Commonwealth of Pennsyvania Departmentathe Audtor General arvsburg.PA 17120-0018 Facebook: Pentsvania Attar General "Twiter@PAAudtorGen ‘worm Panudtor gov NUSTORGENGRAL October 25,2022 ‘The Honorable Lamont G. MeClure, I. County Executive "Northampton County {669 Washington Steet Easton, PA 18042 Dear Me, MeClute: ‘This ep contin theresa of the Deparment ofthe Autor General's pecfomance ait of th Northampton County ~Gracdale Nursing Home (Graces) with regan to costs that were ‘Pimbursed by the Ponnayvana Department of Human Services (DHS). This suit wax Conducted under he authority of Sections 42 and 403 of The Fiscal Cade (Code), and in Secordance withthe 2020-2021 Budget implementation provision af Are XVITL, Sub atte B, Seetion 171541 ofthe Pennsylvania Fisval Code, 72S. § (71S. The at was not, nor wast equi Tobe, conducted in accordance with Government Auting Stands sued by the Comptroller General ofthe United States ‘The performance audit covered the period July 1, 2020 through June 30, 2021, with updates ‘through the report date, Our audit objective was to determine whether services for which the costs wore reimbursed by DHS were rendered. We planned and performed audit procedures to ‘obtain sufficient, appropiate evidence to the extent necessary to satisfy the aut objective. We believe thatthe evidence obtained provides a reasonable bass to support our results and conclusion. ‘We selected and reviewed 60 claims that were reimbursed by DHS and fund tht documentation iintsined by Gracedele supported those services were rendered in accordance with applicable laws, associated regulations, ad policies without exception. Accordingly, we issued no findings ‘or recommendations and management indicated agreement with our aut result‘The Honorable Lamont G. MeClure, Ie. October 25, 2022 Page 2 In closing, f want to thank Gracedale for its cooperation and assistance during this audit. Sincerely, TT yy es. ‘Timothy L. DeFoor Auditor GeneralPERFORMANCE AUDIT REPORT Northampton County — Gracedale Nursing Home Costs reimbursed by the Pennsylvania Department of Human Services October 2022‘This page left blank intentionally‘commonwealth of Pennigvania Department ofthe Auditor General Viarrsburg PA 17120-0018 sacebooks Pennsyvanta Auditor General “Twitter: @PAAualorGen ‘ewPaauaitor gov Rehan October 19, 2022 Ms. Jennifer D, Stewart-King, B.S., NHA, Adiministator ‘Northampton County ~ Gracedale Nursing Home 2 Gracedale Avenue ‘Nazareth, PA 18064 Dear Ms, Stewar-King “This report contains the results ofthe Department of the Auditor General's performance audit of the Northampton County - Gracedale Nursing Home (Gracedale with regard to costs that were reimbursed by the Pennsylvania Department of Human Servies (DHS). This audit was ‘onucted under the authority of Sections 402 and 403 of The Fiseal Code (Code), and in ‘cordance with the 2020-2021 Budget Implementation provision of Article XVI-L, Sub article B, Section 1715-L ofthe Pennsylvania Fiscal Code, 72..S. §1715-L, The ault was not, nor ‘was it required tobe, concluted in accordance with Government auditing Siandards issued by the Compioller General ofthe United States. “The performance aut covered the period July 1, 2020 through June 30, 2021, with updates though the report dat, Our aut objective was fo determine whether services for which the costs were reimbursed by DHS wore rendered. We planned and performed avdit procedures to ‘obiain sufficient, appropriate evidence to the extent necessary to satisfy the audit objective, We belive thatthe evidence obtained provides a reasonable bass to support our results and conelusion. We selected and reviewed 60 claims that were reimbursed by DHS and found tht documentation maintained by Gracedale supported those services were rendered in accordance with applicable Taos, associated regulations, and policies without exception. Accordingly, we issued no findings ‘or recommendations and management indicated agreement with our audit resultsMs, Jennifer D. Stewart Ociober 19, 2022 Page 2 ing, BS, NHA, Administrator In closing, want to thank Gracedale for its cooperation and assistance during this eu Sincerely, =) L. dete ‘Timothy L. DeFoor Auditor General‘A Performance Audit Northampton County ~Gi TABLE OF CONTENTS Background 1 Audit Procedures and Results . 3 Appendix A Objective, Scope, Methodology, and Data Rib nun 4 Appendix B ~ Distribution Ls. : et 9‘APerformance Audit Northampton County - Gracedale Nursing Home ———— Background Gracedale Nursing Home (Gracedale) is county-operated nursing home located in Nazareth, "Northampton County, Pennsylvania, licensed by the Pennsylvania Department of Health (DOH) and registered as & Medical Assistance (MA) services provider with Ue Pennsylvauia Department of Human Services (OHS). Originally opened inthe 1800s as the Northampton County Home to care fr the poor and wards ofthe county, it was renamed Gracedale in 1981 and became a long-term eae facility. Gracedale offers long-irm residency ear, Alzheimer’ ‘memory ear, respite care and shor-term rehabilitation services.* All 688 beds in the fal cotified for MA-ligible residents.» As of June 30, 2021, 41 of 515 residents, or approximately 8 pereent, were eligible for MA Long-Term Care (LTC) services for which Gracedale received reimbursements after submitting MA claims through the DHS PROMISe™ system “The Northampton County Executive along with the county's Director of Human Services ‘oversee Gracedale's operations. The Nursing Home Administrator heads an administrative team. responsible for the day-to-day management of the facility. Gracedae's mission is: To care for the people wth heath care needs inthe most cost-effective manner while preserving ther dignity and the pursuit of the highest quality of ie. * Long-Term Care Services Gracedale provides LTC nursing facility services for residents needing moderate to full assistance with daily living, Financially and medically eligible individuals who need assistance to pay for LTC ata nursing Taility may apply for MA. DHS determines an individuals financial eligibility through its County Assistance Offices (CAO), while the Northampton County Area ‘Agency on Aging (AAA) determines medial eligibility by reviewing a medical evaluation completed by an individuals doctor. The county's AAA reports its eligibility decision tothe CAO. I'the CAO determines thatthe individual qualifies for MA based on the financial and medical records, MA will pay a daily rate for LTC nursing facility services, referred to as “room and board.” > femain baie fom the DOH Hens sud 0 Grace on July 21, 202, ‘Resin infomation oid fom Graedale resident sus eps or ane 30, 2021, PROMISE isthe Proviger Reinuremeat and Operations Managment Infomation Sytem in an eleetonie format. tis BS" {tans roesing and managsrent aration ye tht corporates he lias processing and infomation ctv ofthe following DHS program sex 1) Ofc of Medel Assistance Programs; 2) Oe of| Developent rogrus; 3) Office of Menta Hel and Substance Abuse Series; Oe of Long-Term ing) Spoil Pharmaceical Benes Program; and 6) Healy Beginnings Ps $s gaze rao (aces uly 18, 2022. ‘The Gina alent fo the period ay 1, 220 June 30, 2021, was $221.92, a eth by DHS ItA Performance Audit Northampton County ~ Gracedale Nursing Home ‘The MA LTC rate of reimbursement includes costs for routine services including, but not limited to, the following: Regular room, dietary services, social services. General LTC services to meet daily living and health needs, Hair cae sevice. Laundky services. ‘medical transportation services. is required 0 locate medical services which the facility does not provide, such as dental care. ‘+ Persona eae items including a patient gown, shampoo, ska lotion, comb, brush, toothpaste, and toothbrush,” MA reimbursement is available for nursing facility services provided ata DOH licensed nursing hhome that DHS has ceaiied as an MA-registered Nursing Facility A participating facility must ‘oratrange for, natsing or related services and specialized rehabilitative services to attain tin the highest practicable physical, mental, and psychosocial well-being of each resident. Funding Gracedale eevives a portion ofits MA LTTC Funding through beth the U-S. Department of Health and Human Services and the state DHS Office of Long-Term Living. Gracedale submits MA Grants to States for Medical Assistance Programs, Title XIX ofthe Social Security Act of 1935, as amended (42 U.S.C. § 1396 ef eq). > Medical Assistance Manual, Par Il, Title $5 of the Pennsylvania Code (55 Pa. Code § 1101 et seq). > Nursing Faciliy Services, Title $5 of the Pennsylvania Code (55 Pa. Code § 1187). > Nursing Facility Care, Tite 55 ofthe Pennsylvania Code (55 Pa. Code § 1187)! ia "uy sngodOP-Mometsi gain Gnome Fn 2222, (gee Febery 22,2022). mrad 181,82 (aceesed Febriny 22,202).A Performance Audit ‘Northampton County ~ Gracedale Nursing Home > DHS Long-Term Care Handbook." > Gracedales Billing poliey and procedure (undated) Interviewed Gracedale’s management to gin an understanding ofthe organization's LTC ‘nursing fecility operations associated with our population of MA claims that the DHS approved for reimbursement during the aut period. ‘Obtained Gracedale's written procedures to document the LTC services provided for MA residents inthe facility and developed audit procedures to test internal controls designed to ensure the accuracy of the service descriptions ereated to support Gracedale’s MA reimbursement claims submitted to DHS and compliance with applicable laws and regulations. Considered information obtained at « meeting with DHS staff from the Office of Long ‘Team Living (OLTL) held during «prior audit to gain an understanding ofthe LTC [Nursing Facilities Services program and the serves eligible for MA reimbursement. Auditors also discussed how claims are submited using the PROMISE™ system, which ‘verifies the residents" MA eligibility before DHS approves a claim for reimbursement. ‘Obtained a data file from DHS OLTL containing all Gracedale MA claims that DHS approved for reimbursement during the petiod July 1, 2020, through June ‘30,2021, which included 1,337 claims for 271 residents, totaling $3,320,358. For ‘our audi population, we judgmentally included residents with atleast one approved claim totaling over $750, This adit population consisted of 210 residents with 1,173 claims totaling 3,305,757.05. Randomly selected 60 residents from the DHS OL datafile audit population as defined inthe prior bullet and judgmental selected one claim fr each resident toensure the 60 claims represented services provided throughout the fiscal year under review. The 60 selected claims totaled $221,646. Developed and performed the following procedures for each selected claim fo determine ‘whether intemal eortzols were operating effectively to ensue thatthe MA claims ‘Gracedale submits for reimbursement comply with applicable lave and policies: > Confirmed the MA-enrolled resident had DHS approval to receive MA for LTC services during the service period associated with each selected claim (acess Jane 1,202)‘APPerformance Audit Nor umpton County ~ Gracedale Nursing Home > Reviewed the residents admissions agreement associated with each resident for the selected claim to ensure they consented to entering Gracedale to receive LTC > Obtained Gracedale's census reports and medication administration reports covering the service period for each selected claim to verity the resident was presenta the facility duting the service period ofthe claim submited to DHS for reimbursement, > Agreed the numberof service days DHS approved for reimbursement tothe facility's census reports foreach selected claim, > Recaleulated the claim amounts by multiplying the number of service days bythe applicable DH1S-established reimbursement rate.” When applicable, we reviewed ‘documentation of aay claim adjustments associated witha selected MA claim and approved during the audit period to conclude on the propriety ofthe adjustments and selected claim's reimbursement amount. > Verified the data associated with each MA claim selected for testing from the DHS ‘OLTL file agreed withthe claim's source documents in aecordance with DHS OLTL, policy Data Reliability \We performed an assessment ofthe sufficiency and appropriateness of computer processed information that we used to support our results and conclusion. The assessment included considerations regarding the completeness and accuracy of the data forthe intended purposes. + To-assess the completeness and accuracy ofthe datafile of DHS-approved MA claims summarized by MA provider for federal account code 70161 forthe period July 1, 2020 through June 30, 2021, BITA reconciled the data ile to DHS data provided to the Department and evaluated as part of the Commonwealth's Single Auait forthe fiscal year ‘ended June 30, 2021 conducted jointly by the Department and a certified public ‘counting firm, Based on the procedures performed, we concluded the data to be Sullicientl reliable forthe purposes of soleting MA providers w audi, clang Gracedale‘A Performance Audit Northampton County ~ Gracedale Nursing Home ‘+ To assess the completeness and accuracy ofthe data file received ftom DHS OLTL containing individual Gracedale claims approved by DHS during the period July 1, 2020, through June 30, 2021, we performed the following ‘© Reconciled the total MA claims amount tothe datafile BITA created utilizing monthly files of DHS-approved claims DHS provided and BITA evaluated as port, ‘of the Commonwealth's Single Audit described inthe bullet above). ‘0. Reviewed the data file for possible duplicate reimbursement payments fiom DIES for the same service month or for any other anomalies requiring investigation to ensue the propriety of the claims. ‘© Reviewed 60 selected MA claims from the DHS OLTL daa ile and agreed the data fo source documents maintained by Gracedale, as noted in our Methodology above, ‘We eoneluded the DHS OLIT. data file was sulicient reli engagement Se forthe purposes ofthis‘A Performance Audit ‘Northampton County ~ Gracedale Nursing Home DEI ons eRacoeS “This report was distributed to the following Commonwealth officials: “The Honorable Tom Wott ‘Govemor Ms, Jennifer D. Stewart-King, BS.,.NHA ‘The Honorable Pat Browne ‘Administrator Majority Chair Northampton County — Gracedale Senate Appropriations Committee Nursing Home ‘The Honorable Michelle Brooks Ms, Nancy Jamann Majority Chair Business Office Manager Senate Health and Human Services Northampton County ~ Gracedale Commitee ‘Nursing Home ‘The Honorable Art Haywood ‘Ms, Dawn Tuersfeldiman, RN Minority Chair Director of Nursing Senate Health and Human Services ‘Northampton County ~ Gracedale Commitee ‘Nursing Home ‘The Honorable Prank Farry ‘The Honorable Lamont G. MeClure, Jr. Majority Chair County Executive House Human Services Committee "Northampton County ‘The Honorable Angel Cruz Ms, Sue Wandalowski Minority Chai Director, Human Services House Human Services Committee "Northampton County ‘The Honorable Ben Lukens ‘The Honorable Meg Snead Secretary ofthe Budget Acting Seeretary Office of the Budget, Department of Human Services ‘The Honorable Stacy Garrity Ms. Tina Long, State Treasurer Director, Bureau of Financial Operations Pennsylvania Treasury Department Department of Human Services ‘The Honorable Josh Shapiro Mr, Alesander Matolyak, CPA ‘Attorney General Director, Division of Audit and Review Office ofthe Attorney General Departinent of Human Services‘A Performance Audit ‘Northampton County ~ Gracedale Nursing Home "The Honorable Michael Newsome Mr. William Canfield Scertary of Administration Director Office of Administration Bureau of Audits Office of Comptroller Operations Ms. Mary Spit CollestionsCateloging State Library of Pennsylvania {This report isa matter of public record and is available online at www. Paduditor gov. Media ‘questions about the report canbe directed othe Pennsyivania Department ofthe Auditor General, Ofice of Communications, 229 Finance Building, Harrisburg, PA 17120; via email to: News@@Padudltor gov.