Appendix D3

Appendix D-3 – RFP Financial Survey Contract No. HSS-22-032A Contract Title: Emergency COVID-19: Mental Health and Substance Use Disorder Services Expansion NAME OF BIDDER AGENCY: Click here to enter text.

A. Organization Information

1. Nature of Business

a. Organization type:

☐For−profit ☐Non−profit ☐Not−for−profit

b. IRS tax−exempt status:

☐Non−exempt ☐Exempt − Under IRS Code Section: Click here to enter text.

c. Corporation Data: Are the following documents up to date?

Liability

A. Finance, Accounting, and Internal Controls

1. Basis of accounting system:

☐ Cash ☐ Accrual

2. Does the firm engage an independent auditor to conduct an annual audit of financial statements?

☐ Yes ☐ No

a. If yes, select type of audit:

☐Federal Single Audit ☐ Financial Audit; Last fiscal year audited:

b. If no, is an Independent CPA Review performed? □ Yes □ No; Last fiscal year reviewed:

3. Provide, a listing of the firm’s Chart of Accounts (COA), including both the numeric code and description of each account in the accounting system.

4. The firm must maintain a complete set of accounting records, or books of account for original and secondary entries, in which all financial information of firm are recorded and maintained, including journals, ledgers, and supporting documentation.

Has your firm maintained a complete set of accounting records? □ Yes □ No Note: If selected as a contract agency, these records may be audited by Division representatives at any time.

5. Internal Controls Reference: The Committee of Sponsoring Organizations (COSO) of the Treadway Commission Internal Control Integrated Framework (COSO Framework) for Organizations to use in the assessment of internal control as adapted by the Government Accountability Office (GAO) Standards for Internal Control in the Federal Government issued Sep 2014.

a. Have deficiencies or material weaknesses in internal controls been found during an audit?

☐ Yes ☐ No

b. Does your firm maintain written financial practice policies and procedures?

☐ Yes ☐ No If yes, please provide a copy to the Division in a labeled attachment to this survey.

c. Are Financial Policies and Procedures regularly reviewed and revised as necessary?

☐ Yes ☐ No

d. If not present in the attached policies and procedures, explain the internal management mechanisms in place for safeguarding the assets of the organization, and for preventing and detecting errors, fraud, waste and abuse. Specifically describe the following financial management areas under marked sub−headings:

· Separation of functional responsibilities and duties

· Petty cash procedures (include uses, forms, maximum balance maintained, limits on transactions, procedures for reconciliation and replenishment)

· Receipts (describe flow of receipt, recording, and deposit)

· Disbursements (approvals, safeguarding blank checks, check issuance, required check signatories, maintenance of supporting documents)

· Bank statement (both process and timing of opening, review, reconciliation and approval of statement)

6. Billing Residents for Services

a. Does the firm maintain a schedule of fees?

☐ Yes ☐ No

b. Summarize, the procedures for determining fees due from resident, include information about how a resident is informed about the fee schedule, determination of resident’s ability to pay, the procedures for billing residents, and how the receipt of resident fees is documented.

c. Explain the procedures for billing third−party payers?

B. Program

1. Does the firm maintain a summary of total program funding and a breakdown of approximate funding by source?

☐ Yes ☐ No

a. Briefly describe:

b. Does the program have person(s) responsible for the preparation and review of the program budget?

☐ Yes ☐ No

c. Describe the procedures for preparing the overall program budget, estimating the projected income, and for the periodic budget review and adjustments.

2. Indirect (Facilities and Administration) Costs

d. Describe the agency’s development of its indirect cost pool(s), and the method of distributing indirect (F&A) charges across programs.

Please provide a copy of the policy to the Division in a labeled attachment

d. Does the organization have a Federally approved indirect cost rate?

☐ Yes ☐ No

e. Indirect Cost Rate: ___% Type of rate (predetermined, provisional, final, de minimis, etc.: ___ Allocation (distribution) basis: ___ C. Federal cognizant agency for indirect costs: ___ D. Procurement

1.

2. Does the firm maintain a summary of total program funding and a breakdown of approximate funding by source?

3. What are the organization’s procedures for procurement? Include description of:

a. Solicitation and bids process for service, and

b. Receipt and inspection of goods.

Please provide a copy of the policies to the Division in a labeled attachment.

NOTE: When procuring property and services under a Federal award, non−Federal entities that are not states, must follow Uniform Guidance procurement standards found at 2 CFR 200, §200.318 through §200.326.

E. Property Management

1. Describe the following elements of the firm’s property management process.

a. Does the firm maintain an inventory (listing) of furnishings, office equipment, and other capital property?

☐ Yes ☐ No

b. The inventory record includes (check all that apply; otherwise, write N/A for not applicable):

c. Is the inventory kept up to date?

☐ Yes ☐ No

d. How often is the inventory updated? ___

e. Identify the party responsible for maintaining the inventory? Name/Position: _________________ F. Bidder Agency Signoff

1. Survey completed by (Printed or Typed Name): _____________________________

2. Title/Position: _____________

3. Signature: ______________________________ Date: ___/___/___

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