POPS Chapter 13 - Administrative Agency Core Competencies

Subchapters

13.1 Standards for Financial Responsibility

13.2 Standards for Administrative and Managerial Responsibilities

13.3 Standards for Planning Responsibilities

13.4 Standards for Programmatic Data Management

13.5 Standards for Capacity to Subcontract and Monitor

13.6 Managing Conflict of Interest

The Administrative Agency must:

13.1 Standards for Financial Responsibility

Standards for Financial Responsibility Criteria and Instructions
1. Have a financial management system that meets standards defined in the Uniform Grants Management Standards (UGMS), Subpart C – Post Award Requirements – Financial Administration and the Department of State Health Services (DSHS), Contractor’s Financial Procedures Manual (CFPM), Chapter 4 – Financial Administrative System Requirements.

UGMS

OMB Circulars

DSHS CFPM

The organizations financial management system must:

  • permit the tracing of funds and transactions from subsidiary records/journals to postings in the general ledger,
  • permit preparation of standard financial reports (balance sheet, income statement, etc.) and financial reports required under the grant award,
  • demonstrate that accounting records adequately identify the source and application of funds; accounting transactions are supported by appropriate source documentation; are maintained in a timely manner; are in good order and available for inspection,
  • demonstrate the ability to reconcile quarterly Financial Status Reports (Form 269a) to the general ledger,
  • follow generally accepted accounting principles, and
  • have internal controls in place to effectively safeguard all organization (including grant and sub grantee) cash, real and personal property and other assets.
  • meet the requirements specified in UGMS, applicable Office of Management and Budget (OMB) Circulars, and DSHS Contractors Financial Procedures Manual (CFPM) for the support of salaries/wages and payroll documentation.
2. Demonstrate fiscal solvency.

Provide a copy of the organizations latest financial statements.

  • Must have sufficient cash reserves, demonstrating ability to meet cash flow demands for all organization operations
  • Balance sheet must not reflect a deficit fund balance.
  • Ratio of current assets to current liabilities must be greater than 1
  • Organization must demonstrate ability (business plan) to liquidate any long-term debt/liabilities
  • Organization must disclose any contingent liabilities
3. Demonstrate compliance with IRS reporting and payroll tax requirements. Provide verifiable evidence that the latest IRS Form 941 has been filed with the IRS and that the two most recent payroll tax deposits were deposited within IRS deadline.
4. Demonstrate compliance with unemployment insurance and workers’ compensation requirements. Provide verifiable evidence that unemployment insurance and workers’ compensation insurance premiums are paid timely.
5. Have financial policies and procedures that effectively address all elements of financial management. Provide a copy of the organizations policies and procedures that pertain to financial management.

6. Have a Board of Directors or oversight authority with active involvement in financial management oversight. This includes but it is not limited to the following:

  • review and approval of the organization’s annual budget
  • review of financial statements
  • review of independent audits and organizations response to any findings
  • the Board must meet, at minimum, on a quarterly basis.
 Provide a copy of board minutes that reflect activities listed under the Standards for Financial Responsibility column.
7. Have financial policies and procedures that effectively address all elements of financial management. Provide a copy of the last two single audit reports.
8. Have policies, procedures, and a monitoring tool in place that adequately addresses financial compliance monitoring of subcontractors. The policies and procedures should also address how the organization informs subrecipients of financial compliance requirements pertaining to funds awarded to the subrecipient. Provide a copy of the agency’s policies and procedures pertaining to financial compliance monitoring of subcontractors.
Provide evidence of monitoring efforts, such as monitoring reports.
Provide evidence of how the organization informs subrecipient subcontractors of financial compliance requirements. (i.e. requirements specified in contract)
9. Have adequate number of experienced financial staff (with accounting expertise) responsible for the financial management of organization’s operations and financial compliance monitoring of subcontractors. Provide a list of staff that will be responsible for the financial management of any DSHS awards, to include staff responsible for financial compliance monitoring of subcontractors.
Provide job descriptions of staff listed above.
10. Have documented procedures in place for the review and processing of reimbursement requests from subcontractors. The review should ensure that all costs meet applicable OMB cost principles, UGMS, DSHS program regulations, and the terms of the contract in determining cost reasonableness, are allowable and are allocable. The organization must demonstrate timely payment of obligations to subcontractors. Provide a copy of the agency’s documented procedures pertaining to processing reimbursement requests from subcontractors.
11. Have policies and procedures to reduce liability risk. Provide copies of insurance policies that address requirements specified in DSHS General Provisions, Article XII, Section 12.06 – Liability Coverage. See the DSHS Client Services Contracting Unit webpage.
12. Maintain fidelity bond or insurance coverage equal to the amount of funding that may be provided by DSHS up to $100,000 that covers each employee of organization handling funds under contracts with DSHS. Provide evidence of sufficient insurance coverage. See DSHS General Provisions; Article XII, Section 12.05 – Fidelity Bond. See the DSHS Client Services Contracting Unit webpage.
13. Have a policy that addresses employment or appointment of any person who has an ownership or controlling interest in the organization or an officer or managing employee that has been convicted of a criminal offense. Provide a copy of the organizations policy pertaining to employees and board of directors that have been convicted of a criminal offense. See DSHS Contract General Provisions, Section 10.07 – Criminal Activity and Disciplinary Action and Section 11.01 (f) – Certification. See the DSHS Client Services Contracting Unit webpage.
14. Maintain liability insurance coverage in an amount not less than the total value of this contract, sufficient enough to protect the interests of DSHS Evidence of sufficient liability and bond coverage should be in place at contract start date. See DSHS Contract General Provisions; Article XII, Section 12.04 – Insurance and Bonding. See the DSHS Client Services Contracting Unit webpage.

 

13.2 Standards for Administrative and Managerial Responsibility

Standards for Administrative and Managerial Responsibility Criteria and Instructions
1. Have a clearly stated mission.

The mission statement and the administrative objectives must be available along with evidence of a formal evaluation process. 
2. Have experience providing administrative services to a large geographic area.

Funded agencies must know how to address issues (not necessarily HIV-specific) of serving large and diverse (rural, urban) geographic areas.
3. Have a clear written plan to provide services to the entire assigned geographic area. The plan must include how services will be addressed and delivered in the HSDA(s) and how clients from all the counties in the AA’s jurisdiction will access services. The plan must include each funded service in each county with narrative of how eligible individuals will be linked into all funded services, including comprehensive outpatient health and support services in service delivery area.
4. Have a contingency plan to provide services to the areas, with minimal disruption, during the transition of service providers or loss of agency services.

Plan must include strategy to deliver services in the event of elimination of area service provider. Issues include:

  • transfer of client files and information
  • storage and proper destruction of client files and information
  • notices to clients of service changes not limited to Case Management and medical care facility/provider.
  • collaboration expectations between and prior and the current agency
  • transfer of critical services such as HOPWA, Health Insurance premiums, transportation to medical care, etc.
5. Be governed by a Board of Directors that is a functional and active. Evidence the Board of Directors is a functional and working board as evidenced through by-laws, meeting minutes (at least quarterly), policies, procedures, etc.

6. Have a system to prepare program data and info for presentation to Governing Body.

 Policy/procedures that include preparation and presentation of fiscal and programmatic documentation/information on the agency and subcontractors for board review.
7. The Board of Directors must undergo training consistent with DSHS format.

See general provisions, article XII, general business operation of contractor, section 12.01 - board training.

  • written verification submitted to the division contract management unit no later than the end of the first quarter of the beginning of the contract.
  • training must be completed at least every two years; if mental health then every year.
8. Have personnel policies in place.
  • Staff grievances
  • Staff development/orientation and training
  • Program orientation
  • Staff performance/ evaluation quality assurance
  • Staff qualifications and minimum standards (include licenses – initial and ongoing verification)
  • Staff job descriptions (include monitoring responsibilities if required)
  • Hire and termination
9. Comply with DSHS HIV/STD administrative performance standards.
  • Program Operating Procedures and Standards (POPS)
  • HIV/STD Program policies
  • other DSHS guidance
10. Have policy and procedure to collect client/customer satisfaction information and apply this data to improve program operations The agency provides the policy/procedure as well as evidence of conducting satisfaction surveys and outcomes on an annual basis.
11. Have an administrative policy/procedures manual or operational manual addressing major administrative systems and function.

The manual must include:

  • subcontracting oversight policy
  • program data reporting policy
  • confidentiality of personnel records complying with FLSA
  • Personnel policies
12. Have experience in gathering and tracking expenditure data and a policy to address out-of-compliance issues with subcontractors. Applicants must track the services category (and sometimes subcategory) expenditure of each subcontracting agency to ensure that services are delivered as required.
13. Have experience monitoring the quality of administrative, fiscal, and service delivery systems of subcontractors. Evidence of prior experience monitoring administrative and service delivery activities of subcontractors. (can be non-HIV related experience)
14. Have experience providing technical assistance to subcontractors on administrative and programmatic issues.

Evidence of technical assistance provided in the following areas:

  • Budget development and management
  • Data management and reporting requirements
  • Other reporting requirements
  • Contractual requirements
  • Service Delivery requirements
  • Policy and procedure development
15. The agency has a Quality Management Plan that outlines goals, objectives, and strategies/activities specific to the service population and area.

Components of QM plan must include:

  • QM committee with diverse representation of all areas of agency (financial, eligibility, administrative, RN, MD, QI coordinator and other key leadership)
  • written QM plan describing goals, objectives and activities taking place to facilitate improvements by collecting data, performing surveys, and process improvement
  • describe how QM process is integrated within program management system to be used in making decisions
  • defined utilization data monitoring system to measure and improve outcomes
  • routine medical record review to verify compliance with current HIV treatment guidelines (including verifying reported data in ARIES)
  • documented annual summary and revision of plan
  • documented minutes from QM meetings
  • timeline for QM activities
  • annual review and update of policies and procedures.
16. Be in good programmatic standing with all funding sources. See most current programmatic audits for other DSHS funded contracts.
17. Must be free of sanctions from funding source for evidence of client abuse and/or neglect, for past contract cycle.  
18. The agency has historic evidence of developing and implementing comprehensive outpatient health and support services in its current service delivery area. Documentation of available services in each HSDA. Services available meet the anticipated needs of the clients as established by the planning body and needs assessment to include: medical care, case management, mental health services, substance abuse services, food pantry, social support and housing.
19. Written implementation plan that describes how outpatient health and support services will be delivered to people with HIV for the service delivery area. Implementation plan should include available providers, transportation to providers, supporting linkages between providers and providers of other services through other Ryan White Title providers.

 

13.3 Standards for Planning Responsibilities

Standards for Planning Responsibilities Criteria and Instructions
1. The agency has staff with appropriate knowledge, skills, and abilities to conduct planning.

Planning staff must have the following knowledge, skills, and abilities:

  • Ability to communicate effectively, both verbally and in writing, with culturally and professionally diverse audiences
  • Ability to develop and deliver training materials/presentations
  • Ability to guide groups of diverse individuals through a planning process
  • Ability to exercise independent judgment in evaluating situations and making recommendations
  • Ability to use PC-based software to write reports and prepare presentations
  • Experience in working with volunteer and/or community groups and interdisciplinary teams
  • Ability to develop plans, timelines, budgets, and funding proposals
  • Experience in project management and/or managing multiple priorities
  • Knowledge of needs assessment processes
  • Experience in providing technical assistance to volunteer groups and/or contractors
  • Ability to weigh quantitative and qualitative information in decision making
2. The agency effectively solicits, supports, and uses community input in the planning process.

Agency must solicit input from a variety of geographically diverse community stakeholders, using a variety of collection mechanisms. Stakeholders include:

  1. Consumers (PLWHA) representative of the epidemic in the administrative services area (e.g., race/ethnicity, sex)
  2. Individuals with knowledge of and expertise on the local HIV medical and social support service delivery systems, client needs and barriers to services, public health, HIV/STD prevention, current HIV treatment practices, epidemiology
  3. Other HIV or health planning entities and bodies, as appropriate
  4. Stakeholders with expertise on special topics, as needed to answer specific questions about local service delivery.

Agency must maintain operating procedures for ensuring community input and disseminate updates to stakeholders. These procedures should include a community input plan that specifies how input is to be solicited, and evidence of progress towards implementing the plan.

Agency staff must conduct public hearings concerning the use and distribution of Title II funds and provide feedback to stakeholders and to funding source(s).
3. The agency staff can understand and apply basic information on HIV/AIDS morbidity, needs assessment information, and service utilization data in the development of the comprehensive plan. Agency must demonstrate a basic knowledge of the characteristics of prevalent HIV/AIDS cases within the services area; demonstrate the ability to maintain organized information on the current HIV service delivery system in the plan area; organize and apply information on client characteristics and service utilization provided through the Uniform Reporting System; and show evidence of appropriately applying epidemiologic, utilization and other data in the setting of goals and the development of planning products to achieve those goals.
4. The agency has the capacity to develop a comprehensive plan for HIV medical and social support services. The agency carries out periodic assessment of need for HIV medical and psychosocial support services and barriers to accessing these services, and research best practices for service delivery and strategies for overcoming barriers to entry and maintenance in care. The agency maintains an inventory of service resources within the planning jurisdiction; develops service priorities and allocations (by service category) for each HSDA within the planning area based on needs assessment data, utilization data, and historical expenditures by service category, the resource inventory, and community input. The agency’s plan contains goals and objectives relating to services access, elimination of barriers, and quality of services as well as quantitative objectives for services delivery. The plan is incorporated into the agency’s activities.
5. The agency interprets and applies program specific legislation, government regulations and administrative processes to planning. The agency assures that activities and products are compatible with all applicable local, state, and federal rules, guidelines, and laws, and that the plan includes all required elements as defined by DSHS.

 

13.4 Standards for Programmatic Data Management

Standards for Programmatic Data Management Criteria and Instructions
1. The agency effectively uses the AIDS Regional Information and Evaluation System (ARIES) to manage subcontractors’ client level data.

All Title II, State Services, and State HOPWA contracts for service delivery are appropriately set up in ARIES.
Each contracted service delivery has a contractor-estimated average unit cost associated with it in ARIES.
There is evidence of timely and routine entry of service delivery information by service providers.
There is evidence that providers are instructed to report all CADR required data elements for all Ryan White eligible clients.
2. The AA facilitates service providers’ use of ARIES.

The agency has an adequate plan for providing technical assistance and training to subcontractors/providers on ARIES. Such a plan should contain routine and special offerings of training in all administrative service areas and established methods for contractor requests for assistance and training.
There is evidence that the plan has been implemented.
3. The agency has a data manager with appropriate knowledge, skills, and abilities. The agency has a job description and performance standards for their client-level program data manager that are consistent with DSHS requirements and these core competencies.
4. The agency acts to improve the quality of ARIES data. The agency provides evidence of monitoring and improving the quality of their program data. This includes a data improvement plan and evidence that the plan has been implemented.
5. The agency is responsive to requests for information regarding ARIES operations from the grantor, and to requests for corrections of errant data by grantor. The agency can provide evidence of timely and complete responses to requests for program information or actions required by the grantor.

6. The agency applies program data in planning or program improvement efforts.

 The agency can provide evidence of using program data for planning or program improvement. This must include evidence that service utilization data were used in allocation decisions.
7. The agency assures that ARIES data are maintained in an environment that is physically and electronically secure at both the AA and subcontractor sites. The data manager assigns/maintains ARIES security levels and passwords for authorized system users at subcontractors and in house personnel.
The AA has adequate policies for setting appropriate access rights for the AA and subcontractor staff and there is evidence that such policies are followed.
The data manager uses a security evaluation tool to check hardware location and employee security levels at the AA and subcontractors.
The AA maintains and follows a policy for termination of staff security rights.
8. The agency must maintain appropriate client consent procedures for sharing of client data across provider agencies. There is evidence that appropriate client consent procedures for data sharing across providers are being followed.
There is evidence that AA has given guidance to service providers regarding securing client consent for sharing data across providers.
ARIES data sharing consent form(s) are appropriate.

 

13.5 Standards for Capacity to Subcontract and Monitor

Standards for Capacity to Subcontract and Monitor Criteria and Instructions
1. Have a clearly defined system for open competition for funding including policy and procedures to obtain high quality service providers.

Includes but not limited to: development of a Request for Proposal, provider recruitment plan, active advertising in all pertinent areas, letter of intent, scoring tools, timeline for release, recruiting criteria for the external review committee, final scoring and awards addressing grievances as a result of the competitive process.
2. The agency has had no substantial grievances in the last two years against RFP process and/or services provided.

Agency has signed statement that no grievances have been substantiated against the agency.
3. Have the capacity to contract with agencies to provide comprehensive outpatient health and support services to meet the prioritized needs of people with HIV disease and their families in the service delivery area. Develop contracts with entities to deliver services. The contracts must delineate services to be provided and address quality assurance mechanisms.
4. Be able to build service delivery capacity.

The AA will identify, recruit, and develop contracts with new service providers to meet the medical/clinical and psychosocial needs of clients.
5. Employ or contract with (or have capacity to employ/contract with) qualified staff to conduct monitoring of subcontractors who provide clinical and case management services. The AA must evaluate and ensure the quality of service. Minimal requirements of RN to conduct clinical and case management monitoring. The job description must include capacity, education, experience with contract monitoring and management. Clinical subcontractors must be monitored following U.S. Public Health and DSHS clinical case management standards when providing services.

6. Employ or contract with (or have the capacity to employ/contract with) qualified staff to conduct program monitoring of subcontractors who provide support services. The AA must evaluate and ensure the quality of service delivery.

The job description must include capacity, education and experience with contract monitoring and management. Knowledge, skills, and abilities include:

  • clear and effective communication
  • effective interpersonal skills
  • independent judgment to evaluate situation and make recommendations
  • development of plans, timelines, budgets, contractual requirements, goals and objectives, work-plans, and monitoring tools
  • addressing client and service provider inquiries and follow up on complaints
  • interpret and disseminate DSHS and HRSA requirements.
7. Have written policy and procedure in place, which ensure fair and equitable performance reviews of subcontractors.

Policy and procedures outlining the program monitoring process. This process should include defined systems for announcing and negotiating review dates, utilization of a review tool (s), documentation of deficiencies, follow-up, timelines for monitoring, and prioritizing reviews and closures.
8. Have policy and procedure to resolve any perceived or existing conflicts of interest between the administrative agency and subcontractors.

Policy and procedure outlining the steps to address and resolve conflict of interest including timelines, investigation, documentation, and resolution.
9. Have Memoranda of Agreement (MOA) with other service providers.

MOA includes but are not limited to tuberculosis screening/treatment, HIV prevention, STD, substance abuse, Protocol Based Prevention Counseling (PBC), Prevention Case Management, and housing.
10. Have procedure to sanction subcontractors who are found to be out of compliance.

Procedure to include:

  • level of sanction
  • action required by subcontractor with timelines and closure
11. Agency provides evidence that it monitors the subcontractor system of presenting program data and information to subcontractors governing body.

Board meeting minutes, documentation summary or reporting surveys of programmatic improvement and documentation addressing client issues.
12. Evidence that subcontractors are collecting client/customer satisfaction information on at least an annual basis. Program policy on collecting yearly surveys with documentation of client satisfaction data.
13. Policy on monitoring of subcontractors for quality service delivery. Policy should include frequency of monitoring, priority rating system, follow-up, training of monitoring; development of monitoring tool based on DSHS standards.
14. Evidence that technical assistance has been provided to subcontractors.

Documentation of technical assistance given to subcontractors.
15. Evidence that monitoring of subcontractors has occurred.

Completed tools on subcontractors with documentation on findings and follow up.
16. Evidence of creating contracts for subcontractors.

Contracts should include:

  • services to be performed
  • areas covered where services will be performed
  • budget
  • work plan
  • objectives
  • data submission
  • quality assurance
17. Agency must have and maintain resources for the provision of relevant client services and assure that subcontractors have and maintain Memoranda of Understanding (MOU) with other services providers in the area. MOUs must exist between services providers for clients to receive a large array of services including: TB, STD’s, substance abuse, immunizations, HIV prevention, partner services, mental health, and mental retardation. The MOUs must be renewed annually.
18. Agency must have written procedures that subcontractors who provide or fund ambulatory outpatient medical care adopt and follow USPHS in the care of HIV + clients. Copy of US Public Health Standards must be available.
19. The agency has a written procedure to assure that subcontractors who provide clinical and case management services are qualified to provide clinical and/or case management services. Qualifications include: appropriate licensure to position held, appropriate education for position held and ongoing training on current treatment standards.
20. The agency must have a written policy to ensure that subcontractors for clinical and case management services develop, adhere to and maintain appropriate clinical, and/or case management protocols, policies, and procedures. Policies as mandated by DSHS clinical and case management standards.
21. The agency has not been sanctioned by any funding source for evidence of client abuse/neglect for past contract cycle. Signed statement to say that no grievance has been substantiated against the agency for client neglect/abuse.

 

13.6 Managing Conflict of Interest

Managing Conflict of Interest Criteria and Instructions
1. There is a board approved organizational chart showing key personnel and chain of command.

The chain of command must show internal structure that eliminates conflict of interest between the PA and AA. 
2. The agency has a process that defines the supervision of the AA manager.

A process that delineates who is responsible for the supervision and how staff evaluation occurs.
3. There is a separation of fiscal responsibilities between the AA and PA that eliminates conflict of interest. Process must be followed by fiscal staff of the PA and AA.
4. The AA has a policy that the PA has no competitive or monitoring advantage over other service providers. Process must include an agency competition process to award services funds by defining a review panel not composed of AA or PA persons.
5. Key personnel are funded only by DSHS administrative agency funds. Agency staff shows 100% funding from DSHS grant AA grant.
HIV/STD Program

HIV/STD Program

Program Operating Procedures and Standards (POPS)