REPORT DIGEST

TINLEY PARK
MENTAL HEALTH CENTER

LIMITED SCOPE

COMPLIANCE EXAMINATION

For the Two Years Ended:

June 30, 2007

Summary of Findings:

Total this audit                  2

Total last audit                  2

Repeated from last audit    1

Release Date:

June 12, 2008

State of Illinois

Office of the Auditor General 

WILLIAM G. HOLLAND

AUDITOR GENERAL

To obtain a copy of the Report contact:

Office of the Auditor General

Iles Park Plaza

740 E. Ash Street

Springfield, IL 62703

(217) 782-6046 or TTY (888) 261-2887

This Report Digest and Full Report is also available on the worldwide web at

http://www.auditor.illinois.gov

SYNOPSIS

¨      The Federal Department of Health and Human Services decertified the Center as a provider of Medicare services effective February 23, 2007.  The decertification resulted in an estimated loss of revenue of $50,000 as of June 30, 2007 and a potential loss of revenue of approximately $490,000 on an annual basis.

¨      The Center had inadequate maintenance of patient files.  Files did not always contain information required by State law.

{Expenditures and Activity Measures are summarized on the reverse page.}

EXPENDITURE STATISTICS

FY 2007

FY 2006

FY 2005

     Total Expenditures (All Appropriated Funds).....................

$19,340,396

$20,312,342

$23,470,440

     OPERATIONS TOTAL..................................

         % of Total Expenditures........................

         Personal Services...................................

$18,784,781

97.1%

$12,418,353

$19,348,209

95.3%

$12,978,442

$23,280,490

99.2%

$16,160,263

                % of Operations Expenditures...........

                Average No. of Employees............

                Average Salary Per Employee.......

66.1%

192

$64,679

67.1%

209

$62,098

69.4%

219

$73,791

         Other Payroll Costs (FICA, Retirement)..

                % of Operations Expenditures.......

$2,263,553

12.0%

$2,018,866

10.5%

$3,652,837

15.7%

         Contractual Services...............................

                % of Operations Expenditures.......

$1,211,601

6.5%

$1,591,301

8.2%

$810,434

3.5%

         Commodities...................................................

                % of Operations Expenditures...................

$2,535,796

13.5%

$2,405,345

12.4%

$2,432,865

10.4%

         All Other Items......................................

                % of Operations Expenditures........

$355,478

1.9%

$354,255

1.8%

$224,091

1.0%

     GRANTS TOTAL..........................................

         % of Total Expenditures.........................

$555,615

2.9%

$964,133

4.7%

$189,950

0.8%

Cost of Property and Equipment.................

$52,181,362

$52,347,116

$52,096,000

SELECTED ACTIVITY MEASURES               (Not Examined)

FY 2007

FY 2006

FY 2005

     Average Number of Residents..............................

69

89

109

Ratio of Employees to Residents.........................

Paid Overtime Hours & Earned Compensatory Hours..................................................................

2.78/1


23,016

2.35/1


30,078

2.01/1


39,228

     Value of Paid Overtime Hours & Earned Compensatory Hours............................................

Cost Per Year Per Resident.................................

$1,072,480

             *      

$1,220,055

$246,571

$1,465,815

$246,396

*Department had not calculated at the close of fieldwork.

FACILITY DIRECTOR

     During Audit Period:  Ms. Brenda Hampton

     Currently:  Ms. Brenda Hampton

Federal government decertifies the Center

Revenue loss

Violation of the condition for participation

Department agrees with auditors

Documentation required by law to be in patient files was missing

Department agrees with auditors

FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS

DECERTIFICATION OF CENTER AS MEDICARE SERVICES PROVIDER

      The Federal Department of Health and Human Services decertified the Center as a provider of Medicare services, effective February 6, 2007.  The decertification resulted in an estimated loss of revenue of $50,000 as of June 30, 2007 and a potential loss of revenue approximating $490,000 on an annual basis.

      The Center of Medicare & Medicaid Services conducted a survey of the Center on August 2, 2006 and identified “an immediate jeopardy to the health and safety of the patients”.  The survey concluded the Center was in violation of the Condition for Participation:  Special Medical Record Requirements for Psychiatric Hospitals and Condition of Participation:  Special Staff Requirements for Psychiatric Hospitals.  Revisits concluded the Center remained in violation.  (Finding 1, page 9-10)

Department officials agreed with our recommendation to develop a plan to obtain recertification and initiate controls to ensure compliance in the future.  Department officials stated the Center has developed and is in the process of implementing a plan to obtain recertification and an application for recertification was submitted to the Centers for Medicare and Medicaid Services on December 21, 2007.

INADEQUATE MAINTENANCE OF PATIENT FILES

In our testing of State mandates regarding documentation required to be included in patient files, we noted the following instances of missing documentation.

Of the 12 patient files tested:

• 7 of the 12 (58%) patient files did not contain either a Notice of Discharge Form or a Discharge/Transfer Summary Form as required by the Mental Health Development Disabilities Code.
   

• 6 of the 12 (50%) patient files did not contain a Uniform Screening and Referral form as required by the Code.

• 1 of the 12 patient files did not contain an Authorization to Disclose/Obtain Information Form and 1 of the 12 did not contain an Authorization for Release of Information and Assignment of Benefits Form. (Finding 2, pages 11-12)

Department officials agreed with our recommendation that the Center ensure that all documents required are properly included in each patient file and that the files are maintained in a manner that complies with the federal regulations necessary to obtain recertification.

AUDITORS’ OPINION

      We conducted a compliance examination of the Center as required by the Illinois State Auditing Act.  This was a limited scope compliance examination.  The Center’s accounting records will be covered by the audit of the entire Department of Human Services.  Financial statements for the entire Department will be presented in that report.

____________________________________

WILLIAM G. HOLLAND, Auditor General

WGH:KMC:drh

SPECIAL ASSISTANT AUDITORS

      Our special assistant auditors for this audit were Duffner & Company, P.C.