SPTHB Finance Handbook by Southern Plains Tribal Health Board

FINANCE HANDBOOK FINANCIAL POLICIES AND CONTROLS REVISED AND ADOPTED APRIL 30, 2021

CONTENTS Section 1 - Introduction ��1 Section 2 - Cash and Investments �� 2-4 2.1 Classification of Cash Accounts �� 2 2.2 Types of Cash Accounts �� 2 2.3 Segregation of Duties Over Cash �� 2 2.4 Signature Authority �� 3 2.5 Investments �� 3 2.6 Banking Relationships �� 3 2.7 Federal Deposit Insurance Corporation Coverage (FDIC) �� 4 2.8 Bank Reconciliation �� 4 2.9 Deposits �� 4 2.10 Money at Events �� 4 Section 3 - Accounts Receivable and Revenue Rocognition ��5 3.1 Invoicing �� 5 3.2 Revenue Recognition �� 5 3.3 Indirect Cost �� 5 3.4 Draw Downs �� 5 3.5 In-Kind Contributions �� 5 Section 4 - Other Assets ��6 4.1 Fixed Assets �� 6 4.2 Fixed Asset Depreciation �� 6 4.3 Fixed Asset Disposition �� 6 4.4 Prepaid Assets �� 6 Section 5 - Purchasing and Payables �� 7-9 5.1 Approval Limits �� 7 5.2 Purchases �� 7 5.3 Open Competition �� 7 5.4 Finance Request �� 7 5.5 Accounts Payable �� 8 5.6 Contracts �� 8 5.7 Employee Paid Expenses �� 8 5.8 Indian Preference �� 8 5.9 Credit Cards �� 9 5.10 PEX Cards (Prepaid Expense Cards) �� 9 5.11 Tax Reporting and Compliance �� 9

CONTENTS (CONT’D) Section 6 - Other Liabilities �� 10 6.1 Accruals �� 10 6.2 Reserves for Grant Repayments �� 10 Section 7 - Travel and Expense Reimbursement �� 10-12 7.1 Employee Travel �� 10 7.2 Travel Authorizations and Advances �� 10 7.3 Travel Claims �� 11 7.4 Mileage �� 11 7.5 Non-Employee Travel �� 11 7.6 Combined Travel �� 12 7.7 Rewards Programs �� 12 Section 8 - Financial Reporting �� 12-13 8.1 Fiscal Year �� 12 8.2 Management Review �� 12 8.3 Reporting Frequency �� 12 8.4 Journal Entries �� 13 8.5 Balance Sheet Reconciliations �� 13 8.6 Financial Audit �� 13 Section 9 - Payroll and Related Liabilities �� 14 9.1 Payroll Processing �� 14 9.2 Payroll Liabilities �� 14 9.3 Payroll Reporting �� 14 9.4 PTO Payout �� 14 Section 10 - Budgeting �� 15 10.1 Non-Programmatic �� 15 10.2 Programmatic �� 15 10.3 Allowable Costs �� 15 Section 11 - Reserves �� 16-17 11.1 Operating Reserves Fund �� 16 11.2 Opportunity Reserves Fund �� 17 Section 12 - Document Retention and Destruction �� 18 Section 13 - Whistleblower Policy �� 19-20 Section 14 - Financial Conflict of Interest �� 21

SECTION 1 INTRODUCTION The Southern Plains Tribal Health Board (SPTHB) is a non-profit entity organized in the State of Oklahoma. SPTHB is a tax-exempt organization under section 501(c)(3) of the Internal Revenue Code. It is the overarching policy of the SPTHB that all activities shall be conducted in such a manner as to preserve the tax-exempt status of the organization.

situations arise during the normal course of business operations that require special consideration. All personnel must administer the fundamental policies included herein. Exceptions may include, but are not limited to unusual, unique business conditions that occur during the normal course of operations.

This document represents company-wide financial policies, which have previously been in effect but were not formally documented. This policy manual is effective January 1, 2019 and supersedes any previously documented policies and/or manuals.

All employees have a responsibility to utilize the organization’s assets in the most efficient manner possible and to guard against loss of the organization’s assets whether due to error or fraud. The internal controls described within this manual are designed to help safeguard the organization’s assets against loss and to promote operational efficiency. It is important that all employees adhere to these internal controls to maintain the highest level of fiscal integrity and accountability.

It is the intent of this document to express the SPTHB financial policies and controls and to ensure that they are applied consistently throughout the organization. Inherent within this policy is compliance with Generally Accepted Accounting Principles (GAAP) in accordance with the Statement of Financial Accounting Standards (SFAS) for Not-for-Profit Organizations. Management, including but not limited to the Board of Directors (the Board), will have the responsibility for interpretation of these policies. All questions regarding financial policy should be directed to Management.

This manual includes a Whistleblower Policy that provides a mechanism for any employee to report unlawful, unethical and/or improper conduct. The Board and Management are committed to providing protection and freedom from retaliation to any employee who makes a report under this policy.

Although it is the intent of this document to establish company-wide, standard financial policies, it is also recognized that certain

SECTION 2 CASH AND INVESTMENTS 2.1 Classification of Cash Accounts Three classifications of cash accounts are used to appropriately segregate SPTHB funding. · Unrestricted – Funds available for use for any legitimate reason identified by Management and not specifically restricted as to their use. · Restricted – Funds that are set aside for specific purposes as directed by the funding source. These funds may only be used for activities specifically related to the purpose for which the funding is provided. · Reserved – Unrestricted funds set aside for specific purposes, as designated by the Board.

2.2 Types of Cash Accounts Four types of cash accounts are authorized to maintain SPTHB funds. · Operating – The primary bank account holding unrestricted funds from which accounts payable and payroll payments are issued and into which regular deposits are made. The account is a standard checking account. · Money Market/Savings – The bank account(s) holding Restricted or Reserved funds. The account will generate interest.

· Draw Down – The bank account into which electronic payments from funding agencies are received. This account is designed to be a clearing account that maintains a zero balance. Once funds are received, they are transferred to the Operating account as soon as practical. · Investments – The Board may, at its discretion, choose to invest funds in financial instruments other than standard checking, savings or money market accounts.

2.3 Segregation of Duties Over Cash Proper segregation of duties over cash shall always be maintained. The Finance Department is responsible for recording cash receipts and issuing cash disbursements. Therefore, no member of the Finance Department shall have signature authority on any cash account maintained by the organization. Additionally, the Finance Director will not be issued an SPTHB credit card. Management will review check registers, bank reconciliations and other documents that reflect cash receipts and disbursements. This review will be signified by the signature or initials of the reviewer along with the date of the review. The Finance Department will prepare monthly bank reconciliations within five business days of the end of the month for review by Management.

2.4 Signature Authority Two signatures are required on all checks issued from the accounting system. Authorized signers are the Executive Director, the Board Chair, the Board Treasurer, the Tribal Epidemiology Center Director, and other signers that may be appointed by the Board from time-to-time. The Finance Director is responsible for ensuring that two authorized signatures are obtained on all checks issued from the accounting system. The use of signature stamps for signing checks may be authorized by the Board Chair and/ or the Treasurer. A signature stamp may only be used for one of the two signatures required on each check. One signature must be an original signature. Any authorized signature stamps will be held by the Office Manager. The Office Manager will only use a signature stamp to sign checks when provided with email authorization from the authorized signer whose signature stamp is being used. A copy of the email authorizing use of the signature stamp will be attached to the associated check register and maintained in the accounting files. The use of signature stamps should be used as infrequently as possible.

2.5 Investments It is the responsibility of the Board to exercise judgment, care and discretion in the management of SPTHB funds while being mindful of the balance of potential income versus the potential risk to SPTHB’s financial well-being. The Board will direct the Executive Director and Finance Director to manage the investments of the SPTHB within the guidelines outlined in this section. The over-arching goals for any investments maintained by SPTHB include

· capital preservation, · balancing optimal return with acceptable risk, · maintaining liquidity, and · maintaining FDIC insurance.

The type of investments authorized under this policy include: · Interest Bearing Checking Accounts · Money Market Funds · Interest Bearing Saving Accounts · Certificates of Deposit at insured commercial banking organizations · Direct obligations of the U.S. Government, its agencies and instrumentalities

In general, the maturities on investments shall be 12 months or less. The Board may, from time to time, elect to direct the acquisition of investments for a longer term. It is anticipated that investments with maturities more than 12 months will be rare. Investments will be reviewed on an annual basis.

2.6 Banking Relationships Banking relationships will be reviewed no less than annually by the Finance Director to ensure competitive interest rates are being received and to determine if alternate banking products have become more suitable. The results of any review of banking relationships will be provided to the Executive Committee of the Board along with a recommended course of action. The Executive Committee will review the recommendation and forward their recommendation to the full Board for approval. The Finance Director will execute any Board decisions regarding banking relationships.

SECTION 2 CASH AND INVESTMENTS (CONT’D) 2.7 Federal Deposit Insurance Corporation Coverage (FDIC)

2.9 Deposits

The Finance Director will monitor bank balances on a continual basis to ensure FDIC coverage is maintained. If new bank accounts are needed to maintain FDIC coverage, the Finance Director will research potential institutions and provide the recommendations to the Executive Committee. The Executive Committee will select from the options given and make a recommendation to the full Board for approval. The Finance Director will take the necessary steps to open new bank accounts and to move funding as directed by the Board.

Any checks or cash received will be deposited daily. Checks will be deposited into the Operating account via remote deposit capture or traditional bank deposit. Deposit proof from the bank, such as deposit slip or remote deposit confirmation, will be maintained in the accounting files. Any documentation accompanying the check will be maintained in the files. Checks deposited by remote deposit capture will be attached to the other deposit support and maintained in the files for 90 days. After 90 days, the original checks that have been remotely deposited will be destroyed.

2.8 Bank Reconciliation

2.10 Money at Events

Bank reconciliations will be performed each month within 5 business days of month end. Bank statements will be printed from online banking applications for reconciliation purposes. Completed bank reconciliations will be provided to Management for review and approval. Review and approval will be signified by signature or initials and the date reviewed.

SPTHB periodically hold events at which various payments are accepted in the form of cash, check and credit card. Cash and checks received at events will be counted and a deposit ticket prepared for each day of the event. Cash and checks will be counted by a Finance Department staff member and confirmed by a non-finance staff member. Both staff members will initial the deposit ticket. If it is not possible to make the deposit on the same day, such as when events are held outside of Oklahoma City, the on-site Finance Department staff member is responsible for maintaining control over the deposit.

SECTION 3 ACCOUNTS RECEIVABLE AND REVENUE RECOGNITION

3.1 Invoicing

Invoicing for grants and contracts will be prepared at the frequency and per the terms of the grant or contract. Invoices will be entered and tracked through the accounting system. Supporting documentation for any expenditures charged to a grant or contract will be maintained in the finance files along with a copy of the invoice. A Finance Department staff member will record payments on invoices when they are received and ensure that the funds are deposited in the appropriate bank account.

3.2 Revenue Recognition Revenue will be recognized based on the terms of each grant or agreement and the appropriate GAAP revenue recognition principle.

3.3 Indirect Cost The Indirect cost rate will be negotiated with the National Business Center on an as needed basis. Indirect cost rate proposals will be prepared by the Finance Department based on the most recent audited financial statements. The Modified Total Direct Cost methodology will be used for preparation of the indirect cost proposal. Indirect cost rate proposals will be approved by the Board before being submitted. The Finance Director and the Executive Director will have the authority to negotiate the indirect cost rate with the National Business Center. The Executive Director will be authorized to sign the final indirect cost rate agreement. The

indirect cost rate will be applied to all grants and included on invoices, unless disallowed by funding agency.

3.4 Draw Downs This section applies to all federal grants that use the Payment Management System (PMS) as the method to provide funding to grantees. Drawdowns will be requested on a weekly basis and will include calculated indirect costs each time. The Finance Department is responsible for requesting drawdowns via the Payment Management System. Drawdowns are electronically deposited into the Draw Down account. The Finance Department will verify receipt of drawdowns and record them in the accounting system. Draw downs will be transferred to the Operating cash account as soon as practical.

3.5 In-Kind Contributions In-Kind contributions may be in the form of goods or services, which would have to be purchased if not donated. The Finance Department is responsible for maintaining records and documenting in-kind contributions. In-Kind contributions will be valued at what it would have cost SPTHB had they been purchased. Donated goods will be recorded in revenue and expense as they are used. Donations that are given for donor specified purpose will be tracked separately to ensure that the donation is used as intended by the donor.

SECTION 4 OTHER ASSETS 4.1 Fixed Assets

4.3 Fixed Asset Disposition

Fixed assets are defined as any piece of furniture or equipment valued at fivethousand dollars ($5,000.00) or more and having an expected useful like of one year or greater. All purchases that are classified as fixed assets will be recorded in a fixed asset ledger. A periodic inventory of fixed assets will be performed using the fixed asset ledger as a guide. Assets are the property of SPTHB.

To remove an asset from the Fixed Asset Ledger and the accounting records, an Asset Disposition Form should be completed. The form should include a complete description of the asset, an explanation of the reason for disposition, and a description of the suggested method of disposition (if applicable). Asset dispositions must be approved by the Executive Director. Approved Asset Disposition forms will be submitted to the Finance Director so that the asset and associated depreciation can be removed from the accounting system and the Fixed Asset Ledger. Asset Disposition Forms will be maintained in the Finance records.

Assets will be classified in the following categories with the useful life indicated below. · Furniture and Fixtures – 10 years · Computer Equipment – 5 years · Electronic Equipment (non-computer) – 7 years

4.2 Fixed Asset Depreciation

4.4 Prepaid Assets

Depreciation will be calculated on an annual basis using the straight-line depreciation method and will be classified as a non-grant expense.

Any items, such as insurance premiums, that are paid in advance and cover a future period will be classified as Prepaid Assets and amortized over the appropriate period.

SECTION 5 PURCHASING AND PAYABLES 5.1 Approval Limits The following approval limits apply to purchases based on source of funding. The limits apply to the total cost of a purchase. Purchases shall not be split in order to circumvent these limits. Whenever possible, purchases should be combined to reduce administrative burden, reduce shipping costs and/or obtain volume purchasing discounts.

PURCHASES WITH GRANT FUNDS

PURCHASES WITH UNRESTRICTED FUNDS

Up to $500 - Supervisor/Grant Lead

Up to $500 - Supervisor

$501 to $10,000 - TEC Director/Deputy Director

$501 to $10,000 – Executive Director

$10,000 to $50,000 - Executive Director

Over $10,000 - Board Approval

Over $50,000 - Board Approval

Over $10,000 - Board Approval

5.2 Purchases All purchases must follow the approval requirements and processes outlined in this section. Purchases will be made by a Finance Department member based on approved documents. In rare instances, a non-finance staff member will be authorized to make purchases, but the same approvals requirements and processes still apply.

5.3 Open Competition Goods or services costing more than five-thousand dollars ($5,000.00) each require three bids. The supporting documents demonstrating that three bids have been obtained will be maintained in the Finance files. A sole source purchase may be authorized for subject matter experts, licensed professionals, or when it is impossible or extremely impractical to obtain three bids. The reason that the purchase was made as a sole source must be thoroughly documented, and the documentation must be kept in the Finance files.

5.4 Finance Request A Finance Request Form will be prepared to support vendor invoices by providing the proper coding and approvals for the associated purchase. The form will include a description of the expense, signature of the requestor, required approval signatures and an indication of the program and account to which the invoice is being charged. Account coding will be based on approved budgets. The vendor invoice will be attached to the Finance Request Form, and the completed packet will be submitted to the Finance Department for processing.

SECTION 5 PURCHASING AND PAYABLES (CONT’D) 5.5 Accounts Payable

5.7 Employee Paid Expenses

Invoices are coded to the correct program and account by the Finance Department based on the Finance Request Form, purchase order, contract or another relevant document. Properly approved and coded invoices are entered into the Accounts Payable module of the accounting system by the Finance Department. Checks or Electronic Funds Transfers (EFT) in payment of Accounts Payable will be processed on a weekly basis. A listing of the payment items will be in the weekly Accounts Payable report and will be provided to Management for approval prior to the payments being released. The Finance Department will ensure that two signatures are obtained on each check; that checks are mailed in a timely manner; and that the backup documentation is maintained in the Accounts Payable files.

Employees may from time to time incur non-travel related, SPTHB expenses that require reimbursement. Examples include membership dues, education or reference materials and supplies. Employees may request reimbursement by completing a Finance Request Form detailing the business purpose of the expense and attaching an original receipt. The requirements for completion of a Finance Request Form outlined in Section 4 apply.

5.6 Contracts The Finance Office Director will review all contracts and other legal documents prior to any action on them. As needed, the Finance Director will negotiate changes, route the agreement for SPTHB signature, and coordinate final execution and distribution unless otherwise determined and documented in writing with the grant lead. A contract must be fully executed before payments can be made to subrecipients or vendors. A copy of the fully executed contract will be maintained in the Finance Office.

5.8 Indian Preference Notwithstanding any other provision to the contrary, and in furtherance of the Indian Self- determination and Educational Assistance Act, the SPTHB shall make all reasonable efforts to utilize Indian-Owned organizations and economic enterprises. Indian Owned organizations and economic enterprises can be up to 5% higher in price than other competitive bidders and still be chosen as the low-cost bidder.

SECTION 5 (CONT’D) PURCHASING AND PAYABLES 5.9 Credit Cards SPTHB credit cards will be issued to employees on an as needed basis. Personal use of an SPTHB credit cards constitutes fraud, and the offending employee will be subject to the SPTHB disciplinary policy, up to and including termination. The Executive Director will approve the issuance of credit cards to employees. Employees with credit cards will prepare a monthly report of expenditures with receipts attached within 10 days of receipt of the bill. Credit card reports will be reviewed by the Finance Director and approved by the Executive Director. The Finance Director will not be issued a credit card of any kind.

5.10 PEX Cards (Prepaid Expense Cards) SPTHB PEX Cards will be issued to employees on an as needed basis. The PEX Card may be used for travel expenses following the SPTHB Travel Guidelines. Upon approval, the PEX Card may also be used for small purchases. The PEX Card is funded based on estimated costs listed on the Finance Request Form or the Travel Authorization Form. After use, employees are required to provide proper travel documentation and/or receipts for purchases to the Finance Office within 5 business days. The personal use of a PEX Cards constitutes fraud, and the offending employee will be subject to the SPTHB disciplinary policy, up to and including termination. The Finance Director will not be issued a PEX Card.

5.11 Tax Reporting and Compliance All vendors will be required to provide Form W-9 Request for Taxpayer Identification Number and Certification prior to payments being issued to the vendor. Backup withholding requirements, as specified by the Internal Revenue Service, will be applied. The completed Form W-9 will be maintained in the Finance Department files. Form 1099 – Miscellaneous Income will be prepared and provided to vendors annually based on the Internal Revenue Service requirements in effect at the time.

SECTION 6 OTHER LIABILITIES 6.1 Accruals

7.1 Employee Travel

Accruals are necessary from time to time to record costs or revenue to the appropriate accounting period. Accruals will be prepared at year end to ensure the accuracy of annual financials in preparation for the annual financial audit.

Employees must follow the SPTHB Travel Guidelines based on Federal Uniform Guidance 2 CFR 200.474 in Appendix A.

6.2 Reserves for Grant Repayments

Travel Authorizations should be submitted a minimum of two weeks in advance of travel dates. Meeting/training agenda, GSA per diem page for the travel destination, preferred flight details, hotel reservation information, rental car request and any registration information must be attached to the Travel Authorization. Travel Authorizations must be approved by the employee’s supervisor.

From time to time, reserves for potential grant repayments may be deemed necessary by Management. Specifically, reserves may be necessary for changes in Indirect Cost rates. If a provisional rate is in place that is higher than the final rate, the Finance Department will calculate the difference in rates charged to each grant. For all other grants, the restriction period will be equal to the audit look back period for that grant. Other circumstances may make a reserve necessary. Management will determine when these are necessary along with the applicable restriction period.

7.2 Travel Authorizations and Advances

Travel advances will be issued for overnight travel as approved by the Executive Director and the TEC Director. Employees are permitted to include an overnight stay for any destination that exceeds 75 miles from the office or if special conditions exist. Meals and mileage are the only travel items that will be advanced. Meals will be advanced based on Government Services Administration (GSA) per diem rates for the travel destination. Mileage will be advanced based on destination documentation and current Federal rate.

SECTION 7 PURCHASING AND PAYABLES 7.3 Travel Claims

7.5 Non-Employee Travel

Travel Claims should be submitted within 5 business days of return. Travel Claims are used to clear travel advances and to request reimbursement for out-of-pocket travel expenses. Original receipts must be attached for all listed expenses including but not limited to lodging expenses, mileage documentation, toll receipts, checked baggage fees and transportation receipts. Meals do not need to be substantiated with receipts, as they are covered by the daily GSA per diem rate. Travel claims must be approved by the employee’s supervisor. Any travel reimbursement will be paid to the employee via the weekly Accounts Payable check run. Only expenses related to SPTHB business will be reimbursed. Excluded items include room upgrades, in room movies or pay TV, room service or similar.

Travel reimbursement and/or travel advances will be provided to non-employees under certain circumstances.

7.4 Mileage Mileage should be submitted monthly using the Mileage Form. Documentation supporting the requested mileage must be attached to substantiate miles claimed. Toll receipts or a print out from the Oklahoma Turnpike Authority must be included to substantiate any tolls claimed. If day travel includes the entire work day, the actual cost of lunch or breakfast can be claimed. The original receipt must be included, and the amount cannot exceed the GSA rate for the area. The mileage report should be approved by employee’s supervisor.

· Board members for SPTHB business · Advisory Council members for SPTHB business · Independent Contractors whose contracts specify that travel can be reimbursed by SPTHB. · Participants in SPTHB activities, if specified in the grant or contract, work plan and budget. · Partners working with SPTHB in the execution of programmatic activities, if specified in the grant or contract, work plan and budget.

All authorization and documentation requirements specified in this section will apply to non-employees. Non-employee travel expenses that are charged to a program must be approved by the Grant Lead in advance. All advances must be approved by the Executive Director and/or TEC Director.

SECTION 7 PURCHASING AND PAYABLES (CONT’D) 7.6 Combined Travel

8.1 Fiscal Year

When an employee wishes to combine business travel with personal travel, it must be approved in advance and the following rules will apply. All expenses to SPTHB stop the moment that SPTHB business stops. SPTHB will incur no additional costs associated with the extension of the trip. Any extension or travel date change needs to be approved by the employee’s Supervisor, the Executive Director, and/or the TEC Director.

The fiscal year for financial reporting and information return purposes is January 1 through December 31.

7.7 Rewards Programs Employees are not permitted to use personal rewards programs (airlines, hotels, etc.) to accrue benefits from travel that is paid for by SPTHB or any of its programs. Any benefits resulting from travel paid by SPTHB or any of its programs shall accrue to SPTHB and be used for SPTHB or programmatic purposes.

8.2 Management Review The internal control procedures built into the accounting system are designed to help safeguard the assets of the organization from loss due to error or fraud during daily operations. Management review of financial reports is an important additional internal control. Management review serves to test the accuracy of the recorded data and to ensure compliance with internal control procedures, as well as other established policies and procedures.

8.3 Reporting Frequency Monthly Budget versus Actual reports for programs and for non-programmatic activity will be prepared monthly and provided to Management and Grant Leads, as appropriate. The reports will be based on the approved budgets in effect at the time. Grant Leads are responsible for reviewing programmatic reports in a timely manner and directing any questions to the Finance Department for investigation.

SECTION 8 FINANCIAL REPORTING Quarterly Financial reporting will be made to the Executive Committee and to the full Board on a quarterly basis. Reporting will include the monthly Budget versus Actual reporting and a report of cash position. Annual IRS Form 990 Return of Organization Exempt from Income Tax will be prepared annually based on audited financial statements. The completed form will be provided to Management for review prior to filing.

8.4 Journal Entries Journal entries will be prepared on an as needed basis to ensure the accuracy of financial records. Journal entries will be prepared by a member of the Finance Department and appropriate supporting documentation will be maintained.

8.5 Balance Sheet Reconciliations All items on the balance sheet will be reconciled on an annual basis in preparation for the annual financial audit.

8.6 Financial Audit The organization will contract with an appropriate independent accounting firm to perform a financial audit on an annual basis. The audit will be scheduled as soon as possible after the fiscal year ends. The due date for indirect cost proposals and submission to the Federal Audit Clearinghouse will be considered when scheduling the audit. The independent accounting firm will be re-evaluated after being contracted for three consecutive audits. The independent accounting firm can be contracted beyond three consecutive audits, so long as the audit partner is changed.

SECTION 9 PAYROLL AND RELATED LIABILITIES 9.1 Payroll Processing

9.2 Payroll Liabilities

Payroll is processed on a bi-weekly basis, with payment dates on Friday. Payroll is paid via direct deposit only. Employees are responsible for tracking their time and recording actual hours worked on each program in the designated timekeeping system. Hours should be entered in the timekeeping system by 5:00pm on Friday at the end of each work week. Hours entered in the timekeeping system should be approved by Supervisors by 9:00 a.m. on Monday of payroll week. If Monday is a holiday, the Finance Department will inform the staff of a revised deadline. By entering hours worked in the timekeeping system, the employee is certifying the accuracy of the information entered. When Supervisors approve employee hours in the timekeeping system, they are certifying that the employee was authorized to work on the indicated program(s).

All payroll liabilities, including federal and state taxes and retirement plan obligations, will be paid as soon as practical following the end of each pay period. The Finance Department is responsible for ensuring timely payment of payroll liabilities.

The Finance Department is responsible for entering and processing payroll payments through the payroll system. Withholdings will be made from employee paychecks based on employee authorizations, Form W-4, and applicable law.

9.3 Payroll Reporting The Finance Department is responsible for ensuring all required payroll tax returns are prepared and timely filed. W-2 Wage and Tax Statements and W-3 Transmittal of Wage and Tax Statements will be prepared and distributed on an annual basis within applicable timelines established by the Internal Revenue Service. Deadlines and filing requirements will be monitored by the Finance Director, and filing frequency and content will be modified, as needed.

9.4 PTO Payout Payments for unused PTO upon separation of employment or PTO cash outs will be available to employees based on the SPTHB Employee Handbook. Following the Federal Uniform Guidance 2 CFR 200.431, the costs will be allocated to all related activities, including Federal awards, based on cash value during the period that it is paid.

SECTION 10 BUDGETING 10.1 Non-Programmatic The non-programmatic (Health Board) budget will be drafted by the Executive Director with the assistance of the Finance Director. The Health Board budget will be presented for approval at the October meeting of the Board of Directors for the following year. The approved Health Board budget will become the operating budget for non- programmatic activities. Budget modifications involving movement between budget line items equaling more than 25% of the total budget require prior approval from the Board. Budget modifications involving less than 25% of the total budget do not require prior approval but must be communicated to the Board at the next board meeting.

10.2 Programmatic Budgets will be prepared for each funded program and submitted to the funding agency for approval. Expenditures for programmatic activities will be restricted to the budget approved by the funding agency. Expenses charged to programmatic budgets will be made in accordance with the prevailing Federal cost principles in effect at the time or other applicable guidance provided by the funding agency or in effect at the time the funding is expended. In general, budget modifications involving movement between budget line items equaling more than 25% of the total funding require prior approval from the funding agency. Budget modification requirements may also depend on other funding agency requirements. In general, modifications involving less than 25% of total funding do not require prior approval from the funding agency and will be made at the discretion of Management to ensure completion of program requirements.

10.3 Allowable Costs Finance Department staff, Grant Leads and Management are responsible for understanding cost allowability based on applicable Office of Management and Budget circulars and all applicable grant documents including, but not limited to, the approved budget. The Finance Department will ensure that all costs are given consistent accounting treatment, and that policies, regulations and procedures are applied uniformly to federal and non-federal activities.

SECTION 11 RESERVES 11.1 Operating Reserves Fund SPTHB will maintain an Operating Reserve of unrestricted funds to ensure the stability of the mission, programs, employment, and ongoing operations of the organization. The Operating Reserve is intended to provide an internal source of funds for situations such as increase in expenses, loss of funding, onetime unbudgeted expenses, or uninsured losses. The Reserve may also be used for onetime, nonrecurring expenses that will build long-term capacity. The Operating Reserve is not intended to replace a permanent loss of funds or eliminate ongoing budget gaps. Target Minimum The target minimum Operating Reserve Fund is set at $1,000,000 and is equal to approximately 90 days of average operating costs. The calculation of average monthly operating costs includes all recurring, predictable expenses such as salaries, facilities, office, program, and ongoing professional services. Expenses that will be excluded are travel, subawards, contractual services, depreciation, in-kind, and non-cash expenses. The amount of the Operating Reserve Fund target minimum will be reevaluated every two years.

Funding The Operating Reserve Fund will be funded with surplus unrestricted operating funds. The Board of Directors may from time to time direct that a specific source of revenue be set aside. Examples may include onetime gifts or bequests, special grants, or special appeals. The Operating Reserve Fund will be recorded in the financial records as Board-Designated Operating Reserve. Use of Reserves The Finance Director is responsible for ensuring that the Operating Reserve Fund is maintained and used only as described in this policy. A request to access Operating Reserve funds must be made to the Board of Directors, Executive Committee. The request must include the determination of the use of funds and plans for replenishment. The Executive Committee will present to the Board of Directors for approval. Fund Replenishment If Operating Reserves are used, the organization’s goal is to replenish the funds used within twelve months to restore the Operating Reserves Fund to the target minimum amount.

SECTION 11 (CONT’D) RESERVES 11.2 Opportunity Reserves Fund SPTHB will maintain an Opportunity Reserve of unrestricted funds to provide funding to meet special targets of opportunity or need that further the mission of the organization which may or may not have specific expectation of incremental or long-term increased income. The Opportunity Reserve is also intended as a source of internal funds for organizational capacity building such as staff development, fundraising, infrastructure, or investment. Funding The Opportunity Reserve Fund will be funded with surplus unrestricted operating funds after the annual audit is complete and the target minimum has been met for the Operating Reserves Fund. Use of Reserves The Finance Director is responsible for ensuring that the Opportunity Reserve Fund is maintained and used only as described in this policy. The Executive Director has discretion for the use of the Opportunity Reserve Fund. Before funds are accessed, a budget and scope of work must be submitted to the Finance Director.

SECTION 12 DOCUMENT RETENTION AND DESTRUCTION The following document retention standards have been adopted from the American Institute of Certified Public Accountants. The schedule reflects retention periods for specific types of documents. Notwithstanding the following, SPTHB will adhere to any legal requirements that would supersede the retention periods outlines here. Additionally, all grant documents and related supporting documentation will be maintained for the audit look back period specified in each grant.

AREA

Accounting Records

Bank Records

Corporate Records

Employee Records

Real Property Records

DOCUMENT TYPE Accounts Payable Accounts Receivable Audit Reports Chart of Accounts Depreciation Schedules Expense Records Financial Statements (Annual) Fixed Asset purchases General Ledger Inventory Records Loan Payment Schedules Purchase Orders (1 copy) Sales Records Tax Return Bank reconciliations Bank statements Canceled checks Electronic payment records Board Minutes Bylaws Business Licenses Contracts-major Contracts-minor Insurance policies Leases/mortgages Benefit Plans Employee files (ex-employees) Employment applications Employment taxes Payroll records Pension/profit sharing plans Construction records Leasehold improvements Lease payment records Real estate purchases

RETENTION PERIOD 7 years 7 years Permanent Permanent Permanent 7 years Permanent Permanent Permanent 7 years 7 years 7 years 7 years Permanent 2 years 7 years 7 years 7 years Permanent Permanent Permanent Life +4 years Life +3 years Permanent Permanent Permanent 7 years 1 years 7 years 7 years Permanent Permanent Permanent Life +4 years Permanent

Documents will be destroyed by a secured destruction methodology once the specified retention period has expired.

SECTION 13 WHISTLEBLOWER POLICY SPTHB is committed to the highest standards of ethical, moral and legal business conduct. In line with this commitment, and the commitment to open communication, this policy aims to provide an avenue for employees to raise concerns and reassurance that they will be protected from reprisals or victimization for whistleblowing. This whistleblowing policy is intended to cover protections for employees who may raise concerns regarding SPTHB, such as concerns regarding: · incorrect financial reporting; · unlawful activity; · activities that are not in line with SPTHB policy, including the Code of Ethics; or · activities, which otherwise amount to serious improper conduct.

Harassment or victimization for reporting concerns under this policy will not be tolerated under any circumstances. Every effort will be made to treat the complainant’s identity with appropriate regard for confidentiality. This policy encourages employees to put their names to allegations because appropriate follow-up questions and investigation may not be possible unless the source of the information is identified. Concerns expressed anonymously will be explored appropriately, but consideration will be given to: · The seriousness of the issue raised; · The credibility of the concern; and · The likelihood of confirming the allegation from attributable sources.

SECTION 13 WHISTLEBLOWER POLICY (CONT’D) Allegations made in bad faith may result in disciplinary action, up to and including termination. The whistleblowing procedure is intended to be used for serious and sensitive issues. Such concerns, including those relating to financial reporting, unethical or illegal conduct, may be reported directly to the Human Resource Manager or Executive Director. Employment-related concerns should continue to be reported through your normal reporting channels such as to the Supervisor or Human Resources Manager. The earlier a concern is expressed, the easier it is to act. Although the employee is not expected to prove the truth of an allegation, the employee should be able to demonstrate to the person contacted that the report is being made in good faith. The action taken by SPTHB in response to a report made under this policy will depend on the nature of the concern. The Executive Committee and/or the full Board of Directors shall receive information on each report and follow-up information on actions taken. Initial inquiries will be made to determine whether an investigation is appropriate, and the form that it should take. Some concerns may be resolved without the need for investigation. The amount of contact between the complainant and the person or persons investigating the concern will depend on the nature of the issue and the clarity of information provided. Further information may be sought from or provided to the person reporting the concern. SPTHB prohibits retaliation by or on behalf of SPTHB against staff or volunteers for making good faith complaints, reports or inquiries under this policy or for participating in a review or investigation under this policy. This protection extends to those whose allegations are made in good faith but prove to be mistaken. SPTHB reserves the right to discipline persons who make bad faith, knowingly false, or vexatious complaints, reports or inquiries or who otherwise abuse this policy.

SECTION 14 FINANCIAL CONFLICT OF INTEREST Southern Plains Tribal Health Board follows 2 C.F.R. 200.318 (c)(1). Southern Plains Tribal Health Board shall ensure that no individual in a decision-making capacity shall engage in any activity, including participation in the selection, award, or administration of a contract if a conflict of interest, or appearance of a conflict of interest, would be involved. Such a conflict would arise when the individual, an immediate family member of the individual, the individual’s partner, or, an organization, which employs, or is about to employ, any of the above, has financial or other interest in the firm or organization, selected for award. A conflict of interest would also arise if a parent, affiliate, or subsidiary organization to SPTHB is considered for an award, and SPTHB had a financial or other interest in the organization that would prevent, or appear to prevent, SPTHB from being impartial in conducting the procurement. Similarly, SPTHB’s directors, employees, or volunteers of the agency making the award will neither solicit nor accept gratuities, favors, or anything of more than nominal value from contractors, potential contractors, or parties to sub agreements. Any director or employee, who suspects that an illegal or unethical act has occurred is required to report such instances internally to the Executive Director or TEC Director.

Southern Plains Tribal Health Board™ 9705 N. Broadway Extension, Suite 200, Oklahoma City, OK 73114 405.652.9200 • www.spthb.org

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