policy and Procedure Manual page. *Major Revisions: Significant content changes made to policy. Minor Revisions: Minor edits, grammatical updates, clarifications, and/or formatting changes have occurred. If you need this in large print or an alternate format, please call 971-673-0040. This institution is an equal opportunity provider.

Program Integrity: Separation of Duties, Continued 595.4 Date of Origin: Date policy was initially released