Pennsylvania Department of Health
BRADFORD HILLS NURSING & REHABILITATION CENTER
Patient Care Inspection Results

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BRADFORD HILLS NURSING & REHABILITATION CENTER
Inspection Results For:

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BRADFORD HILLS NURSING & REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a State Licensure Monitoring survey on February 5, 2024, it was determined that Bradford Hills Nursing & Rehabilitation was not in compliance with the following requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


§ 201.13c (b) LICENSURE License renewal:State only Deficiency.
(b) In addition to the application form and fee under subsection (a), a facility shall submit an updated annual financial report that meets the requirements set forth in § 201.12(b)(8) (relating to application for license of a new facility or change in ownership).
Observations:
Based on review of the facility submitted application for renewal of the license, it was determined that the facility failed to submit an annual financial report which shall include the following:

(i) Audited financial statements prepared in accordance with generally accepted accounting principles (GAAP). If GAAP requires consolidated financial statements, then consolidated statements shall be provided. (The GAAP indicates that the following is included in and audited financial statement: Balance Sheet, Cash Flow Statement, Income Statement, Statement of Shareholder Equity Changes and an auditor opinion)
(ii) A visual representation of the current ownership structure, which shall include parent companies, shareholders, and any related parties of the persons identified in paragraphs (1) through (6). (this would be an organizational chart rather than a list)
(iii) A supplemental schedule of annual gross revenues, prepared in accordance with GAAP. The supplemental schedule shall be broken out by payor type.

Findings:
Review of the submitted application revealed that the visual representation of organization structure, audited financial report and supplemental schedule of annual gross revenues by payer type was not contained in the application.

The facility failed to meet the requirements as set forth in 28 Pa Code 201.13c.



 Plan of Correction - To be completed: 05/31/2024

Visual representation of the organization will be revised and resubmitted.

Due to the timing of the ownership change 06/23/2024 there was not audit completed for the the 2023 fiscal year. The 2023 fiscal audit is currently in process, with an estimated completion date of May 31, 2024. It will be submitted once completed.

To ensure that the problem does not reoccur the visual representation will be updated by the Corporate Chief Financial Officer whenever there are many changes.

In addition, there will be an annual independent audit completed each year for submission with the license renewal application.

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