Audit report, for the year ended June 30, 1998, New London Health Center, Medicaid provider no. 00494139A, Nursing Facilities Services Program [June 30, 1998]

TABLE OF CONTENTS

LETTER OF TRANSMITTAL

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Summary of Audit Findings Affecting Allowable Costs and Patient Day Statistics 11

Schedule ofAllowable Costs and Patient Day Statistics

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

RUSSELL W. HINTON
STATE AUDITOR

DEPARTMENT OF AUDITS AND ACCOUNTS
MEDICAID AND LOCAL GOVERNMENT AUDITS
254 Washington Street, S.w., Suite 322 Atlanta, Georgia 30334-8400
Telephone (404) 656-2006 Facsimile (404) 656-7535
August 3, 1999

MICHAEL A. PLANT
DIRECTOR

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 New London Health Center, provider number 00494139A, 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,

RWHIkr/ds

Russell W. Hinton State Auditor

1998 Audit Report: New London Health Center

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
c
pays 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 fmancial, patient census, and other information. Information included in the Nursing Home Cost Report is subject to audit by the Department of 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

New London Health Center, a 144-bed long-term health care facility located in Snellville, 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 by Heritage Health Services, Inc., and operated as a component of McKettrick Health Services, Inc., a chain organization

2

Nursing Facility Services Program

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 New London Health Center 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 New London Health Center 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: New London Health Center

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Scope and Methodology
J

To accomplish these objectives, we perfonned 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 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 New London Health Center 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 the Department of Medical Assistance when calculating the payment rate for New London Health Center, 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.

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Nursing Facility Services Program

As a result of audit procedures related to other (non-property) costs, we noted adjustments which should be made by the Department of Medical Assistance related to depreciation and amortization; capitalrelated interest expense; and lease expense. We have included findings related to these matters in our report.
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 New London Health Center 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: New London Health Center

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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 th~ 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 Consulting Fees Dietary Supplements Medical Waste Removal Supplies Special Services Cable Television Dietary Consulting Fees Dietary Supplements Operation and Maintenance ofPlant Cable Television Medical Waste Removal Supplies Administrative and General Supplies

$

300

(12,952)

(1,436)

732 $

$

(300)

13,596

$

(412)

1,436

(1,514)

(13,356) 412
13,296
(490) 138

Total Adjustment to Allowable Costs

$

0

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Nursing Facility Services Program

Expense Reimbursements

Finding No.2

Documentation examined during the audit showed. that amounts shown on the cost report as revenues were from sales of materials and/or services, the cost of which were included in allowable costs claimed. Federal regulations provide that amounts received for discounts, allowances, refunds and rebates are not to be considered a form of income but should be used to reduce the specific costs to which they apply. We recommend that the provider implement policies and procedures to ensure that allowable costs claimed are reduced by any expense reimbursements received. We recommend that the Department of Medical Assistance make the following adjustment to reduce allowable costs claimed by expense reimbursements shown as revenues.
(HCFA Pub. 15-1 Section 800)

COST CENTER Routine Services Operation and Maintenance ofPlant

$

(714)

(1,651)

Total Adjustment to Allowable Costs

$ ===(2=,3=65:=:)

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 findings 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 increase 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: New London Health Center

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

$

(1,032)

549

1,700

$ ===1=,2=17=

Lack ofSufficient Documentation

Finding No.4

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.
(HCFA Pub. 15-1 Section 2304)

COST CENTER Operation and Maintenance ofPlant Administrative and General

$

(325)

(1,083)

Total Adjustment to Allowable Costs

$ ===(1=,4=08=)

Home Office Costs Paid by Chain Component

Finding No.5

Allowable costs claimed by this component of a chain organization included amounts incurred for the benefit of the entire chain. Federal regulations provide that allowable costs incurred for the benefit of, or directly attributable to, a specific provider must be allocated directly to the chain entity for which they were incurred; however, federal regulations also provide that allowable costs that have not been directly assigned to specific chain components must be allocated among the providers on a basis to equitably.allocate the costs over the chain components or activities receiving the benefits of the costs. We recommend that

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Nursing Facility Services Program

the provider and its home office implement policies and procedures to ensure that costs incurred for the benefit of the entire chain organization are included in home office allowable costs rather than in the provider's allowable costs. We recommend that the Department of Medical Assistance make the following adjustment to remove the costs benefiting the entire chain from this provider's allowable costs.
(HCFA Pub. 15-1 Section 2150.3)

COST CENTER Operation and Maintenance of Plant Administrative and General

$

(20)

(309)

Total Adjustment to Allowable Costs

$ ======(3=29=)

Costs Not Related to Patient Care

Finding No.6

Allowable costs claimed included payments which were not considered to be for patient care operations. Federal regulations provide that costs which are not appropriate or necessary and proper in developing and maintaining the operation of patient care facilities and activities are not allowable in computing allowable costs. We recommend that the provider implement policies and procedures to ensure that expenses claimed in the cost report do not include items not related to patient care. We recommend that the Department of Medical Assistance make the following adjustment to remove the non-patient care expenses from allowable costs.
(HCFA Pub.15-1 Sections 1215, 2104)

ITEMS Interest Expense Personal Purchases

$

(49,968)

(118)

Total Adjustment to Allowable Costs

$ ======(=50=,0..8..6=)

1998 Audit Report: New London Health Center

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COST CENTER Administrative and General Property and Related Expenses
Total Adjustment to Allowable Costs

$

(918)

(49,168)

$ ======(==50=,=,0=8'6=)

Finding No.7

Allocationsfrom Home Office

The provider was a component of a chain organization for the year ended June 30, 1998. As a result of our 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 Expenses

$ (133,354)

Accounts Receivable Credit Balances

Finding No.9

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 $4,315.07 shown in the following table represents overpayments from the Department of Medical Assistance that had not been resolved as of February 5, 1999. We recommend that the provider review its credit accounts receivable and refund overpayments to the appropriate party. We further

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Nursing Facility Services Program

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
Guyton, Thomas Tullis, Mary
Total

Balance

$

2,443.95

1,871.12

$ ==4=,3=1=5.=07=

Patient Day Statistics

Finding No. 10

The provider stated on the cost report that it furnished 39,904 patient days of service. Census records examined during the audit showed that the patient days shown on the cost report were accurate.

1998 Audit Report: New London Health Center

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SUMMARY OF AUDIT FINDINGS AFFECTING ALLOWABLE COSTS AND PATIENT DAY STATISTICS

FINDING
NUMBER

ALLOWABLE COSTS

Routine Services

1 Incorrect Expense Classifications 2 Expense Reimbursements

$ (13,356) (714) $ (14,070)

Special Services

1 Incorrect Expense Classifications

412

Dietary
1 Incorrect Expense Classifications

13,296

Laundry and Housekeeping

3

Allocations of Indirect Expense~ to Non-Patient

Care Areas

(1,032)

Operation and Maintenance ofPlant

1 Incorrect Expense Classifications

2 Expense Reimbursements

3 Allocations to Non-Patient Care Areas

4

Lack of Sufficient Documentation

5 Home Office Costs Paid By Chain Component

$

(490)

(1,651)

549

(325)

(20)

(1,937)

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Nursing Facility Services Program

FINDING NUMBER

ALLOWABLE COSTS

Administrative and General

1 Incorrect Expense Classifications

4

Lack of Sufficient Documentation

5 Home Office Costs Paid By Chain Component

6 Costs Not Related to Patient Care

7

Allocations From Home Office

$

138

(1,083)

(309)

(918)

(133,354)

(135,526)

Propertv and Related Expenses
3 Allocations ofIndirect Expenses to Non-Patient Care Areas
6 Costs Not Related to Patient Care

$

1,700

(49,168)

(47,468)

Total Adjustment to Allowable Costs

$ (186,325)

1998 Audit Report: New London Health Center

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SCHEDULE OF ALLOWABLE COSTS AND PATIENT DAY STATISTICS

ALLOWABLE COSTS Routine Services Special Services Dietary Laudry and Housekeeping Operation and Maintenance ofPlant Administrative and General Property and Related Expenses

COST REPORT TOTALS

FIELD AUDIT FINDINGS

AUDITED TOTALS

$ 1,559,145 $ 126,161 469,175 207,551 150,766 514,733 400,035

(14,070) $ 1,545,075

412

126,573

13,296

482,471

(1,032)

206,519

(1,937)

148,829

(135,526)

379,207

(47,468)

352,567

Total Allowable Costs

$ 3,427,566 $ (186,325) $ 3,241,241

PATIENT DAY STATISTICS

39,904

39,904