83_FR_14110
Page Range | 14047-14060 | |
FR Document | 2018-06532 |
[Federal Register Volume 83, Number 63 (Monday, April 2, 2018)] [Notices] [Pages 14047-14060] From the Federal Register Online [www.thefederalregister.org] [FR Doc No: 2018-06532] ======================================================================= ----------------------------------------------------------------------- LEGAL SERVICES CORPORATION Notice of Revisions to Performance Area Four of LSC's Performance Criteria AGENCY: Legal Services Corporation. ACTION: Notice of revisions to guidelines. ----------------------------------------------------------------------- SUMMARY: To provide grantees with the most effective guidance, in 2018 the Legal Services Corporation revised Performance Area Four to refine and expand the areas of inquiry to focus on those criteria for which LSC has found the most deficiencies, particularly Criteria 1 (Board Governance), 4 (Financial Administration), and 7 (General Resource Development). The 2018 revisions codify the work of LSC staff with numerous grantees and provide evidence-based guidance to recipients on how to run a high-performing nonprofit organization. FOR FURTHER INFORMATION CONTACT: Lynn Jennings, Vice President for Grants Management, Legal Services Corporation, 3333 K Street NW, Washington, DC 20007, (202) 295-1645, [email protected]. SUPPLEMENTARY INFORMATION: LSC's Performance Criteria indicate that legal services programs should be led and managed effectively with high-quality governance, administrative systems, procedures, and policies. Good leadership and strong internal operations increase the likelihood of effective program services for clients. Over the past several years, LSC has observed some areas of weakness in grantee governance through performance quality visits, compliance reviews, and Office of Inspector General (OIG) visits. The 2018 revisions codify the work of LSC staff with numerous grantees and provide evidence-based guidance to recipients on how to run a high- performing nonprofit organization. Since 2010, LSC's Office of Program Performance has conducted 133 Program Quality Visits of 124 grantees. LSC issued 1,901 Tier One \1\ recommendations across the reports summarizing those visits. Of the 1,901 Tier One recommendations, 695 recommendations--36.5%, the most of any performance area--pertained to Performance Area 4. From 2011 to 2016, LSC's Office of Compliance and Enforcement conducted 111 Compliance Reviews of 106 grantees. LSC issued more than 1,200 Required Corrective Actions (RCAs) related to both regulatory and fiscal issues. Approximately 25% of the RCAs identified deficiencies in the grantees' financial administration. Additionally, OIG conducted 41 A-50 reviews between June 2012 and September 2017. As a result of those reviews, the OIG made 160 referrals to OCE. The referrals covered issues related to timekeeping, deficiencies in policies and procedures, cost allocation, and internal controls. --------------------------------------------------------------------------- \1\ According to LSC's Office of Program Performance Procedure Manual:Tier One Recommendations are those recommendations that are determined to be significant and will be included in the next Request for Proposal to the grantee. Tier One Recommendations are those that if addressed, have the potential for significantly improving program quality and/ or program performance within the short term, i.e., two years. A Tier One Recommendation must: be stated in simple straightforward terms such that there is no doubt by the program that a response is required; and have an objective, the value of which equals or outweighs any additional burden that the recommendation imposes on the program (does not apply to statutory or regulatory requirements). --------------------------------------------------------------------------- This is the background against which LSC evaluated the existing criteria for Performance Area 4. The statistics above gave LSC valuable information about which areas of grantee administration, leadership, and governance needed more rigorous evaluation. These Performance Criteria are guidelines for ensuring high program quality. They are not requirements. They reflect best practices to which programs should aspire and which they should, to the extent possible and consistent with program resources, attempt to achieve. These revisions do not reflect a change in the purposes of the Performance Criteria stated in the Introduction to the 2007 revised version. The purposes of the Performance Criteria are twofold. First, the Performance Criteria ``guide LSC's assessments of program performance generally and in the competitive grants process.'' Second, the Performance Criteria serve as a ``useful framework for internal program self-evaluations, planning, and program development, as well as external peer reviews and expert assessments by other funding sources.'' LSC will begin using the revised Performance Area 4 on June 1, 2018. LSC management recognizes that it may take time, guidance, and experience for all grantees to adjust to the revisions. LSC will, therefore, provide training and forums to discuss the implementation of the changes. When conducting program assessments, LSC staff will take the scope of the revisions and each program's capacity into consideration when making recommendations. As the table below indicates, LSC reorganized the order of the Performance Criteria. The current Criterion 3--Overall Management and Administration--includes a limited review of a grantee's technology infrastructure and administration. To more accurately reflect the role technology plays in the daily operations of an organization and in providing efficient and effective client services, LSC proposed creating a separate, new technology criterion, Criterion 3: Technology Infrastructure and Administration. The criterion for Overall Administration and Management would now be Criterion 6, with Internal Communication being folded into the proposed Criterion 6. [[Page 14048]] Performance Area 4: Criterion Ordering ------------------------------------------------------------------------ Current ordering of Performance 2018 Revised ordering of Performance Area 4 Criteria Area 4 Criteria ------------------------------------------------------------------------ Criterion 1: Board Governance.... Criterion 1: Board Governance Criterion 2: Leadership.......... Criterion 2: Leadership Criterion 3: Overall Management Criterion 3: Technology and Administration. Infrastructure and Administration Criterion 4: Financial Criterion 4: Financial Administration Administration. Criterion 5: Human Resources Criterion 5: Human Resources Administration. Administration Criterion 6: Internal Criterion 6: Overall Management and Communication. Administration Criterion 7: General Resource Criterion 7: General Resource Development and Maintenance. Development and Maintenance ------------------------------------------------------------------------ Criterion 1. Board Governance. The program articulates a clear mission for the organization. Each board member demonstrates commitment to the program and its mission through consistent engagement in Board activities that involve all other board members. The board effectively engages in strategic organizational planning with program leadership and staff. It is responsible for major policy decisions, while holding organizational management accountable for effective performance of their responsibilities. The board assists with or oversees, as appropriate, the organization's efforts to develop and maintain resources. The board also promotes public awareness of the program in the community in a manner that aims to enhance the program's overall effectiveness and influence. ------------------------------------------------------------------------ Indicators Areas of inquiry ------------------------------------------------------------------------ Board Composition, Size and Tenure ------------------------------------------------------------------------ As a whole, the board is Is the board membership diverse appropriately diverse and and representative of the service area? representative of the various Is the board either composed of geographical areas and low- an appropriate mix of members that are income populations served by sufficiently expert in areas applicable the program. to the program's operations and achievement of overall goals related to the mission--e.g. non-profit management, financial oversight, fundraising, community engagement--or has it taken steps to ensure that such expertise is available to the board on a consistent basis? Does the board adhere to LSC regulations regarding board composition? The size of the board is Is there evidence that the conducive to effective board's size facilitates the oversight. effectiveness of its operation? When determining board tenure, What is the tenure of each of the board struck a balance the board members, including the board between longevity and board chair(s)? experience and the need for Does the organization impose new ideas and insights. term limits on board membership? If so, what are the term limits? Does the board have a policy or practice regarding length of service on the board and on its Executive Committee? If the board imposes term limits, how does the organization avoid the loss of the experience and expertise of valued directors? Is there a process for removing board members? The board has processes and Does the board have and follow procedures for recruiting and established policies and practices orienting new board members. regarding recruitment, qualification and retention and engagement of new members? Is there a job description for board members explaining their role and duties? Is the job description provided to board members? Is there an onboarding process for new members? Are board members given appropriate orientation and continuing training, including: training on the role of the board, potential conflicts of interest, and on fiscal, fiduciary, and other responsibilities? Is there training on the LSC Act, LSC regulations, LSC performance criteria, and other best practices? ------------------------------------------------------------------------ Board Committees ------------------------------------------------------------------------ The board's committees What is the board's committee structure promotes effective structure? oversight of the organization. What is the composition of each committee? Does each committee have clearly defined responsibilities that are documented in written form? If so, is there periodic review and updating of the documents? Is there a committee responsible for assessing the performance of the board? Is there an executive committee, and, if so, what is its composition? How often does the executive committee meet? What is the scope of business usually conducted? Is there a separate Finance or Audit Committee? Does a member of the audit or finance committee have a financial background? If not, does the committee engage sufficient assistance from non- board sources to provide consistent and competent guidance on financial matters? Is there a separate fundraising committee? ------------------------------------------------------------------------ [[Page 14049]] Board Meetings and Deliberations ------------------------------------------------------------------------ The board fulfills the meeting The board of directors meets at requirements of LSC least four times a year. regulations. There is public notice of meeting and meetings are public. The board has quorum Is the board required to reach requirements that are adhered a membership attendance quorum before to it can take formal action? What is the percentage or number requirement for a quorum? How many times within the past two years has the board tried to meet but has not had a quorum? If there is no quorum, what percentage of the board attended each meeting? Does the organization permit its board to act through virtual meetings such as email voting, in addition to remote participation by teleconferences or videoconference? Are there guidelines or a protocol for virtual meetings? The board and committee Are there pre-circulated meetings are well planned and agendas for all board and committee focused to ensure that the meetings? board and its committees can If so, who sets the agenda? carry out their oversight Do the board chair or committee function. chair and the executive officer contribute to the agenda? Meeting materials............. Do individual members feel that the board packets distributed in the board and committee meetings provide them with useful information about the program and equip them to participate meaningfully in the board or committee meeting? What is the quality of the materials? How far in advance is board information circulated? Do board materials contain updated financial information? Executive session............. Do board meetings include an executive session without any staff (including the executive director)? The board members are engaged What is the level of attendance and regularly attend and at board and committee meetings? participate in board and Do individual members prepare committee meetings. for and participate in meetings? Are client board members actively engaged in board meetings and decisions? Board and committee decisions Are board decisions are appropriately documented. appropriately documented in board minutes? Minutes of full board and committee meetings are prepared, reviewed and approved by the board at least by the next scheduled meeting. Who prepares the meeting minutes? Apart from minutes of board meetings, does the board maintain a separately indexed chronological record of resolutions that reference their initial date of adoption and subsequent actions? ------------------------------------------------------------------------ Board Transparency and Accountability ------------------------------------------------------------------------ The board and members Is the board supportive of the individually, are committed program? to the program and its Does the board have a policy or mission. The board properly practice that effectively deals with discloses and manages any conflicts of interest or potential organizational or personal conflicts of interest? conflicts. Is the policy or practice in writing? Are organizational or individual conflicts addressed quickly and effectively? ------------------------------------------------------------------------ Board Engagement with Strategic Planning ------------------------------------------------------------------------ The board ensures that the Does the board adopt a mission program establishes and statement, that has been adheres to effective collaboratively developed with strategic planning. management? Does the board establish a vision for the future? Does the board approve strategic goals? Does the board articulate core values/principles? What is the board's role in developing the strategic plan? Does the board work in close partnership with the management to ensure a successful planning process? Does the board regularly review progress in accomplishing the goals of the strategic plan and take appropriate action to ensure implementation? Does it periodically discuss progress toward strategic goals with program management? ------------------------------------------------------------------------ Board Oversight of the Organization--Programmatic ------------------------------------------------------------------------ The board is involved in major How are major policy decisions policy decisions, aware of made? issues in and performance of Do board members understand and the program, while leaving adhere to clear distinctions between day-to-day management of board governance and program program operations to program management? management personnel. Do board members understand the major issues at stake for the program? How does the board exercise its oversight of program operations? Does the board receive regular reports providing objective data on program performance? Monitoring: Does the board receive periodic information on the work of the program? Evaluating: Does the board seek information to evaluate the effectiveness of the program's services? ------------------------------------------------------------------------ [[Page 14050]] Board Oversight of the Organization--Financial ------------------------------------------------------------------------ The board exercises effective Are board members aware of and financial oversight. accurate in their perception have a general understanding of the requirements of the program's funding sources. What systems and procedures does the board have to ensure effective financial oversight? Ensure funds are used for How often does the board review intended charitable purposes, financial statements and do they and funds are appropriately understand what the financial accounted for. statements say? Do they have experience in or guidance from board members or other advisors in interpreting the financial statements? Is there a finance and/or audit committee to select the independent auditor? Is the Form 990 presented to the board and management team prior to or after it is filed with the IRS? Are there opportunities for the CFO/Controller or highest ranking financial officer to confer with the board, or members of the board? Has the board established budget guidelines? The board safeguards Are policies in place to investments. evaluate the organization's investment decisions and performance? Are policies in place to safeguard the organization's assets and tax-exempt status? ------------------------------------------------------------------------ Evaluation of the Executive Director ------------------------------------------------------------------------ The board effectively What is the process for evaluates the chief executive evaluating the Executive Director and officer or executive director. other top officers in the organization? Do they employ a 360 evaluation? Who is involved in the evaluation process? How frequently does the board evaluate the chief executive officer or executive director? What, if any, are the criteria used for evaluating the Executive Director? The boards practices Is there a process for appropriate oversight over reviewing and setting executive the Executive Director's compensation? Compensation plan. If so, what is the process? Who is involved in this process? Are all board members aware of the Executive Director's entire compensation package? Is the Executive Director's compensation based on market data? Is there contemporaneous substantiation of the board's deliberation and decision on the Executive Director's compensation? ------------------------------------------------------------------------ Board's Role as Ambassador for the Organization ------------------------------------------------------------------------ The board effectively promotes Do individual members, and expands the reach and including client members, speak on influence of the program in behalf of the organization to external the communities it serves. audiences at appropriate opportunities? Is there a protocol for who speaks on behalf of the board and the organization? Does everyone know the ``elevator speech?'' Do individual members represent the community to the organization by bringing back concerns, ideas, suggestions and compliments when they have merit or possibility? ------------------------------------------------------------------------ Board's Role in Resource Development ------------------------------------------------------------------------ The board effectively promotes Do board members assist and expands the reach and effectively in fundraising and influence of the program in development activity? the communities it serves, Does the board consult and and develops additional communicate with the Executive Director resources for the program. to identify and, where appropriate, pursue all types of needed resources? Determines how board members will participate in fundraising from sources where they have knowledge or influence, such as the private bar? Does the board receive regular reports on staff fundraising activity? The board ensures that the Has the organization adopted program is in compliance with policies to ensure compliance with state and local laws related federal/state laws on solicitation of to solicitation. funds? Are solicitation materials accurate? The board ensures donations Donations are properly recorded comply with LSC Requirements. pursuant to LSC regulations ------------------------------------------------------------------------ Continuous Learning and Assessment ------------------------------------------------------------------------ The board is committed to Does the organization maintain continuous improvement. and provide its board members with an up-to-date board handbook or on-line resources? Do members keep up with issues that affect the functioning and future of the organization? Does the board engage in periodic formal or informal self- assessment processes? ------------------------------------------------------------------------ [[Page 14051]] General Good Governance Practices ------------------------------------------------------------------------ The board ensures legal and Does the board adopt and ethical integrity and regularly evaluate a code of ethics maintains accountability. that describes behaviors it wants to encourage and behavior it wants to discourage? Did the board adopt a policy for handling employee and client complaints? Are there established procedures for employees to report financial impropriety or misuse of the organization's resources? Does the organization have a whistleblower policy? Does the board periodically review the bylaws to ensure that the organization is in compliance with its governing documents and relevant laws? Does the board have policies establishing standards for document retention and destruction? Does the organization keep books and records relevant to its tax- exempt status and IRS filings for appropriate time periods? The board ensures transparency Are the program's Form 990 and and accountability by making annual report reported on its public information available to the website? Are these documents available public on the program's to the public upon request? mission, activities, finance and governance. The members of the board Is there evidence that board members exercise independent judgment engage in independent analysis of in general board decision- materials and information provided to making. them? ------------------------------------------------------------------------ Criterion 2. Leadership. The program has effective leadership that establishes and maintains a shared sense of vision and mission. Program leadership means a commitment to and achievement of the program's goals and objectives according to a model that emphasizes teamwork, transparency, excellence, effectiveness, efficiency, and innovation. ------------------------------------------------------------------------ Indicators Areas of inquiry ------------------------------------------------------------------------ General Leadership ------------------------------------------------------------------------ Key program staff, starting Starting with the chief with the executive director executive officer, are there or chief executive officer, recognized, positive, and effective are respected and recognized leaders in the program? as the program leaders. Do board members, community leaders, clients and the legal community express confidence in the program's leadership? Program leaders hold What specific leadership and themselves accountable for professional development training and motivating staff, and for activities has the program provided? promoting an environment that What are the outcomes of these embraces mentoring and the efforts? professional development of What opportunities are afforded all staff, helping them to staff to develop and exercise achieve their fullest leadership skills? potential. Do staff see themselves as valued members of the program's team? Do program leaders model and encourage teamwork? Do program leaders delegate effectively? Key staff are appropriately Does the program's leadership involved in decision-making seek the opinions and input of staff processes. and other stakeholders in its decision- making processes? The program's leadership Beginning with the executive demonstrates strong, director or chief executive officer, is effective communication there evidence that the leadership of skills and the capacity to the program communicates effectively engage in positive conflict with the board, staff and community resolution. stakeholders? Do program leaders effectively address challenges and issues that impede the program's progress in accomplishing its mission? Starting with the executive director or chief executive officer, is there evidence that program leadership effectively models, motivates and inspires creativity, innovation, excellence, and achievement? ------------------------------------------------------------------------ Mission and Vision ------------------------------------------------------------------------ Program leaders frame a vision Is there a shared sense of and mission. vision and mission? Is it expressed in written form? Are staff aware of it? Program leaders model a high What mechanisms does the level of energy, commitment program's leadership use to measure and integrity in carrying out program effectiveness and adherence to the program's mission. the mission and vision? In what ways does the program's stated mission and vision guide the program's planning and decision-making? ------------------------------------------------------------------------ Diversity ------------------------------------------------------------------------ Starting with the executive In what ways does the program director or chief executive and its leadership demonstrate officer, the program values inclusion and an appreciation for and embraces diversity and diversity? provides opportunities for Is the program's leadership and the development of a diverse management diverse, and, is there group of leaders. evidence that diversity and inclusion are valued by the program? ------------------------------------------------------------------------ [[Page 14052]] Succession Plan ------------------------------------------------------------------------ The program has a leadership Does the program have a clear succession plan that and reasonable succession plan? addresses preserving Is it written? institutional knowledge and strong leadership across all levels of program management. ------------------------------------------------------------------------ Criterion 3. Technology infrastructure and administration. The program provides a stable and secure technology infrastructure sufficient for staff to work efficiently and effectively in the delivery of legal services and to support the operations of the organization. It devotes appropriate resources to provide the capacities outlined in LSC's ``Technologies That Should Be in Place in a Legal Aid Office Today.'' ------------------------------------------------------------------------ Indicators Areas of inquiry ------------------------------------------------------------------------ Technology planning is ongoing Who is involved in technology and integrated into the planning? overall strategic plan of the Does the program get input from program, includes staff staff on technology needs? input, and is reviewed and Has the program ever had an updated at least annually. outside technology audit? How often is the technology plan reviewed and updated? Does the plan include deadlines for implementation? The program has competent IT What type of network does the staff and/or consultants with program have? appropriate training and Are there appropriate certifications to properly firewalls? maintain and support its Are servers hosted on-site, off- technology systems. site, cloud-based? If on-site, where are they and how are they secured (locked office, server room, appropriate A/C)? What is the program's IT security program, its policies, user security training and are the servers, computers and devices patched and kept up to on a regular schedule? Is the network scanned for IT vulnerabilities regularly? The grantee informs employees Does the grantee have a warning of their rights when using banner that appears while employees are grantee-owned computers. logging on and notifies employees of their rights when using their grantee- owned computer? The program devotes What is the internet bandwidth appropriate resources to in each office (any redundant establish and maintain its connection available)? technological infrastructure, Do offices have Wi-Fi available including planning and (is it password protected)? budgeting appropriately for ongoing replacement/upgrades of its technology systems. The program has a proper Is server equipment kept in a written IT security program secure environment with appropriate to include robust IT security ventilation and cooling? Are IT systems policies and procedures currently patched and updated? regarding protecting client Is there a disaster recovery and case data, ensuring the plan (that includes periodic testing) security and integrity of for mission critical technology passwords, use of the systems? Internet and social media, Are there security policies and policies for the use of procedures for protecting client and mobile devices, and if staff case data, sensitive personal and can bring their own devices personnel data, and all communications (BYOD) to access work from loss or unauthorized intrusion? documents. Staff are familiar Are there security policies and with and follow such policies procedures for use of the Internet and and procedures. social media, content security on all devices, and integrity of passwords, retention and deletion of data? Are employees given notice concerning prohibited uses of their computer equipment including a warning banner that notifies employees of their rights (including no expectation of privacy) when using their grantee-owned computer? Is there routine IT security training for staff? Is the user's system access granted based on roles and responsibilities? The program has sufficient What are the backup procedures? procedures to back up its Are test restores done data and has testing periodically from the backups? protocols to demonstrate that data recovery/protection policies work in practice. The program stays informed of What is the replacement cycle new technology developments for technology equipment (desktops/ and how it can make better laptops, servers, printers, scanners, use of technology to meet its copiers, telephones, etc.)? mission. What type of phone system does the program use? How old is it? When was the last upgrade? What reports can it provide? Who maintains it? ------------------------------------------------------------------------ Extent to Which Technology Enhances Program Operations and Service Delivery ------------------------------------------------------------------------ Maximum use of technology is Does the program use technology made to facilitate and effectively to enhance the efficiency enhance internal of program operations and service communication. delivery? How does the program use technology to facilitate and enhance communication? Does the program's website effectively follow the Ernst and Young Best Practices (http://webassessment.lsc.gov/report/)? ------------------------------------------------------------------------ [[Page 14053]] Staff Training ------------------------------------------------------------------------ Program staff are provided Does the program have a policy with appropriate training on for the secure use of its technology, the use of technology. including protecting data (including Personally Identifiable Information), use of the Internet and social media, password policies and if/when staff can bring their own devices? Do staff understand and follow the policy? What software does the program use, including case management system manufacturer and version? Are staff provided with ongoing training in its use? ------------------------------------------------------------------------ Criterion 4. Financial administration. The program has and follows financial policies, procedures, and practices that comport with Generally Accepted Accounting Principles (GAAP), requirements of the program's funding sources, and comply with federal, state and local government regulations. The program has established sound internal controls and conducts effective budget planning and oversight. ------------------------------------------------------------------------ Indicators Areas of inquiry ------------------------------------------------------------------------ Fiscal Policies and Staff ------------------------------------------------------------------------ The program has detailed Is the program's accounting written policies and manual current and updated as procedures describing its appropriate? financial operations which comply with all applicable requirements. The program follows such policies and procedures. The program has sufficient, How many financial staff does capable, trained and the program have? effective staff dedicated to Does the program have competent financial administration. financial personnel? What is the training and background of the financial staff? The job descriptions of personnel are clear and lay out the roles and responsibilities of each position. Is periodic training given to program staff, management, and the governing body regarding LSC regulations and accounting guide, as applicable? Top management and the Is the budget consistent with governing body are actively the program's mission, goals, and involved in the budgeting objectives? process. The budget is Does the program effectively updated periodically and adhere to its budget? changes/variances are Is the budget updated monthly reviewed. The program engages (or at least quarterly), based on in financial planning beyond changes in revenues or expenditures? the current year. Does the program engage in financial planning beyond the current year? The program maintains LSC Does the recipient adhere to funds held for immediate LSC Investment Guidelines? operating expenses in federally-insured bank accounts. ------------------------------------------------------------------------ Board of Directors ------------------------------------------------------------------------ The recipient's governing body Has the board established a has fulfilled its fiduciary financial oversight committee or responsibility to the program committees that perform the roles of a through the establishment of finance committee and an audit a financial oversight committee? committee or committees. The Does the financial oversight financial oversight committee collectively possess the committee(s) has at least one knowledge to set the strategic, member who is a financial financial course for the recipient and expert or the board has oversee management in execution of the access to a financial expert. strategy? Does the financial oversight committee have the leadership of individual well-versed in non-profit GAAP, COSO Internal Control Framework, and other relevant standards and guidelines? Does the financial oversight committee meet on a regular basis? Does the committee have a charter or governing document and fulfill the responsibilities outlined therein? Does the financial oversight committee set the strategic direction of the recipient for financial and audit related matters? The governing body regularly Does a governing body set and determines the compensation review the compensation of the of the program's Executive Executive Director using an independent Director. compensation consultant, comparable pay studies from other nonprofit organizations, and/or a compensation survey? The Executive Director's Are there procedures in place expenses are approved by a that require approval of the Executive member of the board. Director's expenses by a member of the governing body? ------------------------------------------------------------------------ Audited Financial Statements ------------------------------------------------------------------------ The program issues accurate Are the audited financial financial statements on a statements submitted to LSC in timely basis. accordance with the LSC Audit Guide for Recipients and Auditors? Has the program submitted their audited financial statements in a timely manner over the last 3 years? Executed one-time grants, such Are executed one-time grants, as TIG and PBIF awards, are such as TIG and PBIF awards, reported reported separately in the either as a supplemental schedule of program's audited financial related revenue and expense or a statements in accordance with separate column within the financial 45 CFR 1628.3(e). statement? [[Page 14054]] Annual program audits do not Do past audits or outside reveal any significant reports and evaluations reflect problems or issues; where problems? such items have been Have any such problems been identified, the program addressed? addresses them effectively Is there any evidence of and promptly. failure to comply with applicable funder or governmental requirements? What type of auditor's report did the IPA issue regarding the financial statements? Unmodified or modified? If modified, why? What type of auditor's report did the IPA issue regarding Federal Awards? Unqualified or Qualified? If qualified, why? Did the IPA issue findings in the audited financial statements? What were the findings? Have they been addressed? Did the IPA issue a management letter? What did it contain? Has the recipient addressed the issues? Are audit findings repeated from one fiscal year end to the next in the audited financial statements? Does the recipient adequately address audit findings by performing the corrective actions outlined in the audited financial statements? ------------------------------------------------------------------------ Internal Controls ------------------------------------------------------------------------ The recipient has established There is sufficient segregation and maintains adequate of duties. accounting records and Do the accounting policies and internal control procedures. procedures require an appropriate level which is designed to provide of supervisory review and adequate reasonable assurance of checks and balances to ensure the achieving the following accuracy, completeness and timeliness objectives: (1) Safeguarding of transaction processing? of assets against The recipient has established unauthorized use or and adheres to an adequate system of disposition; (2) reliability internal control following the of financial information and principles of the COSO Integrated reporting; and (3) compliance Internal Control Framework. with regulations and laws that have a direct and material effect on the program. ------------------------------------------------------------------------ Contracting ------------------------------------------------------------------------ The program has a contracting Does the program have a policy to prevent abuse, contracting policy? limit waste of scarce funds, Does the policy identify the and prevent possible contracting procedures for the various questioned cost proceeding. types of contracts, dollar thresholds, and competition requirements? Is the process used for each contract action fully documented and is the documentation maintained in a central file? Is the required approval level (including items that need to be approved by LSC) established for each contract type and dollar threshold, including when the board of directors should be notified and/or give approval? Do policies include procedures for documenting and deviating from the approved contracting process, such as when sole-source contracts are executed? Is each contract or agreement executed with a price, time-period, and services to be performed? ------------------------------------------------------------------------ Fraud Prevention ------------------------------------------------------------------------ The program has robust Assess the organization's policies and safeguards in segregation of duties. place to prevent fraud. Who has access to the program's bank accounts? How are permissions and authorizations assigned? Does the program have Whistleblower and Conflict of Interest Policies? Is the program's IT infrastructure adequately secure? Is the physical and logical access to the program's computer network adequately secure? Does the program's governance and management of IT resources promote effective operations and provide a robust system of internal control? Do the program's computer applications incorporate and facilitate a robust system of internal control? Have thorough and well documented hiring practices and procedures? Are staff periodically trained or reminded of the Whistleblower and Conflict of Interest Policies? Does the program employ computer banners on all servers, computers and devices to inform employees of prohibited use activities and no right to privacy of grantee equipment? ------------------------------------------------------------------------ Cash Disbursements ------------------------------------------------------------------------ The program's disbursements Are procedures adequate to are approved in writing by an provide that salary and wage rates are authorized individual. approved by an authorized individual and employees are paid in accordance with approved wage and salary plans? Were invoices properly approved, with dates, before disbursement checks were processed? Do policies and procedures for disbursements address unallowable expenses, purchase approvals, securing and approving new vendors, segregation of purchasing duties, and duplicate payment controls? [[Page 14055]] The program's criteria and Is there a procedure for proper procedures for purchases are payment and approval of expenditures at documented. an appropriate level of management? ------------------------------------------------------------------------ Cash Receipts ------------------------------------------------------------------------ The program has established Is initial accountability for internal control procedures cash established as soon as a cash item related to cash receipts. is received? Do the accounting records adequately identify all cash receipts as to source and purpose? Is an effective chain of custody in place for cash receipts? The program maintains a client Has the program established a trust fund and accounting method to determine the balance for system to account for funds each client trust account? held on the client's behalf. Does the program have a process to ensure that dormant funds are escheated to the state in compliance with state requirements? ------------------------------------------------------------------------ Asset and Property Records ------------------------------------------------------------------------ A physical inventory of Is a physical inventory property purchased with LSC conducted at least once every two (2) funds is conducted at least years? once every two (2) years and Are any differences between the the results are reconciled physical inventory and the accounting with property records. records reconciled? The program has established Is there a surprise count of adequate internal controls to petty cash conducted periodically? safeguard its petty cash Are the petty cash and client funds. trust funds secured in locked location? Are all petty cash disbursements supported by an original receipt or appropriate supporting documentation? ------------------------------------------------------------------------ Subgrants ------------------------------------------------------------------------ The program has established Does the subgrant agreement or adequate procedures related contract with the sub recipient specify to the subgranting of LSC financial reporting responsibility? funds to ensure compliance Where a relationship with a sub and proper fiscal oversight. recipient exists, do the notes to the financial statements of the recipient and subrecipient fully disclose the nature of that relationship? ------------------------------------------------------------------------ Bonding of Recipients ------------------------------------------------------------------------ The program maintains fidelity Does the program carry at least bond coverage at a minimum the minimum level of fidelity bond level of at least ten (10) coverage for fraud and employee percent of the program's dishonesty as described in 45 CFR Part annualized LSC funding level 1629? for the previous fiscal year, or of the initial grant or contract. The program carries adequate Does the program carry fidelity fidelity bond coverage for bond coverage for all staff required to all staff required to be be bonded: Every director, officer, bonded. employee and agent of a program who handles funds? ------------------------------------------------------------------------ Accounting Software ------------------------------------------------------------------------ The program's accounting Does the program use up-to-date software is appropriate to technology to enhance efficient support the operations and financial operation? financial oversight of the Is the software appropriate to organization. support the operations of the organization? Does the accounting software incorporate adequate internal controls? Is the recipient effectively using the software to ensure internal controls are in place? The program limits access to Does the program limit access its accounting software. to its accounting software? Does each user have his/her own password security based on their fiscal functions and are accounting software passwords changed periodically? Is a user's system access granted based on roles and responsibilities? ------------------------------------------------------------------------ Criterion 5. Human resources administration. The program promotes organizational excellence through the recruitment, management, and retention of a high-performing, diverse workforce consistent with its mission and goals. The program develops and communicates sound policies and procedures that ensure compliance with applicable federal, state, and local laws and has a knowledgeable, accessible, and professional staff to the program in the areas of recruitment and retention, training, professional development, compensation and benefits, performance appraisal, and organizational governing personnel development. [[Page 14056]] ------------------------------------------------------------------------ Indicators Areas of inquiry ------------------------------------------------------------------------ Human Resources Staffing and Workplace Policies ------------------------------------------------------------------------ The program has sufficient, Who is responsible for the capable, trained, and human resources functions within the effective professional staff program? assigned to human resources If responsibilities are shared, administration. how are duties defined? What is the background, experience and training of staff responsible for handling human resources?