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 no visual representation of organization; no audited financial report; and no supplement schedule of annual gross revenues by payer type were contained in the application. Interview with the Nursing Home Adminstrator on November 28, 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: 12/19/2023
Facility cannot retroactively correct the audited financial statements for 2022. Carleton Healthcare and Rehabilitation Center commenced operations under new ownership during 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 next year.
(ii)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.
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.
(iii) 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 create a comprehensive 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.
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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