For-Profit Administration and Financial Management Introduction
Purpose
The for-profit organization ensures accountability through effective administration and management, and sound financial management practices.Introduction
Interpretation
In the context of Employee Assistance Program (CA-EAP) services, the community, as used in these standards, is defined more specifically as the host or customer organization, subcontracting organizations, and the covered individuals eligible to receive services from the EAP. It can also be defined by the customer organizations’ workplace demographics.Note:The great majority of for-profit organizations providing human services are owned by a single individual or a small group of individuals. In many of these organizations, the owner, or one of the owners, assumes the role of chief executive officer. However, even when the owner or owners assume no administrative responsibilities at all, and hire a chief executive to be responsible for all administrative and management functions, they must be available to be interviewed by Review Team during the Site Visit.
Note: COA’s Administration and Financial Management (CA-AFM) standards apply to for-profit organizations only. COA's Financial Management (CA-FIN) and Governance (CA-GOV) standards are not applicable to organizations that are assigned the CA-AFM standards.
Note: Please see the CA-AFM Reference List for the research that informed the development of these standards.
Note: For information made about changes in the 2020 Edition, please see the CA-AFM crosswalk. See also the ETH crosswalk for Ethical Practice standards that are now found in CA-AFM.
For-Profit Administration and Financial Management (CA-AFM) 1: Purpose
- delineates the scope of services provided;
- is responsive to the needs and aspirations of the community; and
- serves as a benchmark of organizational effectiveness.
- The purpose or mission statement is in effect and useful in guiding the organization, but it needs updating and is currently under review.
- The purpose or mission statement is poorly written or outdated and as a result, it has limited use in guiding organizational decisions; or
- Provision of human services are not identified as a major component or focus of the organization.
For-Profit Administration and Financial Management (CA-AFM) 2: Strategic and Annual Planning
Note:Please see the Governance Standards Tool Kit - Strategic Plan Template for additional guidance on this standard.
CA-AFM 2.01
- envisioning and setting the organization’s strategic direction; and
- engaging in inclusive, management-directed, organization-wide long-term planning at least every four years.
- One of the standard's elements is not fully implemented.
- Long-term planning has not been done in more than four years; or
- One element is not addressed at all.
- Long-term planning has not been done for more than five years; or
- The strategic plan is wholly inadequate or nonexistent.
CA-AFM 2.02
The organization’s long-term planning process includes:
- a review of the organization’s purpose or mission, values, mandates, and strategic direction;
- a review of the demographics of its defined service population;
- an assessment of strengths and weaknesses;
- an assessment of equity , diversity, and inclusion strategies;
- measurable goals and objectives that flow from its purpose and mandated responsibilities; and
- appropriate strategies for meeting identified goals, including the need to redirect, eliminate, or expand services to respond to changing community demographics and the needs of persons served.
Practices are basically sound but there is room for improvement; e.g.,
- One of the elements is not fully addressed; or
- The review of service population demographics did not include all populations served or geographic locations; or
- The strategy (element (f)) for meeting one or two of the identified goals needs greater specificity.
Practice requires significant improvement; e.g.,
- One of the elements is not addressed at all; or
- The organization did not review the demographics of its service population; or
- Identified goals and objectives are vague; or
- Most identified goals and objectives are not measurable; or
- Strategies for meeting identified goals are cursory and do not provide a sufficient framework for success; or
- Long-term planning has not been done in more than four years.
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.
- Two of the elements are not addressed at all; or
- Long-term planning has not been done for more than five years; or
- The strategic plan is wholly inadequate or nonexistent.
CA-AFM 2.03
- operationalizes the goals and objectives of the long-term strategic plan;
- reflects organizational responses to changing conditions and needs such as, resource allocation, funding and regulatory changes; and
- responds to information from PQI activities.
- HR planning;
- evaluation of training needs;
- budget planning;
- technology and information management planning; and
- PQI summary reports.
- Departmental priorities and objectives could be better defined; or
- While department and program plans are not integrated into an organization-wide annual plan, all but one or two departments or programs have developed a comprehensive annual plan.
- Management objectives are not included; or
- Several departments or programs are not included in the most recent annual plan or have not done an annual plan; or
- One of the elements is not addressed at all.
- Two of the elements are not addressed at all.
CA-AFM 2.04
The organization develops an equity statement outlining its commitment to equity, diversity, and inclusion (EDI) that is shared with its stakeholders.
Interpretation: The equity statement should reflect the organization’s history, connect EDI to its mission, and outline how the organization demonstrates its commitment to EDI.
The organization's practices reflect full implementation of the standard.
Practices are basically sound but there is room for improvement; e.g.,
- The organization has an equity statement, but it has not been shared with its stakeholders.
Practice requires significant improvement; e.g.,
- The organization has begun the process of developing an equity statement, but the process is not yet complete.
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
- The organization does not have an equity statement and little to no work has begun to create one.
For-Profit Administration and Financial Management (CA-AFM) 3: Community Involvement and Advocacy
- informs the public of its purpose;
- remains informed about community needs and strengths; and
- advocates for comprehensive and coordinated service delivery within its community.
CA-AFM 3.01
- While social media or the website provides accurate information, some written materials that continue to be distributed are outdated; or
- Some segments of the general public do not have access to accurate and timely information.
- Generally, public information is not current; or
- Some important information is not available to the public.
CA-AFM 3.02
- communicate its purpose, role, functions, capacities, and scope of services;
- provide information about the strengths, needs, and challenges of the individuals, families, and groups it serves; and
- build community support and presence and maintain effective partnerships.
- regular communication with the media and the general public;
- informing the public of the positive impact agency programs are having on the community and its residents; and
- fostering positive relationships with the local media.
- One of the elements is not fully addressed; or
- The organization has an ongoing program of community education, but it does not cover some of its programs or services.
- Efforts are informal and infrequent; or
- Efforts only address some of the organizations programs or services, or populations served; or
- Element (a) or (b) is not addressed at all.
CA-AFM 3.03
- improvements to existing services;
- filling gaps in service to offer a full array of community supports;
- the full and appropriate implementation of applicable laws and regulations regarding issues concerning the service population;
- improved support and accommodations for people with special needs;
- improved access to needed services for underserved populations and marginalized communities;
- solutions to community-specific needs including racial equity and cultural and linguistic diversity;
- service coordination; and
- a coordinated community response to public health emergencies.
- One of the elements is not addressed at all.
- Two of the elements are not addressed at all.
- Little or no effort is made to collaborate with community members or persons served as described in the standard.
CA-AFM 3.04
- includes representatives of relevant community groups, consumers, service providers, advocates, and others with an interest in the success of the organization achieving its purpose; and
- provides information and feedback to the organization about services, outcomes, the perception of the organization within the community, and other information that would help the organization better serve its defined population and the community.
- establish clear and transparent recruitment and selection guidelines;
- have reasonable expectations about what the group can accomplish within the parameters of its purpose and available resources; and
- actively consider and respond to the group's input, feedback, or recommendations.
- The group is not utilized to the extent that it could be; or
- Advisory group members report a need for better communication or lack of clear objectives or timeframes.
- Advisory group members report being confused about the purpose of the group and/or about their roles and functions; or
- Insufficient community representation results in limited effectiveness; or
- Group members do not know whether or not their feedback or recommendations are being used or considered.
For-Profit Administration and Financial Management (CA-AFM) 4: Administrative Oversight
CA-AFM 4.01
- establishes policies; and
- reviews policies periodically and when legal requirements or regulations change.
- One of the elements could be strengthened in some minor way.
- A systematic review of policies has not been conducted for more than four years.
CA-AFM 4.02
- establishing targets and goals; and
- ensuring adequate resources to support the organization’s services.
- One of the elements has not been fully addressed.
- One of the elements has not been addressed at all.
CA-AFM 4.03
Interpretation: Organization staff may be responsible for assessing different areas of risk throughout the year and sending the results of the assessments to the owner or designee to inform the annual review of overall risks.
- compliance with legal requirements;
- disruption of operations due to a public health emergency;
- technology and information management;
- insurance and liability;
- health and safety of administrative and service environments;
- human resources practices, including use of independent contractors and volunteers;
- contracting practices and compliance;
- client rights and confidentiality issues;
- financial risks;
- public relations, branding, and reputation; and
- conflicts of interest.
- fraud and misuse of funds;
- investments;
- tax liabilities;
- physical assets and financial information;
- fundraising practices;
- funding of benefits, including health retirement benefits, pensions, etc.; and
- deferred revenue.
Practices are basically sound but there is room for improvement; e.g.,
- While the owner or designee assesses risk annually, risk related to different aspects of the organization are reviewed by the owner or designee at different times of year, inhibiting their capacity to comprehensively assess overall risk.
For-Profit Administration and Financial Management (CA-AFM) 5: Conflict of Interest
- Conflict of interest policy provides minimal guidance to stakeholders due to lack of specificity, significant missing elements, or significant stakeholders not covered; or
- Minor conflict of interest concerns are noted.
- Significant conflict of interest concerns have been reported.
CA-AFM 5.01
- defines conflict of interest;
- identifies groups of individuals within the organization covered by the policy;
- addresses policy enforcement;
- provides a framework for evaluating situations that may constitute a conflict; and
- invests management with developing procedures that facilitate disclosure of information to prevent and manage potential and apparent conflicts of interest.
- One of standard's elements is not fully addressed.
- The policy provides minimal guidance to stakeholders due to lack of specificity; or
- Stakeholders are unaware of the policy; or
- Two of the elements are not fully addressed; or
- One of the elements is not addressed at all.
- No policy exists; or
- The policy is not enforced or is ignored in practice.
CA-AFM 5.02
- disclose this information; and
- not participate in any discussion or vote taken with respect to such interests.
- The policy related to one of the standard’s elements needs clarifying.
- Applicable stakeholders are not identified; or
- The types of transactions that must be disclosed are not delineated; or
- Safeguards regarding disclosure or recusal are insufficient; or
- Important stakeholders are not aware of the policy.
- Conflict of interest violations have occurred.
CA-AFM 5.03
- Some aspect of the policy requires clarification.
- Staff report that there have been instances of nepotism or preferential treatment; or
- The organization chart indicates that at least one person is directly supervised by a relative.
CA-AFM 5.04
- making or accepting payment or other consideration in exchange for referrals;
- preferential treatment of organization members, community partners, members of the organization's governing body, advisory groups, personnel, or consultants applying for and receiving the organization’s services; and
- steering or directing referrals to private practices in which personnel, consultants, or the immediate families of personnel and consultants are engaged.
- Some aspects of the policy are vaguely written, but there have been no ethical violations of the principles outlined in the standard.
- Significant aspects of the policy are vaguely written or confusing; or
- The policy does not address at least one of the standards elements; or
- The policy exists but enforcement is lax and there have been a few instances where it has been violated; or
- The policy is generally understood but it is an unwritten expectation.
- No policy exists; or
- The policy is not enforced or is ignored in practice.
For-Profit Administration and Financial Management (CA-AFM) 6: Protection of Reporters of Suspected Misconduct
- The definition of what constitutes a reportable violation lacks specificity.
- There is a perception among staff that procedures do not adequately protect anonymity; or
- Procedures are not readily available or staff and board members are not aware they exist; or
- Procedures do not adequately protect against retaliation.
- Staff report feeling afraid or intimidated.
For-Profit Administration and Financial Management (CA-AFM) 7: Internal Control Environment
- conducting ongoing monitoring of the effectiveness of internal control policies and procedures;
- management review by more than one individual;
- assuring that management directives are carried out;
- prevention of error, mismanagement, or fraud;
- safeguarding and verification of assets; and
- segregation of duties to the extent possible.
- One of the elements are not fully addressed.
- Two elements are not fully addressed; or
- One element is not addressed at all.
- Fraudulent practices or serious financial mismanagement have occurred, and problems have not been remediated; or
- Three or more elements are not fully addressed; or
- Two elements are not addressed at all.
For-Profit Administration and Financial Management (CA-AFM) 8: Revenue and Investments
CA-AFM 8.01
- The organization makes active efforts to diversify or strengthen resources but still relies primarily on one or two major funding sources.
- Minimal efforts have been made to expand, diversify or strengthen the organization’s resource base.
- The organization has no “fallback” position and has made little or no effort to protect itself from the consequences of dependence on a single source of revenue.
CA-AFM 8.02
- outline acceptable levels of risk;
- include criteria for making short- and long-term investments, maintaining cash reserves, etc.;
- address the management, purchase, or sale of real estate, securities, and other assets; and
- ensure practices conform to applicable legal and regulatory requirements.
- Investment procedures were last reviewed and/or updated between two and three years ago.
- The investment procedures have not been reviewed or updated within the last three years.
- There are no investment procedures.
For-Profit Administration and Financial Management (CA-AFM) 9: Financial Planning
Currently viewing: FINANCIAL PLANNING
VIEW THE STANDARDS
CA-AFM 9.01
- the organization's mission and strategic priorities;
- performance improvement and outcomes data;
- direct and indirect operating expenditures;
- contractual requirements;
- changing costs and conditions; and
- anticipated revenue for the program year.
- The process could be made more comprehensive or changing conditions could be better addressed.
- The budget planning process is not comprehensive or formalized in one of the standard's elements.
CA-AFM 9.02
- a monthly and annual analysis of financial performance against budget projection with budget-to-actual variance analyses performed on interim financial statements of activities;
- cash reserves in alignment with an operating reserves policy;
- service revenues and actual service delivery costs; and
- an annual inventory of significant assets, including securities.
- The organization routinely analyzes financial information but is not always stringent about comparing it with data about actual service delivery costs; or
- Financial analyses are conducted quarterly and annually.
- Analysis of financial performance is not performed at least quarterly; or
- Analysis of financial performance is not done annually; or
- The organization does not analyze service revenue information and service delivery costs.
- The organization makes no attempt to either keep adequate service revenue information or to analyze it.
For-Profit Administration and Financial Management (CA-AFM) 10: Financial Accountability
CA-AFM 10.01
An audit provides the highest level of assurance on an organization's financial statements. An audit provides assurance that an organization's financial statements are free of material misstatement and are fairly presented based upon the application of generally accepted accounting principles. An audit includes:
- confirmation with outside parties;
- testing selected transactions by examining supporting documents;
- completing physical inspections and observations; and
- considering and evaluating the internal control system of the organization.
A compilation provides no assurance on an organization's financial statements and does not meet the requirements of the standard.
Organizations seeking reaccreditation have completed audits or reviews of financial statements for each intervening year since their last accreditation.
- The organization undergoing accreditation completed an audit or review of financial statements for the most recent auditable fiscal year; however, it did not conduct an audit for any or all of the intervening years since their last accreditation; or
- The organization undergoing accreditation for the first time completed an audit or review of financial statements in the most recent auditable year; or
- The organization completed the audit or review; however, it was not conducted within eight months of the end of the fiscal year, but the organization implemented procedures to ensure timely completion for future audits.
- The audit or review for the most recent auditable year is scheduled but has not been completed; or
- The most recent audit or review was completed more than eight months after the end of the fiscal year, and no plan is in place to ensure timely completion of future audits.
- An audit or review for the most recent auditable year has not been completed nor has one been scheduled.
CA-AFM 10.02
For-Profit Administration and Financial Management (CA-AFM) 11: Financial Management
CA-AFM 11.01
- timely reconciliation of bank statements and subsidiary records to the general ledger;
- up-to-date posting of cash receipts and disbursements;
- monthly updating of the general ledger; and
- review of the bank reconciliation by a person other than the person who performs the reconciliation and who is not authorized to sign checks.
- The organization has an occasional, minor problem in compliance such as short delays in posting receipts and disbursements or slightly overdue updates to the general ledger.
- Bank reconciliation is not regularly reviewed by two people as required.
CA-AFM 11.02
CA-AFM 11.03
- a financial officer or business manager to maintain the financial accounts who has prior accounting and bookkeeping experience, or an accounting degree, C.P.A. credential, or other recognized accounting/financial certification, as appropriate to the size and complexity of the organization; and
- all personnel who use the system to receive initial and ongoing training on its use.
- Ongoing staff training needs strengthening.
- The organization has a qualified financial officer, but the system is deficient in some significant regard, such as lack of training for some personnel.
CA-AFM 11.04
An organization that assumes fiduciary responsibility for, or disburses client funds:
- segregates client funds from other organization funds; and
- protects client assets.
Interpretation: Fiduciary responsibility refers to an individual’s or organization’s responsibility to act in good faith on behalf of another person. The fiduciary is legally or ethically trusted to make decisions in the best interest of the person and may not use their role to benefit themselves. Examples of fiduciary relationships include those of a guardian and ward or representative payee and beneficiary.
NA The organization does not assume fiduciary responsibility for, or disburse client or non-fee-for-service funds to service recipients.
Examples: Examples of the types of funds that organizations may assume responsibility for or disburse to clients include:
- allowances for children and youth in out-of-home care;
- funds under the control of the organization in guardianship cases; and
- benefits when the organization serves as the representative payee.
- Procedures for segregation of funds or protection of client assets need strengthening.
- One of the elements is not addressed at all.
- The organization has no written procedures, and adequate protection and guidelines have not been developed to protect assets of persons served; or
- There have been instances in which funds for which the organization had a fiduciary responsibility appear to have been misused, e.g., assets or funds have been inappropriately co-mingled or disbursed inconsistently.
For-Profit Administration and Financial Management (CA-AFM) 12: Fundraising
- Staff are unaware of the organization's fundraising policies and/or procedures; or
- Fundraising practices may pose a risk to the organization.
CA-AFM 12.01
- accurately describes the purpose for which solicitations are being made;
- spends funds for the purposes they were solicited, with the exception of reasonable costs for administration of the fundraising program;
- maintains accounting segregation for restricted funds; and
- respects donor confidentiality requests, and ensures that such donors’ names are not published in publicly available documents.
- One of the elements is not fully addressed, but the organization has taken steps to strengthen practice; or
- The organization has a system of controls that may need strengthening; however, contributions are appropriately recorded and acknowledged.
- There have been some violations of donor requests for confidentiality; or
- One of the elements is not addressed at all.
- Unethical or deceptive practices regarding costs in relation to funds raised exist; or
- The organization does not accurately describe the uses of the funds; or
- Two or more of the standards' elements have not been addressed.
CA-AFM 12.02
- Some fundraising costs are not sufficiently reviewed for full analysis.
- The organization does not routinely analyze the costs and benefits of its separate fund-raising activities.