Audit report, for the year ended June 30, 1998, Azalea Trace Nursing Home, Medicaid provider no. 00141886A, Nursing Facilities Services Program [June 30, 1998]

TABLE OF CONTENTS

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IfIN][)I~G~ ~~][) ~C=:=)1\1[1\1[lB:~][)~ ~I=)~S 5

Summary of Audit Findings Affecting Allowable Costs and Patient Day Statistics 10

Schedule of Allowable Costs and Patient Day Statistics

; 12

Report Prepared By:
State ofGeorgia Department ofAudits and Accounts Medicaid and Local Government Audits Division
w., 254 Washington Street, s. Suite 322
Atlanta, Georgia 30334-8400 (404) 656-2006
Michael A. Plant, Director

RUSSELL W. HINTON
STATE AUDITOR

DEPARTMENT OF AUDITS AND ACCOUNTS
254 Washington Street, S.W., Suite 322
Atlanta, Georgia 30334-8400
Telephone (404)656-2006 Facsimile (404)656-7535

MICHAEL A. PLANT
DIRECTOR

August 2, 1999

Members of the Board of Community Health, and The Honorable Russ Toal, Commissioner Georgia Community Health 2 Peachtree Street, N.W., 40th Floor Atlanta, Georgia 30303
Ladies and Gentlemen:
This report provides the results of our audit of Azalea Trace Nursing Home, provider number00141886A, a participant in the Nursing Facility Services Program for the year ended June 30, 1998. This report is intended to be used solely in connection with the administration of the Georgia Department of Medical Assistance Nursing Facility Services Program and is not to be used or relied upon for any other purpose.
Respectfully Submitted,
~ ~ell..W...QHin2ton .LJ.~ State Auditor
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1998 Audit Report: Azalea Trace Nursing Home

1

INTRODUCTION

General Information

The Georgia Medical Assistance Program (Medicaid) is administered by the Georgia Department of Medical Assistance and is jointly funded by the State of Georgia and the federal government. Medicaid p~ys health care providers for furnishing health care services to individuals or families with low income and limited resources. The Department of Medical Assistance has established specific payment guidelines and limitations for each covered medical service.

Through the Nursing Facility Services Program, Medicaid pays for care in institutional settings for recipients who are unable to remain at home or in the community. Nursing homes are paid for this service using rates calculated from Nursing Home Cost Reports submitted by each provider. These cost reports include financial, patient census, and other information. Information included in the Nursing Home Cost Report is subject to audit by the Departmentof Medical Assistance or its agents. In an agreement with the Department of Medical Assistance, the Department of Audits and Accounts has accepted the responsibility of auditing Medicaid providers.

Provider Information

Azalea Trace Nursing Home, a 110-bed long-term health care facility located in Columbus, Georgia, is a provider enrolled in the Georgia Medicaid Nursing Facility Services Program. The facility provides both skilled and intermediate care services to resident patients. The facility was owned and operated as a component of Columbus Regional

2

Nursing Facility Services Program

Healthcare System, Inc., a chain organization which filed a Home Office Cost Report with DMA for the year ended June 30, 1998.

Audit Objectives

The purpose of this audit was to determine whether Azalea Trace Nursing Home maintained adequate documentation to support the allowable costs and patient day statistics reported in its Nursing Home Cost Report for the year ended June 30, 1998; and to determine whether Azalea Trace Nursing Home complied with the federal and state laws, regulations, policies and procedures for the Nursing Facility Services Program in effect for that period. The specific objectives of this audit were to:



determine if allowable costs reported in the Nursing

Home Cost Report are reasonable and allowable, in

all material respects, in accordance with federal and

state laws, regulations, policies and procedures

governing the Georgia Nursing Facility Services

Program;



compare patient day statistics included in the cost

report to provider records to determine if the patient

day statistics are accurately reported; and

recommend appropriate action based on the results of our audit.

1998 Audit Report: Azalea Trace Nursing Home

3

Scope and Methodology

To accomplish these objectives, we performed a limited review of the

provider's internal control structure to the extent necessary to plan our

audit. We interviewed provider personnel and examined records and

documentation to determine the adequacy of amounts and disclosures

included in the Nursing Home Cost Report. We also reviewed, on a

test basis, evidence supporting these amounts and disclosures and

.

0

assessed the accounting principles used and significant estimates made

by management. We evaluated the tested transactions and accounts for

compliance with cost reporting principles included in the Health Care

Financing Administration Provider Reimbursement Manual (HCFA

Pub. 15-1) and DMA Policies and Procedures for Nursing Facility

Services.

In accordance with Section 1002 of Policies and Procedures for Nursing Facility Services, the Department of Medical Assistance has calculated the payment rate for Azalea Trace Nursing Home using a method often called the "Dodge Index System". Under the Dodge Index system, reasonable construction and asset acquisition costs are used in calculating the payment rate rather than the actual costs incurred by the nursing home for property costs such as depreciation and amortization; capital-related interest expense; and lease expense. Because these property costs are not considered by theDepartment of Medical Assistance when calculating the. payment rate for Azalea Trace .Nursing Home, our audit did not include a review of these costs. However, because property taxes and insurance are used by the Department of Medical Assistance to calculate the provider's payment rate, we have reviewed those costs as part of our audit.

4

Nursing Facility Services Program

Allowable costs reported on the Nursing Home Cost Report included the provider's portion of allowable home office costs claimed by Columbus Regional Healthcare System in its Home Office Cost Report filed with The Department of Medical Assistance for the year ended June 30, 1998. Analytical procedures applied to the cost reports filed by the provider and the home office showed that any changes in the allocation of costs from the home. office to the provider would not affect the payment rate calculated by The Department of Medical Assistance for this provider. Our audit of the Home Office Cost Report filed by Columbus Regional Healthcare System was, therefore, limited to an office audit. An office audit is a review of disclosures contained in the cost report and does not include an evaluation of source documentation.
The Department of Audits and Accounts is responsible for providing the Department of Medical Assistance with information regarding the accuracy of cost and patient data for Azalea Trace Nursing Home for the year ended June 30, 1998. If the Department of Medical Assistance implements the recommendations in this report by adjusting the allowable costs and/or patient day statistics used in calculating the provider's billing rate, the provider may appeal to the Department of Medical Assistance for reconsideration of the audit findings. For this reason, we have not included a response from the provider in our report. However, we have discussed the contents of this report with the provider and have considered its responses when preparing the report. In all other respects, this audit was conducted in accordance with generally accepted government auditing standards.

1998 Audit Report: Azalea Trace Nursing Home

5

FINDINGS AND RECOMMENDATIONS

Incorrect Expense Classifications

Finding No.1

Documentation examined during the audit showed that some of the expenses were not classified in accordance with the Uniform Chart of Accounts prescribed by "the Department of Medical Assistance for providers participating in the Medicaid Nursing Facilities Services Program. We recommend that the provider implement policies and procedures to ensure that all of its expenses are classified in the appropriate cost centers. We recommend that the Department of Medical Assistance make the following adjustment to reclassify costs to the appropriate cost centers.
(DMA Policies and Procedures, Appendix D)

COST CENTER Routine Services Communication Expense Software Maintenance Special Services Communication Expense Dietary Communication Expense Operation and Maintenance of Plant Communication Expense Exterminating Service Administrative and General Amortization Expense Communication Expense Exterminating Service Software Maintenance Property and Related Expenses Amortization Expense
Total Adjustment to Allowable Costs

$

(1,213)

(2,653) $

$ (13,802) 2,215
$ (12,717) 15,387 (2,215) 2,653

(3,866) (198) (174)
(11,587)
3,108 12,717
o

6

Nursing Facility Services Program

Lack ofSufficient Documentation

Finding No.2

Some of the expenses included in allowable costs were not supported by adequate documentary evidence. Federal regulations provide that cost information as developed by the provider must be current, accurate, and in sufficient detail to support payments made for services rendered to beneficiaries. We recommend that the provider implement policies and procedures to ensure that all expenses shown on the cost report are supported by sufficient documentation. We recommend that the Department of Medical Assistance make the following adjustment to remove the undocumented expenses from allowable costs.
(HCFAPub.15-1 Section 2304)

COST CENTER Dietary Operation and Maintenance of Plant Administrative and General
Total Adjustment to Allowable Costs

$

(1,418)

(106)

(1,173)

$==:::l!=::(:2::,=6=9=76)

Allocation ofIndirect Expenses to Non-Patient Care Areas

Finding No.3

The provider uses a portion of its building for purposes which are not related to patient care. Indirect expenses related to the non-patient care use of the building are calculated on Schedule B-5 of the cost report. Documentation examined during the audit showed that certain corrections were necessary to amounts reported on Schedule B-5 as allowable costs and square footage. These fmdings required the recalculation of Schedule B-5. A copy of this recalculation has been
/
furnished to the provider. We recommend that the provider implement policies and procedures to ensure that all information used to allocate indirect expenses to non-patient care areas is correct. We recommend that the Department of Medical Assistance make the following adjustment to decrease allowable costs for the net effect of the recalculation.
(HCFA Pub. 15-1 Section 2102.3; General Instructions to the Cost Report)

1998 Audit Report: Azalea Trace Nursing Home

7

COST CENTER Laundry and Housekeeping Operation and Maintenance of Plant Property and Related Expenses
Total Adjustment to Allowable Costs

$ '(15,542) (9,108)
(16,684)
$=====(4=1=,3=3=4=)

Fixed Asset Purchases Claimed as Expense

Finding No.4

Allowable costs claimed included purchases of assets which are considered to be capital additions to property under generally accepted accounting principles. The Uniform Chart of Accounts issued by DMA provides for inclusion of such assets in property accounts. We recommend that the provider implement policies and procedures to ensure that all purchases of fixed assets are shown on the cost report as capital additions. We recommend that the Department of Medical Assistance make the following adjustment to reduce allowable costs by the amount of purchased assets claimed as expense and to increase allowable costs by depreciation allowable.
(HCFA Pub. 15-1 Section 108; DMA Policies and Procedures, Appendix D)

COST CENTER Operation and Maintenance of Plant Cost of Fixed Equipment Property and Related Expenses Allowable Depreciation Expense
Total Adjustment to Allowable Costs

$

(2,080)

177

$======(1=,9=0d3:):

Costs Miselassified as Nurse Aide Testing and Training

Finding No.5

An adjustment' was made during cost report preparation to remove nurse aide testing and training expenses from allowable costs. Documentation examined during the audit showed that some of these costs were not incurred to provide nurse aide testing and training services. Federal regulations provide that cost information as developed by the provider must be current, accurate, and in

8

Nursing Facility Services Program

sufficient detail to support payments made for services rendered to beneficiaries. We recommend that the provider implement policies and procedures to ensure that all costs shown on the cost report as nurse aide testing and training expenses were incurred to provide nurse aide testing and training services. We recommend that the Department of Medical Assistance make the following adjustment to reverse a portion of the provider's adjustment.
(HCFA Pub. 15-1 Section2304)

COST CENTER Administrative and General

$----9-,23-5

Finding No.6

Allocationsfrom Home Office
The provider was a component of a chain organization for the year ended 1998. As a result of our office audit of the home office cost report filed in connection with the Medicaid Nursing Home Facilities Program, we recommended that the Department of Medical Assistance make adjustments to the allowable costs claimed by the home office. We recommend that the provider and its home office implement policies and procedures to ensure that only allowable costs are allocated from the home office to the provider. We recommend that the Department of Medical Assistance make the following adjustment to correct allowable costs to reflect the allocation of the adjustments made to the home office cost report.
(HCFA Pub. 15-1 Section 2150)

COST CENTER Administrative and General Pooled Costs Administrative Expense Property and Related Expenses Investment Income Offset
Total Adjustment to Allowable Costs

$

(25,864)

(5,690)

(31,554)

1998 Audit Report: Azalea Trace Nursing Home

9

Patient Day Statistics

Finding No.7

Census records examined during the audit showed that the nursing home had 38,763 patient days of service rather than the 38,813 shown on the cost report. Federal regulations provide that cost information as developed by the provider must be current, accurate, and in sufficient detail to support payments made for services rendered to beneficiaries. We recommend that the provider implement policies and procedures to accumulate accurate patient day statistics. We recommend that the Department of Medical Assistance make the adjustment of 50 days to correct the statistical information.
(HCFA Pub. 15-1 Section 2304)

Accounts Receivable Credit Balances

Finding No.8

Documentation examined during the audit showed that the provider had numerous credit balances in its individual accounts receivable. Credit balances in the facility's accounts receivable result from overpayments for services provided to its patients. The $529.00 shown in the following table represents overpayments from the Department of Medical Assistance that had not been resolved as of March 22, 1999. We recommend that the provider review its credit accounts receivable and refund overpayments to the appropriate party. We further recommend that the provider implement policies and procedures to ensure that overpayments on patients' accounts are promptly refunded to the payor. We also recommend that the Department of Medical Assistance review this matter and recover any overpayments identified.

Patient Name
Davis, Homer Williams, Clarence
Total

Balance
$ (339.00) (190.00)
(529.00)

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Nursing Facility Services Program

SCHEDULE OF ALLOWABLE COSTS AND PATIENT DAY STATISTICS

ALLOWABLE COSTS

COST REPORT TOTALS

FIELD AUDIT FINDINGS.

AUDITED TOTALS

Routine Services

$ 1,701,592 $

(3,866) $ 1,697,726

Special Services

83,404

(198)

83,206

Dietary

337,786

(1,592)

336,194

Laundry and Housekeeping

306,153

(15,542)

290,611

Operation and Maintenance of Plant

193,179

(22,881)

170,298

Administrative and General

505,408

(14,694)

490,714

Property and Related Expenses

321,452

-\- _ (9,480)

311,972

Total Allowable Costs

$ 3,448,974 $ (68,253) $ 3,380,721

PATIENT DAY STATISTICS

38,813

.( 50)

38,763