Programmatic Risk Survey - Division of Mental Health

1. Quality of Management Systems and Ability to Meet the Management Standards

1.1. Do you have written policies and procedures that guide program delivery on the topics of:

• a. Quality assurance Yes No
• b. Outcome tracking and reporting mechanisms Yes No
• c. Relevant documentation of services/goods delivered Yes No
• d. Staff performance management policies and procedures Yes No
• e. Personnel policies and procedures that include conflict of interest statements Yes No
• f. Complaint/grievance resolution policies and procedures Yes No
• g. Governing body policies and procedures that include conflict of interest statements Yes No
• h. Safeguarding funds, property and other assets against loss from unauthorized use or disposition Yes No
• i. Management of grant term extensions, where applicable Yes No

1.2. Do you have internal controls that govern program delivery on the topics of:

• a. Quality assurance reporting Yes No
• b. Appropriate (to industry) supervision of staff Yes No
• c. Unit costs analysis and management Yes No
• d. Accreditation/licensing compliance program Yes No

1.3. Does the organization have written standards of conduct covering real or perceived conflict of interest related to actions of employees engaged in the selection, award or administration of contracts supported by grant awards? Yes No

1.4. How many years of experience does the project leader have managing the scope of services required under this program? More than five years One to five years Less than a year

1.5. Does the organization have a time and effort system that:

• a. Records all time worked, including time not charged to awards ? Yes No
• b. Is signed-off by the employee and a supervisor? Yes No
• c. Includes an approved methodology? Yes No Not Applicable

1.6. Does the organization have controls for invoicing grants paid based on a rate or unit of service? Yes No

1.7. Does the organization apply the same standard for match requirements as it does for expenses? Yes No N/A

1.8. To what extent are you able to produce periodic grant status reports to inform stakeholders about program outcomes? Reports are an established part of grant management procedures We’re developing reports as part of grant management procedures We do not currently have established reports as part of grant management

2. History of Performance

(The applicant's record in managing grant awards, if it is a prior recipient of awards, including timeliness of compliance with applicable reporting requirements, conformance to the terms and conditions of previous awards, and if applicable, the extent to which any previously awarded amounts will be expended prior to future awards)

2.1. How many years of experience does your organization have with grants of comparable scope and/or capacity? More than five years One to five years Less than a year

2.2. If your organization has experience with grants of comparable scope and/or capacity, provide a brief description of similar project goals and outcomes; specify the applicable year:

2.3. During your last two fiscal years, how frequently has your organization submitted project performance reports on time? Always Reported late up to three times Reported late four or more times

2.4. Have there been any significant changes in your organization in the last fiscal year related to:

• a. Leadership change(s) Yes No
• b. Significant program / grant initiative(s) Yes No
• c. Structural changes Yes No
• d. Fiscal changes Yes No
• e. Statutory or regulatory requirements Yes No
• f. Other Yes No

2.5. Provide a brief explanation for all "YES" responses to question 2.4.

2.6. Does the organization utilize a sub-grantee/sub-recipient/sub-award to manage, administer or complete a project? Yes No

If "NO" to question 2.6, go to question 2.10

2.7. What responsibilities does the sub-grantee/sub-recipient/sub-award perform?

• a. Participant eligibility determination Yes No
• b. Performance reporting Yes No
• c. Program delivery functions Yes No
• d. Financial reporting Yes No
• e. Other

2.8 What percentage of grant funds does the organization pass on to sub-grantees/sub-recipients/sub-awards? Less than 10% 10-20% More than 20%

2.9. Does your organization have an implemented policy for sub-grantee monitoring? Yes No

If NO, go to 2.10. If YES, does it include

If "YES" to question 2.9, does it include:

• on-site review
• review of prior monitoring
• desk/quantitative review

2.10. Do you obtain prior written approval from the funding agency when:

• a. The scope or objective of the program changes Yes No
• b. Key personnel specified in the application change Yes No
• c. The approved project director disengages for more than 3 months or reduces 25% of time devoted to the project Yes No
• Question is not applicable because organization has not been subject to these requirements

2.11. Does your organization have performance measurements that tie to financial data? Yes No

3. Reports and Findings from Audits

Audits performed under Subpart F of this part or the reports and findings of any other available audit.

3.1. During the last two fiscal years, has your organization been out of compliance with programmatic terms and conditions of awards? Organization has not been audited; Go to Question 3.6 No occurrences of non-compliance; Go to Question 3.6 One to three occurrences of non-compliance Four or more occurrences of non-compliance

3.2. If your organization had at least one occurrence of non-compliance with programmatic terms and conditions, summarize each occurrence.

3.3. Have corrective actions been implemented within the specified timeframe? Yes No

3.4. Provide explanation for any corrective actions that were not implemented within the timeframe specified and for any corrective actions that remain open.

3.5. Have there been conflict of interest-related findings within the last two fiscal years? Yes No

If YES, specify the conflict of interest-related finding and your response to the finding.

3.6. Has your organization been subject to conditional approvals due to program issues? Yes No

If YES, specify the terms of the special condition and whether or not the special condition is still applicable.

4. Applicant's Ability to Effectively Implement Statutory, Regulatory, or Other Requirements

4.1. To what extent does your organization have policies to ensure programmatic expenses are reasonable, necessary and prudent (allowable)? Policies are implemented and followed Policies are not fully implemented The organization does not currently have these types of policies

4.2. To what extent does your organization have policies to ensure programmatic activities are allowable? Policies are implemented and followed Policies are not fully implemented The organization does not currently have these types of policies

4.3. To what extent is your organization able to comply with all statutory requirements of this program?

• Fully able to comply with all statutory requirements
• With the following exception(s), the organization is able to comply:

4.4. Has the organization been out of compliance with any statutory, regulatory or other requirements of grant funding within the last two fiscal years? Yes No

If YES, specify the terms of the special condition and whether or not the special condition is still applicable.

5. Grant Specific Questions

5.1 Has the Grantee provided training on Quality Assurance? Yes No

5.2 Does the Grantee have clinical expertise to support quality improvement processes and to provide training and technical assistance to staff? Yes No

5.3. Does the Grantee have significant knowledge and expertise in the area of disability and aging? Yes No

5.4. Does the Grantee have significant experience with managing chronic health conditions? Yes No

5.5. Does the Grantee have have necessary staff to meet programmatic requirements? Yes No

Programmatic Risk Assessment Certification

On behalf of the applicant entity, I attest that the statements included herein are true, complete and accurate to the best of my knowledge. All occurrences of non-compliance with programmatic requirements have been disclosed.