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 (AA) shall meet and comply with the following:

13.1 Standards for Financial Responsibility

Standards for Financial Responsibility Criteria and Instructions

1. AA has a financial management system that meets standards defined in the Texas Grant Management Standards (TxGMS).

TxGMS

OMB Circulars

The AA’s financial management system must:

  • Permit the tracing of funds and transactions from subsidiary records or 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 accounting records identify the source and application of funds and maintain appropriate source documentation supporting accounting transactions in a timely manner, in good order, and available for inspection;
  • Demonstrate the ability to reconcile quarterly Financial Status Reports (Form 269a) to the general ledger, follow accepted accounting principles;
  • Have internal controls in place to effectively safeguard organization (including AA and subrecipient) cash, real and personal property, and other assets; and
  • Meet the requirements specified in TxGMS and applicable Office of Management and Budget (OMB) Circulars for the support of salaries, wages, and payroll documentation.

2. AA demonstrates financial solvency.

Provide a copy of the AA's latest financial statements.

  • AA must have sufficient cash reserves, demonstrating ability to meet cash flow demands for organization operations.
  • Balance sheet must not reflect a deficit fund balance.
  • The current assets must exceed the current liabilities.
  • AA must demonstrate the ability (business plan) to liquidate long-term debt and liabilities.
  • AA must disclose contingent liabilities.

3. AA demonstrates compliance with IRS reporting and payroll tax requirements.

The AA files the latest IRS Form 941 and the two most recent payroll tax deposits with the IRS and provides verifiable evidence that the organization made the deposits within the IRS deadline.

4. AA demonstrates compliance with unemployment insurance and workers’ compensation requirements.

AA pays unemployment and workers’ compensation insurance premiums in a timely manner and provides verifiable evidence of the timely payments.

5. AA has financial policies and procedures that effectively address all elements of financial management.

Provide a copy of the AA's policies and procedures pertaining to financial management.

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

  • Review and approval of the organization’s annual budget
  • Review of financial statements
  • Review of independent audits and the organization's response to findings
  • The Board must meet on a quarterly basis at a minimum.

Provide a copy of board minutes reflecting activities listed under the Standards for Financial Responsibility column.

7. AA meets federal single audit requirements.

Provide a copy of the two most current single audit reports.

8. AA has policies, procedures, and a monitoring tool in place which address financial compliance monitoring of subrecipients. The policies and procedures also address how the AA informs subrecipients of financial compliance requirements pertaining to funds awarded to the subrecipient.

Provide a copy of the AA’s policies and procedures pertaining to financial compliance monitoring of subrecipients.

Provide evidence of monitoring efforts, such as monitoring reports.
 
Provide evidence of how the AA informs subrecipients of financial compliance requirements. (i.e., requirements specified in the contract)

Provide a program income (PI) policy for AA and subrecipients that complies with DSHS requirements and guidance.

Provide evidence of PI compliance.

9. AA has adequate number of experienced financial staff (with accounting expertise) responsible for the financial management of organization’s operations and financial compliance monitoring of subrecipients.

Provide a list of staff responsible for the financial management of DSHS awards, to include staff responsible for financial compliance monitoring of subrecipients.

Provide job descriptions of staff listed above.

10. AA has documented procedures in place for the review and processing of reimbursement requests from subrecipients. The review ensures costs meet applicable OMB cost principles, TxGMS, DSHS program regulations, and the terms of the contract in determining cost reasonableness, are allowable and allocable. The organization must demonstrate timely payment of obligations to subrecipients.

Provide a copy of the AA’s documented procedures pertaining to processing reimbursement requests from subrecipients.

11. AA has policies and procedures to reduce liability risk.

Uniform Terms and Conditions - Non-Governmental Entity

Uniform Terms and Conditions - Governmental Entity

Provide copies of insurance policies addressing requirements as specified in The Uniform Terms and Conditions (UTCs). Non-governmental entities utilize the Grant UTCs and governmental entities utilize the Government Entity UTCs.

12. AA maintains fidelity bond or insurance coverage equal to the amount of funding that DSHS may provide up to $100,000 which covers each employee of the organization handling funds under contracts with DSHS.

Provide evidence of sufficient insurance coverage as specified in The Uniform Terms and Conditions (UTCs). Non-governmental entities utilize the Grant UTCs and governmental entities utilize the Government Entity UTCs.

13. AA has a policy addressing the employment or appointment of any person who has an ownership or controlling interest in the organization or an officer or managing employee who has a criminal offense conviction.

Provide a copy of the AA's policy pertaining to employees and the Board of Directors or oversight authority who have criminal offense convictions. Refer to The Uniform Terms and Conditions (UTCS). Non-governmental entities utilize the Grant UTCs and governmental entities utilize the Government Entity UTCs.

14. AA maintains liability insurance coverage in an amount not less than the total value of this contract, sufficient to protect the interests of DSHS.

Evidence of sufficient liability and bond coverage in place at the contract start date. Refer to The Uniform Terms and Conditions (UTCs). Non-governmental entities utilize the Grant UTCs and governmental entities utilize the Government Entity UTCs.

 

13.2 Standards for Administrative and Managerial Responsibility

Standards for Administrative and Managerial Responsibility Criteria and Instructions

1. AA has a clearly stated mission and Mission Statement.

The availability of the mission statement and administrative objectives must accompany substantive proof of a formally evaluated process.

2. AA has experience providing administrative services to a large geographic area.

AAs must know how to address issues (not necessarily HIV-specific) of serving large and diverse (rural, urban) geographic areas.

3. AA has a clear written plan to provide services to the entire assigned geographic area.

The plan must include how services address and deliver in the HSDA(s) and how clients from the counties in AA’s jurisdiction access services. 

The plan must include each funded service in each county with a narrative of how subrecipients link eligible individuals into funded services, including comprehensive outpatient health and support services in the service delivery area or areas.

4. AA has a contingency plan to provide services to the areas, with minimal disruption, during the transition of subrecipients or loss of AA services.

The plan must include a strategy to deliver services in the event of the elimination of area subrecipients. Issues include, at a minimum:

  • 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 or provider;
  • Collaboration expectations between the prior and the current subrecipient; and
  • Transfer of critical services such as Housing Opportunities for Persons With AIDS (HOPWA), health insurance premiums, transportation to medical care, etc.

5. A functional and active Board of Directors or oversight authority governs AA.

Evidence of a functional and working Board of Directors or oversight authority. Board of Directors or oversight authority perform their strategic and fiduciary duties and participate in the organization's day-to-day functions.

6. AA has a system to prepare program data and information for presentation to Governing Body.

Policy and procedures which include preparation and presentation of fiscal and programmatic documentation or information on the AA and subrecipients for board review.

7. The Board of Directors or oversight authority must undergo training consistent with the DSHS format.

Refer to The Uniform Terms and Conditions (UTCs). Non-governmental entities utilize the Grant UTCs and governmental entities utilize the Government Entity UTCs. Board Training.

  • Organization submits written verification to the division contract management unit no later than the end of the first quarter of the beginning of the contract.
  • Board completes training every two years, and annually for mental health-related services.

8. AA has personnel policies in place.

Policies include, at a minimum

  • 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)
  • Disciplinary actions
  • Hire and termination

9. AA complies with DSHS HIV/STD administrative performance standards.

10. AA has a policy and procedure to collect client or customer satisfaction information and apply this data to improve program operations.

The AA provides the policy or procedure as well as evidence of conducting satisfaction surveys and outcomes on an annual basis.

11. AA has an administrative policy and procedures manual or operational manual addressing major administrative systems and functions.

The manual must include:

  • Subcontracting oversight policy
  • Program data reporting policy
  • Confidentiality of personnel records complying with the Fair Labor Standards Act (FLSA)
  • Personnel policies

12. AA has experience in gathering and tracking expenditure data and a policy to address out-of-compliance issues with subrecipients.

AAs must track the services category (and sometimes subcategory) expenditure of each subrecipient to ensure subrecipients deliver services as required. 

AAs must have procedures for subrecipient non-compliance and evidence subrecipient follows procedures.

13. AA has experience monitoring the quality of administrative, fiscal, and service delivery systems of subrecipients.

Evidence of prior experience monitoring administrative and service delivery activities of subrecipients (can be non-HIV-related experience).

14. AA has experience providing technical assistance to subrecipients 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; and
  • Policy and procedure development.

15. AA has a Quality Management (QM) plan outlining goals, objectives, strategies, and activities specific to the service population and area.

Components of QM plan must include:

  • QM committee with a diverse representation of the multidisciplinary team including key leadership;
  • Up-to-date date QM committee roster with roles and responsibilities listed;
  • Written QM plan has a brief, visionary, quality statement related to HIV/STD services, which describes the overall goals and purpose of the QM program;
  • One quality improvement project ongoing at all times following a defined approach or methodology for conducting quality improvement activities and projects;
  • Description of how AA selects quality improvement projects, engages subrecipients, and shares project information with stakeholders;
  • Quality goals for the QM program with an emphasis on improvement in the annual priorities of the overall program;
  • Infrastructure appropriate to the size and population of program consisting of leadership involvement, dedicated staffing and resources, and stakeholder involvement;
  • Method for data collection and analysis of program service utilization annually
  • Stratify data to identify health disparities;
  • Method for performance measurement appropriate to program size, population and goals quarterly, and as needed;
  • Method for sharing data with stakeholders;
  • Primary and other data sources the QM program uses data collection, processing, and storage;
  • Routine medical record review to verify compliance with current HIV treatment guidelines (including verifying accuracy of reported data in TCT;
  • Review and update plan including a cover page with the program name, timeframe the plan encompasses, and the plan must include information somewhere of who authored and approved the QM plan;
  • Document minutes from QM meetings. Meeting minutes must align with QM goals and workplan activities;
  • Workplan with timeline for QM activities; and
  • Processes for annual review and update of policies and procedures.

16. AA has good programmatic standing with funding sources.

See most current programmatic audits for other DSHS-funded contracts.

17. AA complies with Policy 540.001, Sanctions Imposed Upon a Contractor for Non-Compliance with Contracts Involving State/Federal Funds and Policy 540.002, Sanctioning an HIV/STD Contractor for Subcontractor Noncompliance. AA has no sanctions from funding sources for the most recently completed contract cycle.

AA provides evidence of compliance with Policy 540.001 and Policy 540.002.

18. AA has historical 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. AA has a written implementation plan describing how subrecipients deliver outpatient health and support services to people with HIV for the service delivery area.

The implementation plan includes at a minimum:

  • Available services (service categories), 
  • Subrecipients (contracted service providers), 
  • Transportation to subrecipients, and 
  • Support linkages between subrecipients and other service providers (e.g., sub-of-subs).

 

13.3 Standards for Planning Responsibilities

Standards for Planning Responsibilities Criteria and Instructions

1. AA 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 and 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 groups, community groups, and interdisciplinary teams;
  • Ability to develop plans, timelines, budgets, and funding proposals; 
  • Experience in project management, managing multiple priorities, or both;
  • Knowledge of needs assessment processes;
  • Experience in providing technical assistance to volunteer groups, contractors, or both; and
  • Ability to weigh quantitative and qualitative information in decision making.

2. AA effectively solicits, supports, and uses community input in the planning process.

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

  • Consumers (PLWH) representative of the epidemic in the administrative services area (e.g., race, ethnicity, sex);
  • 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;
  • Other HIV or health planning entities and bodies, as appropriate; and
  • Stakeholders with expertise on particular topics, as needed to answer specific questions about local service delivery.

The AA must maintain operating procedures for ensuring community input and disseminate updates to stakeholders. These procedures include a community input plan specifying how AA solicits input, and evidence of progress towards implementing the plan.

AA staff must conduct public hearings concerning the use and distribution of Ryan White Part B and State Services funds and provide feedback to stakeholders and funding source(s).
 

3. AA 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.

The AA must demonstrate a basic knowledge of the characteristics of prevalent HIV 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. AA has the capacity to develop a comprehensive plan for HIV medical and social support services.

The AA carries out periodic assessment of the need for HIV medical and 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 AA 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, resource inventory, and community input. The AA’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 AA incorporates the plan into the AA’s activities.

5. AA participates in statewide HIV planning processes and utilize information from statewide planning processes and products to shape local and regional planning goals and practices.

The AA demonstrates participation in the statewide integrated HIV planning stakeholder body by staff responsible for planning activities. The AA demonstrates the use of statewide priorities and activities in the comprehensive plan for HIV medical and social support services.

6. AA interprets and applies program-specific legislation, government regulations, and administrative processes to planning.

AA assures compatibility of activities and products with applicable local, state, and federal rules, guidelines, and laws, and the plan includes required elements as defined by DSHS.

 

13.4 Standards for Programmatic Data Management

Standards for Programmatic Data Management Criteria and Instructions

1. AA effectively uses the TakeChargeTexas (TCT) application to manage subrecipients’ client-level data.

AA appropriately sets up Ryan White Part B, State Services, and State HOPWA contracts for service delivery in TCT.

Each contracted service delivery has a contractor-estimated average unit cost associated with it in TCT.

Evidence of timely and routine entry of service delivery information by subrecipients.

Evidence that AA data managers instruct subrecipients to report RSR-required data elements for Ryan White-eligible clients and complete all requirements.

2. AA facilitates and ensures subrecipients’ use of TCT, to include timely direct data entry or data imports.

The AA has an adequate plan for providing technical assistance and training to subrecipients or providers on TCT. Such a plan contains routine and special offerings of training in administrative service areas and established methods for contractor requests for assistance and training.

AA provides documentation they have implemented the data improvement plan.

3. AA has a data manager with appropriate knowledge, skills, and abilities.

The AA has a job description and performance standards for their client-level program data manager consistent with DSHS requirements, policies and procedures, and these core competencies.

4. AA acts to improve the quality of TCT data.

The AA provides evidence of monitoring and improving the quality of its program data. This includes a data improvement plan and evidence they have implemented the plan.

5. AA responds to requests for information regarding TCT operations from DSHS (Recipient) and to requests for corrections of errant data by recipient.

AA can provide evidence of timely and complete responses to requests for program information or actions required by DSHS (Recipient).

 

6. AA applies program data in planning or program improvement efforts.

 

The AA can provide evidence of using program data for planning or program improvement. This must include evidence the agency used service utilization data in allocation decisions.

7. AA assures they maintain TCT data in an environment physically and electronically secure at both AA and subrecipient sites and complies with all security requirements in URS security policy, 231-001.

AA provides evidence of URS and TCT security compliance with Policy 231.001.

 

13.5 Standards for Capacity to Subcontract and Monitor

Standards for Capacity to Subcontract and Monitor Criteria and Instructions

1. AA has a clearly defined system for open competition for funding including policies and procedures to obtain high-quality subrecipients.

Includes, but is not limited to:

  • The development of a Request for Proposal, 
  • Provider recruitment plan, 
  • Active advertising in pertinent areas,
  • Letter of intent, scoring tools,
  • Timeline for release,
  • Recruiting criteria for the external review committee,
  • Final scoring, and
  • Awards addressing grievances because of the competitive process.

2. AA has had no substantial grievances in the last two years against the RFP process, services provided, or both.

AA signs a statement attesting neither they, nor their subrecipients, have substantiated grievances.

3. AA has the capacity to contract with subrecipient 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 subrecipients to deliver services. The contracts must delineate services provided and address quality assurance mechanisms.

4. AA can build service delivery capacity.

AA identifies, recruits, and develops contracts with new subrecipients to meet the medical, clinical, and psychosocial needs of clients.

5. AA employs or contracts with (or AA has the capacity to employ or contract with) qualified staff to conduct monitoring of subrecipient who provide clinical and case management services. AA must evaluate and ensure the quality of service.

Minimal requirements for RN to conduct clinical and medical case management monitoring. The job description must include capacity, education, and experience with contract monitoring and management. AA monitors clinical subrecipients follow U.S. Public Health and DSHS clinical case management standards when providing services.

6. AA employs or contracts with (or AA has the capacity to employ or contract with) qualified staff to conduct program monitoring of subrecipients who provide support services. 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 situations 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; and
  • Interpreting and disseminating DSHS and HRSA requirements.

7. AA has written policies and procedures in place, which ensure fair and equitable performance reviews of subrecipients.

Policy and procedures outlining the program’s subrecipient monitoring process. At a minimum, this process includes:

  • Defined systems for announcing and negotiating review dates;
  • Utilization of standardized review tool(s);
  • Documentation of deficiencies; 
  • Follow-up, timelines for monitoring and prioritizing reviews; and
  • Review closures.

8. AA has a policy and procedure to resolve perceived or existing conflicts of interest between the AA and subrecipients.

Policy and procedure outlining the steps to address and resolve conflict of interest including timelines, investigation, documentation, and resolution.

9. AA has Memoranda of Agreement (MOA) with other subrecipients, service providers, and sub-of subrecipients.

MOA includes but is not limited to tuberculosis screening or treatment, HIV prevention, STD, substance abuse, Evidence-Based Prevention Counseling (PBC), Prevention Case Management, and housing.

MOA must include the requirement that the subrecipients, providers, and sub-of-subrecipients provide medical records of all billed treatment and services for Ryan White and State Services client or patient to contracting agency.

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. AA provides evidence it monitors the subrecipients system of presenting program data and information to the subcontractors governing body.

Board meeting minutes, documentation summary or reporting surveys of programmatic improvement, and documentation addressing client issues.

12. AA provides evidence subrecipients collect client or customer satisfaction information on an annual basis, at a minimum.

Program policy on collecting annual surveys with documentation of client satisfaction data.

13. Policy on monitoring of subrecipients for quality service delivery.

Policy includes:

  • Frequency of monitoring;
  • Priority rating system;
  • Follow-up;
  • Provision of training of monitoring methods and procedures;
  • Development of monitoring tools based on DSHS standards and guidelines; and
  • Corrective action plan procedures.

14. AA provides technical assistance to subrecipients.

Documentation of technical assistance given to subrecipients.

15. AA monitors subrecipients and uses DSHS monitoring tools.

AA provides completed DSHS subrecipient monitoring tools with documentation on findings, and follow-up.

16. Evidence of creating contracts for subrecipients.

Contracts include:

  • Services subrecipients provide;
  • Areas covered where subcontractors perform services;
  • Budget and work plan objectives; and
  • Data submission quality assurance requirements.

17. AA must have and maintain resources for the provision of relevant client services and assure subrecipients have and maintain Memoranda of Understanding (MOU) with other services providers in the area.

MOUs must exist between subrecipients for clients to receive a large array of services including TB, STDs, substance abuse, immunizations, HIV prevention, partner services, mental health, and intellectual disabilities. Agency ensures subrecipients renew MOUs annually.

18. AA has a written procedure to assure qualifications of subrecipients who provide clinical and case management services to provide clinical services, case management services, or both.

Qualifications include appropriate licensure to the position held, appropriate education for the position held, and ongoing training in current treatment standards.

19. AA must have a written policy to ensure subrecipients for clinical and case management services develop, adhere to, and maintain appropriate clinical services, case management protocols, policies, and procedures.

Policies as mandated by DSHS clinical and case management standards.

20. AA has not sanctioned the subrecipient for evidence of client abuse or neglect for the most recently completed contract cycle.

AA signs and provides the signed statement that no substantiated grievances against the agency or subrecipient for client neglect or abuse for the most recently completed contract cycle.

21. The agency has not been sanctioned by any funding source for evidence of client abuse/neglect for past contract cycle.

AA signs and provides the signed statement that no substantiated grievances against the agency or subrecipient for client neglect or abuse for the most recently completed contract cycle.

 

13.6 Managing Conflict of Interest

Managing Conflict of Interest Criteria and Instructions

1. AA has a board-approved organizational chart showing key personnel and the chain of command.

The chain of command must show an internal structure that eliminates conflict of interest between the subrecipient and AA.

2. AA has a process defining the supervision of AA manager.

A process delineates who has responsibility for the supervision of staff and how staff evaluation occurs.

3. There is a separation of fiscal responsibilities between AA and subrecipient that eliminates conflict of interest.

The fiscal staff of the subrecipient and AA must follow the process.

4. AA has a policy that the subrecipient has no competitive or monitoring advantage over other service providers.

The process must include a competition process to award services funds by defining a review panel not composed of AA or subrecipient staff.