REPORT ON THE COST REPORT REVIEW CENTINELA HOSPITAL MEDICAL CENTER INGLEWOOD, CALIFORNIA PROVIDER NUMBER: HSC30240H NATIONAL PROVIDER IDENTIFIERS: 1336328244 AND 1619936440 FISCAL PERIOD FEBRUARY 1, 2008 TO DECEMBER 31, 2008 part2 potx

... Fullerton, CA 92835 PROVIDER: CENTINELA HOSPITAL MEDICAL CENTER PROVIDER NO.: HSC30240H NATIONAL PROVIDER INDENTIFIERS: 1336328244 AND 1619936440 FISCAL PERIOD: FEBRUARY 1, 2008 TO DECEMBER 31, ... SERVICE COST This is trial versionwww.adultpdf.com REPORT ON THE COST REPORT REVIEW CENTINELA HOSPITAL MEDICAL CENTER INGLEWOOD, CALIFORNIA PROVIDER NUMBER: HSC30240H NATIONAL PROVIDER IDENTIFIERS: ... CALIFORNIA SCHEDULE 4APROGRAM: NONCONTRACT Provider Name: Fiscal Period Ended: CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008 Provider No.ZZT30240H SPECIAL CARE AND/ OR NURSERY UNITS REPORTED...

... OF CALIFORNIA CONTRACT SCH 5 Provider Name: Fiscal Period Ended: CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008 Provider No: HSC30240H RATIO COST TO CHARGESANCILLARY COST CENTERS37.00 Operating ... SERVICESCOMPUTATION OFThis is trial versionwww.adultpdf.comSTATE OF CALIFORNIA CONTRACT SCH 4B Provider Name: Fiscal Period Ended: CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008 Provider No: HSC30240H ... versionwww.adultpdf.comSTATE OF CALIFORNIA SCHEDULE 5PROGRAM: NONCONTRACT Provider Name: Fiscal Period Ended: CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008 Provider No:ZZT30240HRATIOCOST...

... Transitional Care Unit 000000000000This is trial versionwww.adultpdf.comSTATE OF CALIFORNIA CONTRACT SCH 7 Provider Name: Fiscal Period Ended: CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008 Provider ... II36.02 Transitional Care UnitThis is trial versionwww.adultpdf.comSTATE OF CALIFORNIA SCHEDULE 8 Provider Name: Fiscal Period Ended: CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008 NET EXP ... ACCUMULATE TRATIVE & COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00COMPUTATION OF COST ALLOCATION (W/S B)048,9430000000013,482,6432,319,651000000000000025,346000000003,536,622608,466059400000000234,93040,419029,265000000004,737,187815,02008,2750000000 01,0 14,411174,52708,04000000000 1,0 25,657176,46104,23200000000792,284136,31004,54300000000896,717154,2780000000000...

... STATE OF CALIFORNIA SCHEDULE 10 Provider Name: Fiscal Period Ended: CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008 GENERAL SERVICE COST CENTERS(From Sch 10A)AUDITEDREPORTED ADJUSTMENTSTRIAL ... 4,391This is trial versionwww.adultpdf.comSTATE OF CALIFORNIA SCHEDULE 10APage 1 Provider Name: Fiscal Period Ended: CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008 TOTAL ADJ AUDIT ADJ AUDIT ... 029.5971110.88513021.16876115.322528145.9495030.0000001.8416760.0269650.7269000.0038132.5996700.000000This is trial versionwww.adultpdf.comSTATE OF CALIFORNIA SCHEDULE 10APage 1 Provider Name: Fiscal Period Ended: CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008 TOTAL ADJ AUDIT ADJ AUDIT...

... Adjusted Report References CENTINELA HOSPITAL MEDICAL CENTER AdjustmentsExplanation of Audit Adjustments FEBRUARY 1, 2008 THROUGH DECEMBER 31, 2008 HSC30240H Cost Report ADJUSTMENTS TO REPORTED ... Paid Claims Summary: Report Date: February 18, 2010 Payment Period: February 1, 2008 through December 31, 2009 Service Period : Feberuary 1, 2008 through December 31, 2008 42 CFR 413.20, 413.24, ... Adjustments FEBRUARY 1, 2008 THROUGH DECEMBER 31, 2008 HSC30240H Cost Report This is trial versionwww.adultpdf.comState of California Department of Health Care Services Provider Name Fiscal Period Provider...

... versionwww.adultpdf.comSTATE OF CALIFORNIA SCHEDULE 5PROGRAM: NONCONTRACT Provider Name: Fiscal Period Ended:SAN FRANCISCO GENERAL HOSPITAL JUNE 30, 2009 Provider No:ZZR00228WRATIO COST TO CHARGESANCILLARY ... reasonable cost, no further calculation necessary for this schedule.COMPUTATION OF LESSER OFMEDI-CAL REASONABLE COST OR CUSTOMARY CHARGESThis is trial versionwww.adultpdf.comSTATE OF CALIFORNIA ... STATE OF CALIFORNIA DESIG PUB HOSP SCH 5 Provider Name: Fiscal Period Ended:SAN FRANCISCO GENERAL HOSPITAL JUNE 30, 2009 Provider No:HSC00228WRATIO COST TO CHARGESANCILLARY COST CENTERS37.00...

... NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP NEW CAPCOSTS COSTS COSTS COSTS COSTS COSTS COSTS COSTS COSTS COSTS COSTS COSTSMVBLE EQ BLDG & FIX BLDG 2 BLDG 3 BLDG 5 BLDG 9 BLDG ... BALANCE COST ALLOC BLDG & COSTS COSTS COSTS COSTS COSTS COSTS COSTS COSTS COSTS COSTSEXPENSES (From Sch 10) FIXTURES BLDG 2 BLDG 3 BLDG 5 BLDG 10 BLDG 20 BLDG 30 BLDG MRI BLDG 80 BLDG 90 LAND ... BALANCE COST ALLOC BLDG & COSTS COSTS COSTS COSTS COSTS COSTS COSTS COSTS COSTS COSTSEXPENSES (From Sch 10) FIXTURES BLDG 2 BLDG 3 BLDG 5 BLDG 10 BLDG 20 BLDG 30 BLDG MRI BLDG 80 BLDG 90 LAND...

... TOTALCOMPUTATION OF COST ALLOCATION (W/S B) SCHEDULE 8.2 Fiscal Period Ended: JUNE 30, 2009NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP NEW CAP ADMINIS- OPERATIONS LAUNDRY &COSTS COSTS COSTS COSTS COSTS COSTS ... 23,401510,192 11,0 68,17827,603,44623,40123,401628,03823,4015,43012,7773,512,4625,027,2215,4305,43039,0395,4305,632106,3722,593,5145,292,0355,6325,6325,63232,299283,9899,254,47122,726,87532,29932,299154,07232,29907,80326,515102,62822,207,60926,51526,51526,51524,3488,078125,914 1,5 32,57224,34824,34810,78324,3483,118,600 1,9 09103,4674,662,876 1,9 09 1,9 09 1,9 096,8803,454,0015,553,0136,8806,88028,7466,8807185 51,8 45809,9507187187187,503116,938417,2873,476,3487,5037,5033,6577,503195118,2211 61,2 171951951952152,532,0402152152154,306,2953,56632186316,018,6813,5663,5663,5663,1403,30818,3202,755,5283,3083,3084,5703,3088,0298,492753,9702,082,9088,0298,0298,029000000000040,53735,1884,619,1648,319,33040,53740,5371 11,4 6940,537 11,3 5254,29815,324,40922,244,362 11,3 52 11,3 52490,792 11,3 52 1,8 873,698,2566,5 81,7 01 1,8 87 1,8 87109,071 1,8 87033,0975,704,11419,660,14625,90525,90525,9058,2692,1653,9 11,6 437,342,3378,2698,2698,26928,7963,177,9457,066,49328,79628,79628,79613,9692,2 91,1 014,5 31,0 4513,96913,96913,9692,126,9582,5 71,0 887,1927,1927,192463,7600055,034352,204 51,8 2826,341 11,1 16,78332,124,328352,204352,20466,535352,20400000000000089,157 ... Room40.00Anesthesiology41.00Radiology - Diagnostic43.00Radioisotope44.00Laboratory44.01Laboratory Pathology46.00Whole Blood49.00Respiratory Therapy50.00Physical Therapy51.00Occupational Therapy53.00Electrocardiology54.00Electroencephalography55.00Medical...

... 15,900,440 * To adjust the provider& apos;s reclassification of medical supplies charged to patients to agree with the supporting documentations.CMS Pub. 15 -1, Sections 2300, 2304, and 23064 ... AdjustmentsJULY 1, 2008 THROUGH JUNE 30, 2009 HSC00228W Cost Report This is trial versionwww.adultpdf.comSTATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10APage 1 Provider Name: Fiscal Period ... 463,760 To reverse the provider& apos;s reclassification of medical supplies charged to patients to agree with the provider& apos;s general ledger.CMS Pub. 15 -1, Sections 2300, 2304, and 23065 10A...

... HOSPITAL AdjustmentsExplanation of Audit AdjustmentsJULY 1, 2008 THROUGH JUNE 30, 2009 HSC00228W Cost Report ADJUSTMENTS TO REPORTED COSTS9 10A A 6.00 7 Administrative and General * $85,292,593 ($2 01,2 32) $85,0 91,3 61 To ... Requisitions 25,359,374 (4,405,182) 20,954,192 To adjust costed requisitions statistics to agree with the provider& apos;srecords and for proper cost determination.CMS Pub. 15 -1, Sections 2300, ... (310) 1,9 949 B-1 96.01 14 Other Than Hospital 4,368 310 4,678 To adjust Nursing Administration statistics to agree with the provider& apos;srecords.CMS Pub. 15 -1, Sections 2300, 2304, and 230615...