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 the current ownership structure, no audited financial statement and a supplemental schedule of annual gross revenues by payor 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: 12/15/2024
1. Facility cannot retroactively
correct the audited financial
statements for 2023. Darway
Healthcare and Rehabilitation
LLC commenced operations under
new ownership during fiscal year
of 2022 and did not have a full
year of operations. As such, an
audit by a CPA Firm was not
issued or required as this was the
initial year of operations. An
audited financial report will be
completed and submitted prior to
next years renewal. The nursing
home administrator will work with
the appropriate personnel to create
a visual representation of the
organization, including an
organizational chart. This will
provide a clear understanding of
the facility's structure and
hierarchy.
2. The nursing home administrator
will collaborate with the
professional accounting firm to
create/ensure a detailed
supplement schedule is included.
This schedule will outline the
annual gross revenues broken
down by payer type, such as
Medicare, Medicaid, private
insurance, and self-pay. The
supplement schedule will be
completed and submitted as part
of the application for 2024
renewal. The nursing home
administrator will work with the
appropriate personnel to create a
visual representation of the
organization, including an
organizational chart. This will
provide a clear understanding of
the facility's structure and
hierarchy.
3. The nursing home administrator
will create a timeline for the
completion of all corrective
actions for next renewal of license.
This timeline will include specific
deadlines for obtaining the visual
representation of the organization,
completing the audited financial
report, and developing the
supplement schedule. The timeline
will be communicated to all
relevant personnel to ensure
accountability and adherence to
deadlines. The nursing home administrator has been educated on the specific requirements outlined in this
regulation.
4. The nursing home administrator
will monitor and review future
application submissions. This
system will include regular audits
of submitted applications to ensure
compliance with all requirements.
The nursing home administrator
will ensure renewal license
includes a visual organization
chart, audited financial report, and
supplement schedule to meet
requirements per regulation each
year
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