FAC Explorer

Finding 12723 (2022-001)

Significant Deficiency Repeat Finding
Requirement
AB
Questioned Costs
-
Year
2022
Accepted
2023-01-11
Audit: 17581
Organization: Sma Healthcare, Inc. (FL)
Auditor: James Moore & CO P L

AI Summary

  • Core Issue: One out of 60 clients did not have the required Seven Part Assessment form completed.
  • Impacted Requirements: This oversight may lead to noncompliance with the Block Grant for Community Mental Health Services documentation rules.
  • Recommended Follow-Up: Introduce extra review procedures to ensure timely completion of the Seven Part Assessment form.

Finding Text

Criteria: The Block Grant for Community Mental Health Services provides for a set of documentation requirements for clients in the program, including the completion of a Seven Part Assessment to document activities allowed. This form is required to be completed within 60 days when clients are discharged after being provided mental health services. Condition: Seven Part Assessment form was not properly completed for 1 of the 60 clients tested. Cause: The requirement to perform this control element was overlooked by the case managers. Effect: The missing Seven Part Assessment form could result in noncompliance with the grant agreement. Recommendation: We recommend implementing additional review procedures to verify that the Seven Part Assessment is completed in a more timely manner.

Corrective Action Plan

In October of 2017, management implemented an electronic assessment form within the electronic clinical record. The financial assessment staff now prepares the form while the client is present, with both parties signing the form electronically upon completion. As further corrective action, in November of 2018, we added presence of the financial assessment form to the compliance review process. The compliance percentage of that measure is reported monthly to staff and also to the Quality Performance Review Committee of the board of directors. Our internal tracking indicates compliance now exceeds 98%. We will continue the monitoring and education efforts and expect to move toward full compliance.

Categories

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Other Findings in this Audit

  • 12724 2022-002
    Significant Deficiency
  • 589165 2022-001
    Significant Deficiency Repeat
  • 589166 2022-002
    Significant Deficiency

Programs in Audit

ALN Program Name Expenditures
93.959 Block Grants for Prevention and Treatment of Substance Abuse $6.90M
93.958 Block Grants for Community Mental Health Services $4.42M
93.788 Opioid Str $2.42M
93.829 Section 223 Demonstration Programs to Improve Community Mental Health Services $1.79M
93.243 Substance Abuse and Mental Health Services_projects of Regional and National Significance $1.03M
93.558 Temporary Assistance for Needy Families $619,223
21.019 Covid-19 - Coronavirus Relief Fund $350,210
93.912 Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement $340,399
93.767 Children's Health Insurance Program $331,228
16.575 Crime Victim Assistance $263,552
16.838 Comprehensive Opioid Abuse Site-Based Program $256,021
16.738 Edward Byrne Memorial Justice Assistance Grant Program $113,259
93.150 Projects for Assistance in Transition From Homelessness (path) $74,835
93.421 Strengthening Public Health Systems and Services Through National Partnerships to Improve and Protect the Nations Health $71,471
20.601 Alcohol Impaired Driving Countermeasures Incentive Grants I $51,612
14.235 Supportive Housing Program $49,078
93.778 Medical Assistance Program $41,111
93.991 Preventive Health and Health Services Block Grant $36,894
93.623 Basic Center Grant $29,480
93.136 Injury Prevention and Control Research and State and Community Based Programs $27,000