1 i 11 I i i ill 1 11III I I I I1 1 j ! IllI 111@l @Iiiii !ill *10@l #1 It REGIONAL ADVISORY GROUP AND COMITTEES 1. Evaluate membership of Regional Advisory Group (RAG). Is the membership representative from a geographical standpoints Is it representative of professional and consumer interests? 2 Is the RAG constituted in accordance with the law and DRNP guidelines? Are members knowledgeable of RW activities? If possible,, interview representatives of RAG. Have By Laws or a Constitution been adopted? 36 Has the role of the RAG been identified? 40 Does the RAG function as a Board of Trustees (policy-making) or as only an advisory groop? 51 To there any evidence that the RAG has exceeded the policy-making function assigned to it? 6. How are policies promulgated by the RAG disseminated.and compliance assured? 7. Review copies of RAG and Cr,-ittee minutes to ascertain if follow-up action is taken when indicated. 80 Is there a scheduled rotation of members on the RAG.and committees? 9. What Committees are there and how frequently do they meet? Review'the minutes to ascertain the activities of the Committees and for further leads. 100 Are written charges given to Committees7 Do they clearly define the responsibility of the Committee to define problem areas, and to develop plans and project proposals? 11. On what basis were the Committees established? How have they evolve ? What changes have been made in them to reflect changes at regional and national levels? What is the relative-degree of action and inaction of the Committees? 12. What are the mechanics of comittee activity?@ Who appoints them and what is the rationale for selection?' Are there committee reports? What use is made of them? 130 Has the region made decisions as to who or what groups are to be represented on committees? What assurance is there that committees are representative (dependent upon their particular purposes)? 14. What is the core staff input in terms of staffing committees and providing information to tomitt6es on new developments, policies, etc.? - 150 Are committees informed of each other's relevant activities? What happens to minutes of cr ittees? 16. How does core staff reduce duplication of effort between various commit- tees, i.e.p between regional level committees and area or sub-regional level committees in such areas as data collection and analysis, project review, and coordination with other agencies and organizations -- and avoid duplication between RNP committees and committees of CHP or ot er Agencies and organizationq? 17. What is the role of the committed(s) in the areas o (a) planning and program development (b) rebudgeting (c) evaluation of program development and projects (d) establishing riorities and goals p CORE STAFF AND CENTRAL ADMINISTRATION A. ORGANIZATION .1. What type of institution is the grantee? 2. Develop a brief history of the program. 30 What is the size of the Region? Is it sub-divided? If so, evaluate this in terms of numbers, duplication of administrative efforts, cost, liaison with the central office, and advantages or disadvantages of such a division. 4. Review the position descriptions to determine if they are current and accurate. Does each employee have a cnpy? Are they required by grantee?. 5. Evaluate the degree to which employees understand the relationship of their work to related elements of the RNP. 6. obtain a copy of the RNP orgauizatiotal chart and functional statements. Does the actual organization conform to these documents? 7. Number of full-time appointment 9 Number of part-time appointments? Do part-time appointees carry their respective share of program responsibilities 'Lo there 80 ev@der@e of over-organization and excessive layering of supervision? 9. Is the FM organized and staffed to meet stated goals and objectives? 10* Is the staffin, ?attern consistent @ith DRNP submissions? 11. Are there budgeted positions for core staff or projects which have remained unfilled for long periods? Rkview the recruitment efforts for these to determine if ti-ete has been a concerted effort to fill them. What was done with the money? 12. Evaluate the relationship existing between Core Staff and grantee. Is the Core Staff an active partner? Can it act independently and with authority? 13. Are personnel policies of the Grantee clearly stated? Does the RNP understand And adhere to these policies? 14. Does the RMP have written personnel policies covering the following: (a) Vacation, sick time, leave of absence, working hours, fringe benefits, etc. (b) Relocation allowances. (e) Wage and Salary Administration 15. How are salaries determined?' 16. How are salary increases determined and administered? 17. What assurance is there that-affiliates have current written personnel policies and that these policies are consistently followed? 18. What is the policy regarding acceptance of consultation fees by: (a) staff (b) affiliates (c) faculty (d) all others B, DIRECTION OF THE.PROGRAM 1. Are delegations of authority written or made orally? There should be a minimum of oral delegation. 2. In discussion with personnel, determine how well they understand what authority they have. 34 Have recommendations made by GAO, HEW, and site visit teams been imple- mented or received proper consideration? 4. Dots the Core Staff conduct site visits to operational projects to review progress? S* How is the coordinator kept apprised of problem areas or significant accomplishments? 6. Are leave records and time cards adequately maintained? 7-. Are there policy and procedure manuals or a system of references to readily locate pertinent policies? 8. What'mechanisms have been set up to assure good records control, including answering mail and phone requests? C. COMMICATION 1. What public information program is there to acquaint the public, medical community and other health organizations with the RMP? What success or resistance has it met? How has it attempted to overcome resistance? 2. What channels of communication are open between the RMP and consumer groups? 3. Review the reports required by the Region or RAG. Evaluate the accuracy and necessity. 4. Is there a system of regular and special reports: (a) to and from committees? (b) to and from projects and affiliated institutions? (c). in connection with contracts? (d) to and from DRMP? 5. Evaluate internal communication within the RMP. D. RESEARCH AND EVALUATIO14 1. Does the communication and information system include data collection? if so (a) How is it collected and analyzed? (b) Is it coordinated with other agencies and organizations? (c) Is it kept current? (d) Is resulting information disseminated to other groups? 2. Have existing sources of data been categorized as to purpose, source, quality, availability, etc.? 3. How does the Region update its inventory of resources and capabilities? The inventory should provide a basis for setting priorities and to identify missing resources. 4. How does RHP encourage groups to develop a project to accomplish a need? 5. Has region drafted written procedures or guidelines to assist proposers in the development of projects? Can staff provide writing or editorial help? 6. Do these procedures include mechanism for informing potential sponsors of changing priorities, regional and national? 7. Does staff participation in early stages of project development help guard against weaknesses in budgets? 8* Are there established methods for estimating and substantiating projected costs? 9. How.are priorities of the Regions' objectives set? 10, Evaluate the review process. Is there a procedure for control of time sequences in the review process? 11. What written guidelines are available to assist reviewers in reviewing proposals? 12. Have channels been created to sup@ly feed back from critical review wherever it is done -- to project sponsors? 13. What methods are used to evaluate effectiveness of approved projects? Who does it? E, FINANCIAL MA14AGEMENT 1* How does the Region maintain control of project funds? The RNP should be able to identify excess funds as soon as they occur. 2. Are there written policies regarding the disbursement of core funds? 3. What is the procedure for the disbursement of funds from the grantet to the affiliate institution. Does a member of the Core Staff th r tian the fiscal agent authorize disbursements? 4. is a member of the Core'Staff responsible as to the allowability of a proposed expenditure? 5. Is money forwarded to the affiliate before or after expenditures are made on RHP projects? 6, What type of fiscal expenditure reports art required from the affiliate institution? How often are these required? 7. How are the fiscal records mair fined by the RHP reconciled with those of the grantee and project director? How often? 8. Does a memb-r of the Core Staff review the accounting records of those -eceiving grant @:unds? If not, h does the PMP assure t t proper an ow adequate records are maintained? 9. Does the RIMP r?q-lire periodic audit of the affiliate's financial records regarding RIIP funds? 10. Who audits the Core financial rtcords? 110 What means does the RMP have to determine the amount of funding available to project from other sources? Does the RNP phase these out as funding from other sources becomes available? 12. Review budget forecasts of selected projects and compare with actial operating costs.. What accounted for substantial variations? 13* Is inc.,,ne generated from RHP activity accounted for separately and returned to the government Possible sources of income are from use of equipment, patient care, sale of publications. 14. iteview the policies concerning consul'6nt services. They should require (1) a statement of service to be performed and that it cannot be performed by payn*nt of direct salaries to staff members of the grantee or an affili- ated institution; (2) a description of the process of selection of indivi- dual most qualified; agd (3) evidence that the fee is appropriate* Is there a WrItten agreement wit the consultant showing fee, type--Of servicei performance dates? 15. Has the grantee institution Established indirect cost rates with its affili- ated institutions? (N]:D,Special Issue; January 16, 1969) 16. Is the grantee or R14P in a position to.aid in the development of indirect cost rates for affiliate institutions? 17. What is required of an affiliate in establishing an indirect cost rate? 18. Does the RW have an established indirect cost rate with the government for the Core Staff? 19. If to , was it developed by RMP personnel or by an outside accounting agency? 10. Wh at assurance is there that there is no co-mingling of federal and non- federal funds? 21. How is the receipt of goods or.services documented to support payment for it? 22. Is there a separation of responsibility for the authorization or pur- chasing and the subsequent payment? 23. Review the tizekeeping and payroll procedure. There should be a separation of the various functions. 24. Who on the Core Staff authorizes the expenditures for travel? Is there a limit set on the expenditure of funds without prior approval o -)r the board of lir6ctors? 25. Is there a fiscal management marial prepared by the RNP an given to affiliates? F. PURCHASING, CONTRACTING, 6 EQUIPMENT 1. Is there a written purchasing policy? Does it call for competitive bidding? Under what circumstances is competitive bidding employed, or not employed? There should be documentation showing the bid prices and the reason for making the award. 2. If the affiliates have no policy, what assurance is there that federal funds are being used for the greatest dollar value? 3. How does the grantee know the affiliate's purchasing policies are ,consistently employed? 4. How are decisions made regarding the 'Selection of the brand of techni- cal scientific equipment? 5. Since funds approved for equipment might be lost if not obligated prior to the end of the fiscal year, is there a requirement that it be pur- chased early in the funding period? 6. what controls are established for the accountability of equipment by the RMP and the affiliates? 7. Does the grantee have equipment inventory records? is all equipment labeled and periodically inventoried? 8. Does the affiliate understand that the grantee has title and accounta- bility for all equipment purchased with RMP funds? 9. What provision has been made for maintenance of equipment? 10. How is it proposed to dispose of obsolete, non-functioning equipment? Is there a clear understanding between the grantee and the affiliate concerning the final disposition of equipment at the close of a project?, 11. Review contracts'which have been made by the alP. How was it determined to accomplish the task by contract rather than with staff? In what man- ner does the staff supervise the contract? What reports are required from the contractors? 12. Does work done by a contractor include an evaluation of his performance C, LEGAL RESPONSIBILITY 1. Is there a written document between the grantee and all affiliates regarding overall legal responsibilities for the operation of RHP projects? 2. Does the Affiliation of Agreement contain a clause which holds the affiliate responsible in the event of an audit disallowance? 3. Is the RHP named in malpractice and liability insurance coverage of the affiliate institutions? 44 Do the Articles of Incorporation governing the operation of the RNP and the Affiliation Agreement have the approbation of an attorney? 5. What personal liability coverage is available to protect employees and volunteers injured while engaged in RNP activities 6. Does the RW have the on-going services of an attorney?