Finding 480446 (2023-007)

Significant Deficiency
Requirement
L
Questioned Costs
-
Year
2023
Accepted
2024-08-05

AI Summary

  • Core Issue: The Organization failed to maintain individual records of program participants, which is a significant deficiency.
  • Impacted Requirements: The Westchester County contract mandates that individual records be kept available for audit.
  • Recommended Follow-Up: Implement a review process to ensure timely updates of encounter notes and proper management of participant listings.

Finding Text

2023-007 Controls over Records Assistance Listing Number: 93.958 Name of Program and Cluster: Block Grants for Community Mental Health Services Agency: U.S. Department of Health and Human Services Reporting Significant Deficiency Condition: The Organization did not keep individual records of program participants. Criteria: Per the Westchester County contract, the Organization is required to keep individual records of program participants available for audit by the county. Context: Two out of five participants selected for testing had encounter notes updated one to six months after the date of service. The participant list provided for audit included inactive clients and clients that did not enter the program until after year end. Cause: There is no review or noted controls over the records maintained for the program. Effect: The Organization does not have updated records for individuals in the program. Recommendation: RBT recommends developing a review process to confirm encounter notes are added in a timely manner and participants no longer enrolled in the program are inactivated. Additionally, the program should maintain current participant listings.

Corrective Action Plan

Controls over Records Per the Westchester County Contract the Organization did not keep individual records of program participants Statement of Concurrence or Nonconcurr nce: Concur 1. Corrective Action: Team Leader Chris Rivera will review all notes on a weekly basis and sign off on documentation after review. 2. Best practice standards are that notes should be entered by the end of the next business day for the previous day's encounters. 3. The deadline for notes to be entered for the previous week's encounters is Monday at noon. If staff have not completed notes by Monday morning, they are mandated to complete notes prior to leaving the office for visits and other staff members will help with coverage needs. 4. Staff will identify an hour on their schedule daily to stay up to date on documentation. 5. The Program Assistant will run a monthly report of open participants in the Westchester Crisis Stabilization Team program on the last day of every month. Inactive participants or discharges will be completed at the time of discharge. Review of the monthly open participants will ensure that any inactive participants are quickly identified, and proper discharge process will occur by the 5th of every month. 6. Current caseload rosters will be provided to team members and Team Leader for review and printed out by Program Assistant by the 1st of every month. 7. Program Assistant will provide an update of completed discharges to the Team Leader upon completing discharge. 8. Quarterly waste, fraud, abuse audits will be completed by Quality Assurance and the Team Leader 9. Routine monthly audits of 2 charts at random will be completed by the Team Leader Responsible Person to Oversee Corrective Action Plan: Tammy Robson Assistant Executive Director 845-264-7399 Christopher River Westchester Crisis Stabilization Team Date Corrective Plan will be put in Place: Corrective action measures are currently being implemented and will be in effect as of 7/1/24. Chart audits and discharges of inactive participants will be completed by 7/15/24.

Categories

Reporting Significant Deficiency

Other Findings in this Audit

  • 480443 2023-006
    Material Weakness
  • 480444 2023-006
    Material Weakness
  • 480445 2023-006
    Material Weakness
  • 480447 2023-008
    Material Weakness
  • 480448 2023-008
    Material Weakness
  • 480449 2023-008
    Material Weakness
  • 480450 2023-009
    Significant Deficiency
  • 480451 2023-010
    Significant Deficiency
  • 480452 2023-010
    Significant Deficiency
  • 1056885 2023-006
    Material Weakness
  • 1056886 2023-006
    Material Weakness
  • 1056887 2023-006
    Material Weakness
  • 1056888 2023-007
    Significant Deficiency
  • 1056889 2023-008
    Material Weakness
  • 1056890 2023-008
    Material Weakness
  • 1056891 2023-008
    Material Weakness
  • 1056892 2023-009
    Significant Deficiency
  • 1056893 2023-010
    Significant Deficiency
  • 1056894 2023-010
    Significant Deficiency

Programs in Audit

ALN Program Name Expenditures
93.958 Block Grants for Community Mental Health Services $422,306
21.027 Coronavirus State and Local Fiscal Recovery Funds $55,366
14.267 Continuum of Care Program $28,044