Finding Text
2024-012 Controls Over Reporting for SMT Program U.S. Department of Health and Human Services 93.958 – Block Grants for Community Mental Health Services Reporting – Significant Deficiency – Internal Control Finding Conditions: The Organization does not have adequate controls in place over reporting requirements. Criteria: Per the Westchester County contract, the Organization is required to keep individual records of program participants available for audit by the County. Context: 3 out of 4 participants selected had instances of encounter notes entered months after the original encounter. 1 of 4 participants was not active in the program and had not been removed from the participant listing. For monthly reporting, reports were submitted but no documentation of review or timely reporting was maintained. Cause: The Organization did not follow control procedures routinely and has not adopted sufficient relevant controls over the records for the program. Effect: Encounter notes may be inaccurate or not complete if audited by the State or HHS. Recommendation: RBT recommends that the Organization establish a system of internal control over records for the program to ensure notes are entered and reviewed timely and that inactive participants are indicated as such. Monthly reports should be documented as reviewed and noted when submitted. Management Response: See Corrective Action Plan.