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 there was no visual representation of the ownership structure; no audited financial report; and no supplement schedule of annual gross revenues by payer type contained in the application. Interview with the Administrator on December 12, 2023, indicated that the information was not available at the time the application was submitted and would not be available until Spring 2024.
The facility failed to meet the requirements as set forth in 28 Pa Code 201.13 c.
| | Plan of Correction - To be completed: 11/30/2024
Please note that the filing of this Plan of Correction does not constitute any admission to the alleged violations set for in the statement of deficiencies. This Plan of Correction is being filed as evidence of the facility's continued compliance with all applicable laws.
1. The nursing home administrator will work with the appropriate personnel to provide the visual representation of the organization, including an organizational chart. Audited financials - the facility can't retroactively correct since the facility had a change of ownership (CHOW) on May 2023 as such annual audited financial will be available only after a full year of operations. An audited financial report will be completed and submitted after a full year of operating. The nursing home administrator will engage with their professional accounting firm to conduct an audit of the facility's financial records and submit it with next year's renewal after a full year of operations has occurred. The audited financial report will be submitted for 2024 renewal. 2. The nursing home administrator will collaborate with the professional accounting firm to create/ensure a detailed supplement schedule is included. This schedule will cover the required information outlined in the statue/regulation. The supplement schedule will be completed and submitted as part of the application for 2024 license renewal. 3. The nursing home administrator has been educated on the specific new requirements outlined in this regulation. 4. The nursing home administrator will monitor and review future application submissions. The nursing home administrator will ensure the renewal license application includes a visual organization chart, audited financial report, and supplement schedule to meet requirements per regulation each year. The information will be reviewed at QAPI.
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