Standards for Certification

Self-Evaluation Form

- Step 1 of 4

I. Mission and Program

The organization’s mission addresses a documented healthcare service need, is formally and specifically stated, and is approved by the Board.

A-1. Board approved mission statement exists.

Met
Not Met

Attach copy of Mission Statement with date of Board approval printed on it. If Board approval date not included on Mission Statement, attach copy of board meeting minutes, verifying board approval of Mission Statement OR submit statement from Board Chair confirming compliance of board approval.

A-2. Board approved mission statement reviewed annually by Board.

Met
Not Met

Attach copy of board meeting minutes verifying annual board review OR submit statement from Board Char confirming compliance to this indicator

A-2-a. Organizational strategic plan specifically links program to mission statement.

Met
Not Met

Attach copy and highlight section of strategic plan verifying compliance to this indicator

The organization identifies goals that are consistent with its mission.

B-1. Board approved goal statements.

Met
Not Met

Attach copy of goals with Board approval date printed on it. If Board approval dates are not included on Goal Statement attach copy of board meeting minutes verifying board approval of goals OR statement from Board Chair confirming compliance of board approval.

B-2. Board reviews goals annually.

Met
Not Met

Attach copy of board meeting minutes verifying annual board review OR statement from Board Chair confirming compliance to this indicator

B-2-a. Organizational strategic plan specifically articulates goals.

Met
Not Met

Attach copy and highlight section of strategic plan verifying compliance to this indicator

Programs and client services address organization’s goals.

C-1. The organization’s programs and goals are described on Form A.

Attached
Not Attached

C-1-a. Strategies for meeting selected goals are identified.

Met
Not Met

Complete as applicable, if Strategic Plan is being submitted and goals are listed may not need to complete.

Attach copy and highlight section of strategic plan verifying compliance to this indicator

C-2. A timeline and responsibility designations are clearly identified in the strategic plan

Met
Not Met

Attach copy and highlight section of strategic plan verifying compliance to this indicator

The organization serves a documented need/ population and its programs do not inappropriately duplicate other community programs serving the same need and/or population.

D-1. The organization is duplicating another organization’s program that may serve the same need and population.

If yes, Form B is completed and attached.

II. Legal

The organization is aware of and complies with all applicable federal, state and local laws.

A-1. Copy of by-laws and board approval.

Met
Not Met

Attach copy of by-laws with board approval. If by-laws do not state date of board approval attach board meeting minutes validating board approval OR statement form board chair.

B-1. Copy of Articles of Incorporation.

Met
Not Met

Attach copy of Articles of Incorporation letter

C-1. Copy of Letter of Registration from South Carolina Secretary of State.

Met
Not Met

Attach copy of Approval from Dept. of The Secretary of State, contains state seal.

D-1. Receipt of Federal ID Number.

Met
Not Met

Attach copy of IRS letter issuing Federal ID see E below.

E-1. Copy of federal tax exemption letter 501©(3).

Met
Not Met

Attach copy of IRS tax exempt letter (since federal ID # is placed on this letter, may use this letter to validate D also)

F-1. Copy of IRS 990 Form or equivalent, as required.

Met
Not Met

Attach copy of most recent Form 990 – Return of Organization Exempt From Income Tax

G-1. Copy of SC Board of Pharmacy permit or permits.

Met
Not Met
N/A

Attach copy of SC BOP permit/s.

H-1. The organization withholds payroll taxes in an appropriate manner and pays in accordance with federal and state regulations.

Met
Not Met
N/A

Attach copy of current Federal Form W3

I-1. The organization files 1099 formsfor contract employees.

Met
Not Met
N/A

Attach copies of 1099 forms

III.Governance

An elected, volunteer board of directors governs the organization.

A-1. The organization’s by-laws set term limits with staggered terms.

Met
Not Met

Attach copy of supporting documentation addressing this circumstance if applicable.

B-1. The organization’s board conductsin-person, face-to-face meetings, at least quarterly with a quorum present in accordance with the by-laws.

Met
Not Met

Attach copy of meeting minutes &/OR organization’s By-Laws with highlight section identifying compliance to this indicator.

C-1. The organization maintains written meeting minutes reflecting actions of board, including any reports and are maintained permanently.

Met
Not Met

Attach copy of most current Board meeting minutes with related Agenda and Reports.

D-1. The organization has a written policy promoting diversity within the board and staff.

Met
Not Met

Attach copy of organization’s policy which verifies compliance to this indicator, such as EEO policy.

D-2. The organization’s board andstaff reflect the diversity of the local community.

Met
Not Met

Attach a statement that indicates the percentage of gender, ethnicity, and age representation on your board.

IV. Financial

A nonprofit’s financial system assures that accurate financial records are kept and that the organization’s financial resources are used solely in furtherance of the organization’s charitable purposes. Organization conducts periodic reviews to address regulatory, risk management and liability concerns.

A-1. Internal financial statements, prepared at least quarterly, are provided to the board of directors and identify and explain any material variation between actual and budgeted revenues and expenses.

Met
Not Met

Attach copy of current financial statements reported quarterly, (Bank Reconciliation & Budget YTD VS. Actual YTD Financials) & board meeting minutes verifying compliance to this indicator

A-2. At least one non-staff, board-appointed individual provides financial oversight for the organization.

Met
Not Met

Attach copy of organization’s By-Laws and highlight section identifying compliance to this indicator.

B-1. The financial practices of the organization are in compliance with Standard Accounting Principles on Form C.

Met (Complete Form C)
Not Met

B-1-a. The organization has board approved financial policies that ensure compliance with Standard Accounting Principles on Form C.

Met
Not Met

Attach copy of board approved accounting/financial policies & procedures, may verify board approval by board meeting minutes or board chair statement

C-1. Annual budget approved by Board prior to fiscal year.

Met
Not Met

Attach copy of budget & board meeting minutes verifying compliance to this indicator.

D-1. The organization annually reviews its programs and services and carries appropriate insurance, i.e., vehicle, fire, liability, etc.

Met
Not Met

Attach copy of board meeting minutes verifying compliance of review and copies of current insurance statements for vehicle (as applicable), fire, general liability and other as applicable.

D-2. The organization has a fidelity bond or other insurance coverage for acts of dishonesty of staff and board members with financial duties.

Met
Not Met

Attach copy of current bond or insurance statement verifying compliance to this indicator

E-1. For organizations with annual income (cash basis, excluding in-kind contributions) of $500,000 or greater, an independent accounting firm performs an annual audit. The annual audit is in compliance with generally Accepted Accounting Principles (GAAP) and reviewed by the Board

Met
Not Met
N/A

Attach copy of audit summary letter with copy of board meeting meetings verifying compliance to this Indicator.

E-2. All board members are covered by Director’s and Officer’s Insurance.

Met
Not Met

Attach copy of current insurance statement.

F-1. For organizations with annual income (cash basis, excluding in-kind contributions) at least $100,000 but less than $500,000 financial review by an independent accountant is performed annually.

Met
Not Met
N/A

*Note – Some grantors require annual audit instead of financial review.

Attach copy of accountant’s summary review with board meeting minutes verifying compliance to this indicator.

G-1. The organization makes the IRS 990 Form available upon request.

Met
Not Met

*Note – Some grantors require annual audit instead of financial review.

Attach copy of IRS 990