For ALN 93.958, the full seven-part comprehensive assessment required for FACT clients was not completed fully within 60 days of client admission into the program for 1 of the 60 clients tested. Additionally, 3 of the 60 clients tested did not have the discount fee that was shown on their comprehensive assessment. Finally, 1 of the 60 clients tested had an incorrect discount fee applied. This appears to be the result of staff oversight. As a corrective action, all FACT team staff responsible for completion of the assessment will be retrained on a recurring basis. We feel as though the current process to review compliance is comprehensive. SMA’s internal clinical compliance department conducts routine audits. When conducting audits of the FACT program, the compliance staff members review charts for compliance with the comprehensive assessments. The results of those internal audits are reviewed at the Process Improvement Committee where program managers are required to present a corrective action plan if charts do not meet a pre-set compliance threshold. The clinical compliance results are also presented to the Quality Program Review subcommittee of the board. Furthermore, the
FACT program directors are responsible for monitoring documentation timeframes to ensure that when new clients are admitted to the program, documentation is completed timely.