REPORT DIGEST

TINLEY PARK MENTAL HEALTH CENTER

LIMITED SCOPE COMPLIANCE EXAMINATION

For the Two Years Ended: June 30, 2009

Summary of Findings:

Total this audit: 6

Total last audit: 2

Repeated from last audit: 2

Release Date: June 29, 2010

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 are also available on the worldwide web at www.auditor.illinois.gov

____________________________

SYNOPSIS

• The Tinley Park Mental Health Center (Center) did not obtain certification from the Federal Department of Health and Human Services to be a provider of services under the Medicare Program.

• The Center did not adequately maintain patient files.

• The Center did not exercise adequate controls over voucher processing.

FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS

DECERTIFICATION OF CENTER AS MEDICARE SERVICES PROVIDER

The Tinley Park Mental Health Center (Center) did not obtain certification from the Federal Department of Health and Human Services to be a provider of services under the Medicare Program (Title XVIII of the Social Security Act).

On February 6, 2007, the Center for Medicare & Medicaid Services (CMS) issued notice the Center was decertified effective February 23, 2007 and could no longer seek payment for services from the Medicare program. In December 2007, the Center submitted an application for recertification to CMS, stating all previous noncompliance issues had been corrected. CMS conducted a resurvey in September 2009. On October 21, 2009, CMS informed Center management the Center still did not meet the requirements for participation in the Medicare program. The resurvey concluded the Center did not meet the following two conditions of participation: Special Medical Record Requirements for Psychiatric Hospitals (42 CFR 482.61) and Special Staff Requirements for Psychiatric Hospitals (42 CFR 482.62). (Finding 1, page 9-10)

We recommended that the Center implement a plan to obtain recertification and strengthen controls to ensure compliance with the Medicare Provider Agreement and the Social Security Act.

Center officials agreed with our recommendation and stated the Center continues its efforts to regain recertification as a Medicare provider of psychiatric inpatient services. The hospital has corrected and remains in compliance with the findings from a February 2007 survey. The hospital has implemented corrective actions and is in compliance with the findings from a September 2009 survey.

In April 2010, the Division of Mental Health, on the hospital’s behalf, requested a hearing before an administrative law judge. The hospital contends CMS surveyors were in err in stating the original findings had not been corrected. The hospital contends that CMS erred in denying the hospital an appeal and in not reestablishing the hospital’s certification following the September 2009 survey. The facility will continue its effort to maintain compliance with all subsections of the CMS Standards for Psychiatric Hospitals.

INADEQUATE MAINTENANCE OF PATIENT FILES

The Center did not adequately maintain patient files.

Six of 19 (32%) patient files tested did not contain sufficient evidence the Center had complied with required statute. One file tested did not contain evidence the Center had notified designated persons of the patient’s admission within 24 hours of admission. The remaining five patient files did not contain a properly completed Notice of Admission Form requesting the patient, at admission, if they wish to notify any designated persons. (Finding 2, page 11)

We recommended that the Center maintain sufficient documentation to ensure compliance with the Mental Health and Developmental Disabilities Code.

Center officials agreed with our recommendation and stated Center management will hold an in-service training for the Center’s intake and social work staff on the proper documentation of patient files to ensure the files are maintained according to the federal regulations.

INADEQUATE CONTROLS OVER VOUCHER PROCESSING

The Center did not exercise adequate controls over voucher processing.

Some of the weaknesses noted follow:

• Three of 62 (5%) vouchers tested, totaling $27,908, did not agree to supporting documentation. One voucher contained errors in the proposal amount and did not show details of what was billed. The other two vouchers did not show sufficient details of what was billed. As a result, we were unable to determine if the expenditures were reasonable or necessary.

• Seven of 62 (11%) vouchers tested, totaling $56,382, were approved for payment from 2 to 86 days late. (Finding 3, page 12-14)

We recommended the Center strengthen internal controls over expenditures by following all applicable State laws, rules and regulations.

Center officials agreed with our recommendation and stated that Center management will meet with vouchering staff and establish a checklist of requirements for vouchers processed, as well as re-reviewing the steps followed during the voucher process to identify and correct any errors.

OTHER FINDINGS

The remaining findings are reportedly being given attention by the Center. We will review the Center’s progress toward the implementation of all our recommendations in our next engagement.

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:AKS

AUDITORS ASSIGNED

The compliance examination was conducted by the Office of the Auditor General’s staff.