EIN: 590976866
UEI: N8E6JL12CMV6
Data as of August 23, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on January 8, 2026. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by July 8, 2026 (46 days ago).
What is a management decision? →3 of the 60 clients tested on the Block Grant for Community Mental Health Services did not have the discount fee that was used properly calculated and documented on their Financial Assessment Form. Additionally, 4 of the 60 clients tested on the Block Grant for Community Mental Health Services had service dates that did not fall within one year after the FAF completion date. 1 of the 60 clients tested on the Block Grant for Prevention and Treatment of Substance Abuse and 1 of 40 clients tested on the Opioid STR Program did not have a completed FAF. 1 of the 60 clients tested on the Block Grant for Prevention and Treatment of Substance Abuse had a FAF missing the client signature. Cause: The requirement to perform these control elements were not followed by the case managers. Effect: The Financial Assessment Forms that were not properly completed or not completed within the required timeframe could result in noncompliance with the grant agreement or noncompliance with established controls. Recommendation: We recommend that the process be updated to ensure all Financial Assessment Forms required be completed fully and accurately for all patients within one year of service, and that additional controls be put in place to ensure the discount rate applied is documented and proper.
Show full finding ▾Hide full finding ▴2025-001 – ALN 93.958 – Block Grant for Community Mental Health Services; ALN 93.959 – Block Grant for Prevention and Treatment of Substance Abuse; ALN 93.788 Opioid STR Program: Activities Allowed/Allowable Costs - Completion of Financial Assessment Form – (Repeat Comment) Criteria: The Block Grant for Community Mental Health Services and the Block Grant for Prevention and Treatment of Substance Abuse provide for a set of documentation requirements for clients in the covered programs, including the completion of a Financial Assessment Form (FAF) to document financial eligibility over allowable costs. Based on the client’s income and number of dependents, this form is used to determine a “discount class”, and calculate a sliding scale discount percentage and/or dollar amount of SMA’s fees that the client would be responsible for paying. This form is required to be completed when clients are discharged after being provided mental health services. FAF are to be updated yearly for patients with active billable services, noting all service dates with a billed service should fall within one year of the FAF completion date. Condition: 3 of the 60 clients tested on the Block Grant for Community Mental Health Services did not have the discount fee that was used properly calculated and documented on their Financial Assessment Form. Additionally, 4 of the 60 clients tested on the Block Grant for Community Mental Health Services had service dates that did not fall within one year after the FAF completion date. 1 of the 60 clients tested on the Block Grant for Prevention and Treatment of Substance Abuse and 1 of 40 clients tested on the Opioid STR Program did not have a completed FAF. 1 of the 60 clients tested on the Block Grant for Prevention and Treatment of Substance Abuse had a FAF missing the client signature. Cause: The requirement to perform these control elements were not followed by the case managers. Effect: The Financial Assessment Forms that were not properly completed or not completed within the required timeframe could result in noncompliance with the grant agreement or noncompliance with established controls. Recommendation: We recommend that the process be updated to ensure all Financial Assessment Forms required be completed fully and accurately for all patients within one year of service, and that additional controls be put in place to ensure the discount rate applied is documented and proper.
For ALN 93.958, the discount fee was not properly calculated and/or documented on the Financial Assessment Form for 3 of the 60 clients tested. Additionally, 4 of the 60 clients tested on the Block Grant for Mental Health had dates that did not fall within one year after the FAF completion. For ALN 93.959, 1 of the 60 clients tested on the Block Grant for Prevention and Treatment of Substance Abuse did not have a completed FAF and 1 of the 60 tested had a missing client signature. For ALN 93.788, 1 of the 40 clients tested on Opioid STR Program did not have a completed FA. Our internal tracking of completion of the Financial Assessment Form at admission indicates that compliance with this requirement occurs about 90% of the time. We have identified that some of the missing FAs are a result of Telehealth appointments and clients not coming into the office. As a corrective action, the Client Service Specialist will be trained by their managers to ensure data is entered accurately and how to properly apply the FAs. SMA will also include the completion of the Financial Assessment Form both at admission and annually with data to be reviewed monthly by the managers. In addition, we will be working with IT to identify a way to collect the FAs from clients that utilize Telehealth services. Reporting will be sent out monthly and if out of compliance the managers will be required to be present at the quarterly Quality Assurance Committee meeting if not at 100%.
2024-001
FAC accepted this audit on December 17, 2024 — management decision was due June 17, 2025.
7 of the 60 clients tested did not have the discount fee that was used shown on their Financial Assessment Form. Additionally, 8 of the 60 clients tested had service dates that did not fall within one year of the FAF completion date. Cause: The requirement to perform these control elements were not followed by the case managers. Effect: The Financial Assessment Forms that were not properly completed or not completed within the required timeframe could result in noncompliance with the grant agreement or noncompliance with established controls. Recommendation: We recommend that the process be changed so that all Financial Assessment Forms required be completed fully and accurately for all patients within one year of service, and that additional controls be put in place to ensure the discount rate applied is documented and proper.
Show full finding ▾Hide full finding ▴2024-001 – ALN 93.958 – Block Grant for Community Mental Health Services – Activities Allowed/Allowable Costs: Completion of Comprehensive Assessment (Repeat Comment) Criteria: The Block Grant for Community Mental Health Services provides for a set of documentation requirements for clients in the covered programs, including the completion of a Financial Assessment Form (FAF) to document financial eligibility over allowable costs. Based on the client’s income and number of dependents, this form is used to determine a “discount class”, and calculate a sliding scale discount percentage and/or dollar amount of SMA’s fees that the client would be responsible for paying. This form is required to be completed when clients are discharged after being provided mental health services. FAF are to be updated yearly for patients with active billable services, noting all service dates with a billed service should fall within one year of the FAF completion date. Condition: 7 of the 60 clients tested did not have the discount fee that was used shown on their Financial Assessment Form. Additionally, 8 of the 60 clients tested had service dates that did not fall within one year of the FAF completion date. Cause: The requirement to perform these control elements were not followed by the case managers. Effect: The Financial Assessment Forms that were not properly completed or not completed within the required timeframe could result in noncompliance with the grant agreement or noncompliance with established controls. Recommendation: We recommend that the process be changed so that all Financial Assessment Forms required be completed fully and accurately for all patients within one year of service, and that additional controls be put in place to ensure the discount rate applied is documented and proper.
For ALN 93.958, the discount fee that was shown on their Financial Assessment Form was not used for 7 of the 60 clients tested. Additionally, 8 of the 60 clients tested had service dates that did not fall within one year of the Financial Assessment Form. Our internal tracking of completion of the Financial Assessment Form at admission indicates that compliance with this requirement occurs about 89% of the time. As acorrective action, the Client Service Specialist will be trained to ensure data is entered accurately. SMA will also include the completion of the Financial Assessment Form both at admission and annually to be reviewed monthly by the programs. In addition, an action plan will be required to be present at the quarterly Quality Assurance Committee meeting if not at 100%.
2023-001
1 of the 60 clients tested did not have the Financial Assessment Form properly signed by the client. Additionally, 2 of the 60 clients tested had service dates that did not fall within one year of the FAF completion date. Cause: The requirements to perform these control elements were not followed by the case managers. Effect: The Financial Assessment Forms that were not properly completed or not completed within the required timeframe could result in noncompliance with the grant agreement or noncompliance with established controls. Recommendation: We recommend that the process be reviewed and staff be trained and have regular training updates to ensure that the required Financial Assessment Forms are completed fully and signed for all clients, and that additional controls be put in place to ensure the discount rate applied is documented and proper.
Show full finding ▾Hide full finding ▴2024-002 – ALN 93.959 – Block Grant for Prevention and Treatment of Substance Abuse – Activities Allowed/Allowable Costs: Completion of Financial Assessment Form (Repeat Comment) Criteria: The Block Grant for Prevention and Treatment of Substance Abuse provides for a set of documentation requirements for clients in the covered programs, including the completion of a Financial Assessment Form (FAF) to document financial eligibility over allowable costs. Based on the client's income and number of dependents, this form is used to determine a "discount class", and calculate a sliding scale discount percentage and/or dollar amount of SMA's fees that the client would be responsible for paying. This form is required to be completed when clients are discharged after being provided mental health services. FAF are to be updated yearly for patients with active billable services, noting all service dates with a billed service should fall within one year of the FAF completion date. Condition: 1 of the 60 clients tested did not have the Financial Assessment Form properly signed by the client. Additionally, 2 of the 60 clients tested had service dates that did not fall within one year of the FAF completion date. Cause: The requirements to perform these control elements were not followed by the case managers. Effect: The Financial Assessment Forms that were not properly completed or not completed within the required timeframe could result in noncompliance with the grant agreement or noncompliance with established controls. Recommendation: We recommend that the process be reviewed and staff be trained and have regular training updates to ensure that the required Financial Assessment Forms are completed fully and signed for all clients, and that additional controls be put in place to ensure the discount rate applied is documented and proper.
For ALN 93.959, a Financial Assessment Form was not properly signed for 1 of the 60 clients tested. Additionally, 2 of the 60 clients tested had service dates that did not fall within one year of the Financial Assessment Form completion date. Obtaining a client's signature on the form has been challenging, particularly during recent years as use of telehealth services has expanded. As a corrective action, team members will be trained in how to properly document receipt of verbal approval. Our internal tracking of completion of the Financial Assessment Form at admission indicates that compliance with this requirement occurs about 89% of the time. As a corrective action plan, SMA will include the completion of the Financial Assessment Form both at admission and annually to be reviewed monthly by the programs. In addition, an action plan will be required to be present at the quarterly Quality Assurance Committee meeting if not at 100%.
2023-002
5 of the 40 clients tested did not have the Master Treatment Plan completed within the established timeframe. Cause: The requirements to perform these control elements were not followed by the clinical staff. Effect: The Master Treatment Plans that were not completed within the required timeframe could result in noncompliance with the grant agreement or noncompliance with established controls. Recommendation: We recommend that the process be reviewed and staff be trained and have regular training updates to ensure that the required Master Treatment Plans are completed within established timeframe.
Show full finding ▾Hide full finding ▴2024-004 – ALN 93.558 – Temporary Assistance to Needy Families Grant – Activities Allowed/Allowable Costs: Timeframe for Completion of Master Treatment Plan (New Comment) Criteria: The Temporary Assistance to Needy Families Grant provides for a set of documentation requirements for clients in the covered programs, including the completion of a Master Treatment Plan within established timeframe (30 days and 15 days from the date of admission for Outpatient and Residential II, respectively) to document allowable costs. Condition: 5 of the 40 clients tested did not have the Master Treatment Plan completed within the established timeframe. Cause: The requirements to perform these control elements were not followed by the clinical staff. Effect: The Master Treatment Plans that were not completed within the required timeframe could result in noncompliance with the grant agreement or noncompliance with established controls. Recommendation: We recommend that the process be reviewed and staff be trained and have regular training updates to ensure that the required Master Treatment Plans are completed within established timeframe.
For ALN 93.558, a Master Treatment Plan was not completed for 5 of the 40 clients tested within the established timeframe. As a corrective action, the program director will provide training to the team members of the program's proper established timeframe to complete a Master Treatment Plan. In addition, SMA will monitor the program by completing internal record reviews. The results will be provided to the program director and if a 90% or higher is not achieved for 2 months, a written corrective action will be required, and a verbal will be required at the quarterly Quality Assurance Committee meeting.
FAC accepted this audit on December 27, 2023 — management decision was due June 27, 2024.
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 used shown on their comprehensive assessment. Finally, 1 of the 60 clients tested had an incorrect discount fee applied. Cause: The requirement to perform these control elements within 60 days was not followed by the case managers. Effect: The seven-part comprehensive assessments that were not properly completed within the required timeframe could result in noncompliance with the grant agreement. Recommendation: We recommend that the process be changed so that all seven-part comprehensive assessments required for FACT clients be completed fully for all patients within 60 days, and that additional controls be put in place to ensure the discount rate applied is documented and proper.
Show full finding ▾Hide full finding ▴2023-001 – ALN 93.958 – Block Grant for Community Mental Health Services – Activities Allowed/Allowable Costs: Completion of Comprehensive Assessment Criteria: The Block Grant for Community Mental Health Services provides for a set of documentation requirements for clients in the covered programs, including the completion of a seven-part comprehensive assessment for clients in the FACT program. This form is required to be completed when clients are discharged after being provided mental health services. Activities allowed for the FACT program require a seven-part comprehensive assessment be completed fully within sixty days of client admission into the program. Condition: 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 used shown on their comprehensive assessment. Finally, 1 of the 60 clients tested had an incorrect discount fee applied. Cause: The requirement to perform these control elements within 60 days was not followed by the case managers. Effect: The seven-part comprehensive assessments that were not properly completed within the required timeframe could result in noncompliance with the grant agreement. Recommendation: We recommend that the process be changed so that all seven-part comprehensive assessments required for FACT clients be completed fully for all patients within 60 days, and that additional controls be put in place to ensure the discount rate applied is documented and proper.
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.
2022-001
A Financial Assessment Form was not properly completed for 1 of the 60 clients tested. Additionally, 1 of the 60 clients tested did not have the Financial Assessment Form properly signed. Finally, 1 of the 60 clients tested had an incorrect discount fee applied. Cause: The requirement to perform these control elements were overlooked by the case managers. Effect: The missing and improperly completed Financial Assessment Forms could result in noncompliance with the grant agreement. Recommendation: We recommend that the process be reviewed and staff be trained and have regular training updates to ensure that the required Financial Assessment Forms are completed fully and signed for all clients, and that additional controls be put in place to ensure the discount rate applied is documented and proper.
Show full finding ▾Hide full finding ▴2023-002 – ALN 93.959 – Block Grant for Prevention and Treatment of Substance Abuse – Activities Allowed/Allowable Costs: Completion of Financial Assessment Form Criteria: The Block Grant for Prevention and Treatment of Substance Abuse provides for a set of documentation requirements for clients in the program, including the completion of a Financial Assessment Form to document financial eligibility over allowable costs. This form is required to be completed when clients are discharged after being provided mental health services. Condition: A Financial Assessment Form was not properly completed for 1 of the 60 clients tested. Additionally, 1 of the 60 clients tested did not have the Financial Assessment Form properly signed. Finally, 1 of the 60 clients tested had an incorrect discount fee applied. Cause: The requirement to perform these control elements were overlooked by the case managers. Effect: The missing and improperly completed Financial Assessment Forms could result in noncompliance with the grant agreement. Recommendation: We recommend that the process be reviewed and staff be trained and have regular training updates to ensure that the required Financial Assessment Forms are completed fully and signed for all clients, and that additional controls be put in place to ensure the discount rate applied is documented and proper.
For ALN 93.959, a Financial Assessment Form was not properly completed for 1 of the 60 clients tested. Additionally, 1 of the 60 clients tested did not have the Financial Assessment Form properly signed. Finally, 1 of the 60 clients tested had an incorrect discount fee applied. Our internal tracking of completion of the financial assessment form indicates that compliance with this requirement occurs about 98% of the time. Obtaining the client signature on the form has been challenging, particularly during recent years as use of telehealth services has expanded. As a corrective action, SMA will include completion of the assessment form compliance results to be reviewed at the monthly Process Improvement Committee. Program managers are required to present a corrective action plan when results are out of compliance with the standard. In addition, SMA will develop a procedure to allow staff to document receipt of verbal approval of the completed financial assessment form when the client is unable to be present at service location site.
2022-002
FAC accepted this audit on January 11, 2023 — management decision was due July 11, 2023.
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.
Show full finding ▾Hide full finding ▴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.
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.
2021-001
Financial Assessment Forms were 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 Financial Assessment Forms could result in noncompliance with the grant agreement. Recommendation: We recommend implementing additional review procedures to verify that all eligible individuals have FAF signed and completed.
Show full finding ▾Hide full finding ▴Criteria: The Block Grant for Prevention and Treatment of Substance Abuse provides for a set of documentation requirements for clients in the program, including the completion of a Financial Assessment Form to document activities allowed. This form is required to be completed when clients are discharged after being provided mental health services. Condition: Financial Assessment Forms were 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 Financial Assessment Forms could result in noncompliance with the grant agreement. Recommendation: We recommend implementing additional review procedures to verify that all eligible individuals have FAF signed and completed.
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.
FAC accepted this audit on January 5, 2022 — management decision was due July 5, 2022.
Financial Assessment Forms were 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 Financial Assessment Forms could result in noncompliance with the grant agreement. Recommendation: We recommend that the process be reviewed and staff be trained and have regular training updates to ensure that the required Financial Assessment Forms are completed for all clients.
Show full finding ▾Hide full finding ▴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 Financial Assessment Form to document activities allowed. This form is required to be completed when clients are discharged after being provided mental health services. Condition: Financial Assessment Forms were 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 Financial Assessment Forms could result in noncompliance with the grant agreement. Recommendation: We recommend that the process be reviewed and staff be trained and have regular training updates to ensure that the required Financial Assessment Forms are completed for all clients.
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.
2020-001
FAC accepted this audit on November 29, 2020 — management decision was due May 29, 2021.
Financial Assessment Forms were not 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 Financial Assessment Forms could result in noncompliance with the grant agreement. Recommendation: We recommend that the process be reviewed and staff be trained and have regular training updates to ensure that the required Financial Assessment Forms are completed for all clients.
Show full finding ▾Hide full finding ▴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 Financial Assessment Form to document activities allowed. This form is required to be completed when clients are discharged after being provided mental health services. Condition: Financial Assessment Forms were not 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 Financial Assessment Forms could result in noncompliance with the grant agreement. Recommendation: We recommend that the process be reviewed and staff be trained and have regular training updates to ensure that the required Financial Assessment Forms are completed for all clients.
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.
2019-001
FAC accepted this audit on November 19, 2019 — management decision was due May 19, 2020.
Financial Assessment Forms were not completed for 2 of the 60 clients tested. Cause: The requirement to perform this control element was overlooked by the case managers. Effect: The missing Financial Assessment Forms could result in noncompliance with the grant agreement. Recommendation: We recommend that the process be reviewed and staff be trained and have regular training updates to ensure that the required Financial Assessment Forms are completed for all clients.
Show full finding ▾Hide full finding ▴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 Financial Assessment Form to document activities allowed. This form is required to be completed when clients are discharged after being provided mental health services. Condition: Financial Assessment Forms were not completed for 2 of the 60 clients tested. Cause: The requirement to perform this control element was overlooked by the case managers. Effect: The missing Financial Assessment Forms could result in noncompliance with the grant agreement. Recommendation: We recommend that the process be reviewed and staff be trained and have regular training updates to ensure that the required Financial Assessment Forms are completed for all clients.
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.
2018-001
FAC accepted this audit on November 29, 2018 — management decision was due May 29, 2019.
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2017-002
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2017-003
FAC accepted this audit on March 21, 2018 — management decision was due September 21, 2018.
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