STATE OF CALIFORNIA ADULT SUBACUTE SCH 2 Provider Name: Fiscal Period Ended: ALHAMBRA HOSPITAL MEDICAL CENTER JUNE 30, 2007 Provider No: LTC 70043G COST CENTER COL. DIRECT AND ALLOCATED EXPENSE 0.00 Adult Subacute $ 2,363,723 $ 2,363,723 $ 0 1.00 Old Cap Rel Costs-Bldg & Fixtures 0 0 2.00 Old Cap Rel Costs-Movable Equipment 0 0 3.00 New Cap Rel Costs-Bldg & Fixtures 263,723 314,131 50,408 4.00 New Cap Rel Costs-Movable Equipment 0 0 4.01 00 4.02 00 4.03 00 4.04 00 4.05 00 4.06 00 4.07 00 4.08 00 5.00 Employee Benefits 22,774 21,961 (813) 6.01 Non-Patient Telephones 0 0 6.02 Data Processing 0 0 6.03 Purchasing/Receiving 0 0 6.04 Patient Admitting 0 0 6.05 Patient Business Office 0 0 6.06 00 6.07 00 6.08 00 6.00 Administrative and General 342,636 338,862 (3,774) 7.00 Maintenance and Repairs 0 0 8.00 Operation of Plant 468,926 475,280 6,354 9.00 Laundry and Linen Service 77,252 77,928 676 10.00 Housekeeping 21,924 22,490 566 11.00 Dietary 64,468 64,749 281 12.00 Cafeteria 90,463 92,332 1,869 13.00 Maintenance of Personnel 0 0 14.00 Nursing Administration 0 0 15.00 Central Services & Supply 4,164 4,392 228 16.00 Pharmacy 0 0 17.00 Medical Records and Library 91,104 44,666 (46,438) 18.00 Social Service 23,767 22,864 (903) 19.00 00 19.02 00 19.03 00 20.00 00 21.00 Nursing School 0 0 22.00 Intern & Res Service-Salary & Fringes 0 0 23.00 Intern & Res Other Program 0 0 24.00 Paramedical Ed Program 0 0 TOTAL DIRECT AND 101.00 ALLOCATED EXPENSES $ 3,834,924 $ 3,843,377 $ 8,453 (To Adult Subacute Sch 1) * From Schedule 8, Part I, Line 36.00 SUMMARY OF ADULT SUBACUTE FACILITY EXPENSES REPORTED AUDITED * DIFFERENCE This is trial version www.adultpdf.com STATE OF CALIFORNIA ADULT SUBACUTE SCH 3 Provider Name: Fiscal Period Ended: ALHAMBRA HOSPITAL MEDICAL CENTER JUNE 30, 2007 Provider No: LTC 70043G TOTAL RATIO TOTAL SUBACUTE SUBACUTE ANCILLARY CHARGES COST TO ANCILLARY ANCILLARY COST * CHARGES CHARGES ** COSTS*** ANCILLARY COST CENTERS (Adult SA Sch 4) 37.00 Operating Room $ 3,167,973 $ 15,068,745 0.210235 $ 0 $ 0 41.00 Radiology - Diagnostic 2,434,853 10,756,349 0.226364 52,182 11,812 43.00 Radioisotope 431,248 1,854,743 0.232511 0 0 44.00 Laboratory 3,175,765 21,740,181 0.146078 295,140 43,113 46.00 Whole Blood & Packed Red 873,403 623,641 1.400490 0 0 49.00 Respiratory Therapy 2,532,287 19,155,590 0.132196 5,319,759 703,249 50.00 Physical Therapy 699,685 3,958,002 0.176777 45,027 7,960 52.00 Speech Pathology 77,916 530,593 0.146847 15,960 2,344 53.00 Electrocardiology 735,125 4,110,438 0.178843 0 0 54.00 Electroencephalography 75,249 105,813 0.711151 0 0 55.00 Med Supply Charged to Patients 3,159,034 6,182,537 0.510961 1,371,895 700,985 56.00 Drugs Charged to Patients 4,077,315 28,451,429 0.143308 3,706,006 531,100 57.00 Renal Dialysis 447,219 1,789,364 0.249932 0 0 61.00 Emergency 3,003,592 6,232,588 0.481917 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 101.00 TOTAL $ 24,890,664 $ 120,560,013 $ 10,805,969 $ 2,000,563 (To Adult Subacute Sch * From Schedule 8, Column 27 ** Total Other Allowable Ancillary Charges included in the rate. *** Total Other Ancillary Costs included in the rate. SCHEDULE OF TOTAL OTHER ALLOWABLE ADULT SUBACUTE ANCILLARY COSTS** TOTAL ANCILLARY This is trial version www.adultpdf.com STATE OF CALIFORNIA ADULT SUBACUTE SCH 4 Provider Name: Fiscal Period Ended: ALHAMBRA HOSPITAL MEDICAL CENTER JUNE 30, 2007 Provider No: LTC 70043G ANCILLARY CHARGES 37.00 Operating Room $ $ $ 0 41.00 Radiology - Diagnostic 32,687 19,495 52,182 43.00 Radioisotope 0 44.00 Laboratory 272,618 22,522 295,140 46.00 Whole Blood & Packed Red 0 49.00 Respiratory Therapy 5,177,220 142,539 5,319,759 50.00 Physical Therapy 35,044 9,983 45,027 52.00 Speech Pathology 15,960 15,960 53.00 Electrocardiology 0 54.00 Electroencephalography 0 55.00 Med Supply Charged to Patients 1,355,230 16,665 1,371,895 56.00 Drugs Charged to Patients 3,607,747 98,259 3,706,006 57.00 Renal Dialysis 0 61.00 Emergency 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 101.00 TOTAL ANCILLARY CHARGES $ 10,480,546 $ 325,423 $ 10,805,969 (Adj 29) AUDITED ADJUSTMENTS TO OTHER ALLOWABLE ADULT SUBACUTE ANCILLARY CHARGES (To Adult Subacute Sch 3) REPORTED ADJUSTMENTS This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: Fiscal Period Ended: ALHAMBRA HOSPITAL MEDICAL CENTER JUNE 30, 2007 Provider No: LTC 70043G COL. 1.00 Old Cap Rel Costs-Bldg & Fixtures $ 0 $ N/A 2.00 Old Cap Rel Costs-Movable Equipment 0 N/A 3.00 New Cap Rel Costs-Bldg & Fixtures 314,131 N/A 4.00 New Cap Rel Costs-Movable Equipment 0 N/A 4.01 0N/A 4.02 0N/A 4.03 0N/A 4.04 0N/A 4.05 0N/A 4.06 0N/A 4.07 0N/A 4.08 0N/A 5.00 Employee Benefits 567 21,395 6.01 Non-Patient Telephones 0 0 6.02 Data Processing 0 0 6.03 Purchasing/Receiving 0 0 6.04 Patient Admitting 0 0 6.05 Patient Business Office 0 0 6.06 00 6.07 00 6.08 00 6.00 Administrative and General 11,782 223,796 7.00 Maintenance and Repairs 0 0 8.00 Operation of Plant 45,702 36,103 9.00 Laundry and Linen Service 5,474 5,755 10.00 Housekeeping 3,624 1,667 11.00 Dietary 3,075 29,315 12.00 Cafeteria 12,452 29,943 13.00 Maintenance of Personnel 0 0 14.00 Nursing Administration 0 0 15.00 Central Services & Supply 1,360 911 16.00 Pharmacy 0 0 17.00 Medical Records and Library 3,008 19,935 18.00 Social Service 94 18,304 19.00 00 19.02 00 19.03 00 20.00 00 21.00 Nursing School 0 0 22.00 Intern & Res Service-Salary & Fringes 0 0 23.00 Intern & Res Other Program 0 0 24.00 Paramedical Ed Program 0 0 101.00 TOTAL ALLOCATED INDIRECT EXPENSES $ 401,268 $ 387,122 (To Adult Subacute Sch 1) ADULT SUBACUTE SCH 5 COST CENTER EMP BENEFITS AUDITED SAL &AUDITED CAP ALLOCATION OF INDIRECT EXPENSES ADULT SUBACUTE (COL 2) RELATED (COL 1)ALLOCATED EXPENSES This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 8 Provider Name: Fiscal Period Ended: ALHAMBRA HOSPITAL MEDICAL CENTER JUNE 30, 2007 NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG & MOVABLE BLDG & MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 0.00 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 COMPUTATION OF COST ALLOCATION (W/S B) GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs-Bldg & Fixtures 0 2.00 Old Cap Rel Costs-Movable Equipmen 0 0 3.00 New Cap Rel Costs-Bldg & Fixtures 2,769,328 0 0 4.00 New Cap Rel Costs-Movable Equipme 0 0 0 0 4.01 0 0 0 0 0 4.02 0 0 0 0 0 0 4.03 0 0 0 0 0 0 0 4.04 0 0 0 0 0 0 0 0 4.05 0 0 0 0 0 0 0 0 0 4.06 0 0 0 0 0 0 0 0 0 0 4.07 0 0 0 0 0 0 0 0 0 0 0 4.08 0 0 0 0 0 0 0 0 0 0 0 0 5.00 Employee Benefits 273,337 0 0 7,243 0 0 0 0 0 0 0 0 6.01 Non-Patient Telephones 0 0 0 0 0 0 0 0 0 0 0 0 6.02 Data Processing 0 0 0 0 0 0 0 0 0 0 0 0 6.03 Purchasing/Receiving 0 0 0 0 0 0 0 0 0 0 0 0 6.04 Patient Admitting 0 0 0 0 0 0 0 0 0 0 0 0 6.05 Patient Business Office 0 0 0 0 0 0 0 0 0 0 0 0 6.06 0 0 0 0 0 0 0 0 0 0 0 0 6.07 0 0 0 0 0 0 0 0 0 0 0 0 6.08 0 0 0 0 0 0 0 0 0 0 0 0 6.00 Administrative and General 5,130,468 0 0 185,193 0 0 0 0 0 0 0 0 7.00 Maintenance and Repairs 0 0 0 0 0 0 0 0 0 0 0 0 8.00 Operation of Plant 2,723,856 0 0 315,706 0 0 0 0 0 0 0 0 9.00 Laundry and Linen Service 260,747 0 0 20,193 0 0 0 0 0 0 0 0 10.00 Housekeeping 89,762 0 0 21,922 0 0 0 0 0 0 0 0 11.00 Dietary 824,208 0 0 39,290 0 0 0 0 0 0 0 0 12.00 Cafeteria 540,603 0 0 100,541 0 0 0 0 0 0 0 0 13.00 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 14.00 Nursing Administration 1,085,364 0 0 28,339 0 0 0 0 0 0 0 0 15.00 Central Services & Supply 201,961 0 0 223,21500000000 16.00 Pharmacy 1,276,665 0 0 25,05400000000 17.00 Medical Records and Library 632,733 0 0 44,55500000000 18.00 Social Service 62,215 0 0 0 0 0 0 0 0 0 0 0 19.00 0 0 0 0 0 0 0 0 0 0 0 0 19.02 0 0 0 0 0 0 0 0 0 0 0 0 19.03 0 0 0 0 0 0 0 0 0 0 0 0 20.00 000000000000 21.00 Nursing School 000000000000 22.00 Intern & Res Service-Salary & Fringes 0 0 0 0 0 0 0 0 0 0 0 0 23.00Intern & Res Other Program 000000000000 24.00Paramedical Ed Program 000000000000 INPATIENT ROUTINE COST CENTERS 25.00 Adults & Pediatrics (Gen Routine) 7,252,966 0 0 289,961 0 0 0 0 0 0 0 0 26.00 Intensive Care Unit 3,114,050 0 0 101,21400000000 27.00 Coronary Care Unit 000000000000 28.00 Neonatal Intensive Care Unit 000000000000 29.00Surgical Intensive Care 000000000000 31.00 Subprovider I 2,460,484 0 0 169,15000000000 0.00 000000000000 32.00 000000000000 33.00Nursery 000000000000 34.00 Medicare Certified Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 35.00 Distinct Part Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 36.00 Adult Subacute Care Unit 2,363,723 0 0 314,131 0 0 0 0 0 0 0 0 36.01 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 36.02 Transitional Care Unit 000000000000 This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 8 Provider Name: Fiscal Period Ended: ALHAMBRA HOSPITAL MEDICAL CENTER JUNE 30, 2007 NET EXP FOR OLD CAPITAL OLD NEW CAPITAL NEW TRIAL BALANCE COST ALLOC BLDG & MOVABLE BLDG & MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST 0.00 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 COMPUTATION OF COST ALLOCATION (W/S B) ANCILLARY COST CENTERS 37.00 Operating Room 1,960,873 0 0 190,823 0 0 0 0 0 0 0 0 38.00 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 39.00 Delivery Room and Labor Room 0 0 0 0 0 0 0 0 0 0 0 0 40.00 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 41.00 Radiology - Diagnostic 1,438,337 0 0 262,60200000000 41.01 000000000000 41.02 0 0 0 0 0 0 0 0 0 0 0 0 42.00 Radiology - Therapeutic 0 0 0 0 0 0 0 0 0 0 0 0 43.00 Radioisotope 365,648 0 0 3,84300000000 44.00 Laboratory 2,443,275 0 0 67,76400000000 44.01Pathological Lab 000000000000 46.00 Whole Blood 771,239 0 0 82600000000 47.00 Blood Storing and Processing 000000000000 48.00 Intravenous Therapy 000000000000 49.00 Respiratory Therapy 2,020,228 0 0 19,48200000000 50.00 Physical Therapy 371,268 0 0 93,336 0 0 0 0 0 0 0 0 51.00 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 52.00 Speech Pathology 44,659 0 0 9,22200000000 53.00 Electrocardiology 529,352 0 0 34,23700000000 54.00 Electroencephalography 16,793 0 0 20,59600000000 55.00 Medical Supplies Charged to Patients 2,123,99300000000000 56.00 Drugs Charged to Patients 2,113,76300000000000 57.00 Renal Dialysis 389,381 0 0 0 0 0 0 0 0 0 0 0 58.00 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 59.00 000000000000 59.01 000000000000 59.02 000000000000 59.03 000000000000 60.00Clinic 000000000000 60.01 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 61.00 Emergency 2,277,853 0 0 120,426 0 0 0 0 0 0 0 0 62.00Observation Beds 000000000000 71.00 000000000000 82.00 000000000000 83.00 000000000000 84.00 0 0 0 0 0 0 0 0 0 0 0 0 85.00 0 0 0 0 0 0 0 0 0 0 0 0 86.00 0 0 0 0 0 0 0 0 0 0 0 0 NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop & Canteen 0 0 0 9,22200000000 97.00Research 000000000000 98.00Physicians' Private Office 000000000000 99.00 Nonpaid Workers 000000000000 99.01 Marketing 0 0 0 3,843 0 0 0 0 0 0 0 0 99.02 0 0 0 0 0 0 0 0 0 0 0 0 99.03 000000000000 99.04 000000000000 99.05 000000000000 100.00 M.O.S.T 114,658 0 0 5,82200000000 100.01 Outpatient Dailysis 0 0 0 41,57700000000 100.02 Whittier - NRCC 000000000000 100.03 El Monte - NRCC 0 0 0 0 0 0 0 0 0 0 0 0 100.04 Garfield - NRCC 000000000000 TOTAL 48,043,790 0 0 2,769,328 0 0 0 0 0 0 0 0 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER TRIAL BALANCE EXPENSES GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs-Bldg & Fixtures 2.00 Old Cap Rel Costs-Movable Equipmen 3.00 New Cap Rel Costs-Bldg & Fixtures 4.00 New Cap Rel Costs-Movable Equipme 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 Employee Benefits 6.01 Non-Patient Telephones 6.02 Data Processing 6.03 Purchasing/Receiving 6.04 Patient Admitting 6.05 Patient Business Office 6.06 6.07 6.08 6.00 Administrative and General 7.00 Maintenance and Repairs 8.00 Operation of Plant 9.00 Laundry and Linen Service 10.00 Housekeeping 11.00 Dietary 12.00 Cafeteria 13.00 Maintenance of Personnel 14.00 Nursing Administration 15.00 Central Services & Supply 16.00 Pharmacy 17.00 Medical Records and Library 18.00 Social Service 19.00 19.02 19.03 20.00 21.00 Nursing School 22.00 Intern & Res Service-Salary & Fringes 23.00 Intern & Res Other Program 24.00 Paramedical Ed Program INPATIENT ROUTINE COST CENTER 25.00 Adults & Pediatrics (Gen Routine) 26.00 Intensive Care Unit 27.00 Coronary Care Unit 28.00 Neonatal Intensive Care Unit 29.00 Surgical Intensive Care 31.00 Subprovider I 0.00 32.00 33.00 Nursery 34.00 Medicare Certified Nursing Facility 35.00 Distinct Part Nursing Facility 36.00 Adult Subacute Care Unit 36.01 Subacute Care Unit II 36.02 Transitional Care Unit SCHEDULE 8.1 Fiscal Period Ended: JUNE 30, 2007 ADMINIS- ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE & COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00 COMPUTATION OF COST ALLOCATION (W/S B) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 41,997 0 0 0 0 0 0 0 0 5,357,658 0 0 0 0 0 0 0 0 0 0 0 0 0 94 0 0 0 0 0 0 0 0 3,039,656 381,516 0 0 0 0 0 0 0 0 0 0 280,940 35,262 0 0 0 0 0 0 0 0 0 0 111,684 14,018 0 4,675 0 0 0 0 0 0 0 0 868,174 108,967 0 2,625 0 0 0 0 0 0 0 0 643,769 80,801 0 0 0 0 0 0 0 0 0 0 0 0 0 9,054 0 0 0 0 0 0 0 0 1,122,757 140,920 01,30300000000426,48053,529 010,700000000001,312,419164,725 03,73800000000681,02685,478 0 610 0 0 0 0 0 0 0 0 62,825 7,885 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000000 00 0000000000 00 0 0 0 0 0 0 0 0 0 0 0 0 0000000000 00 0000000000 00 0 66,254 0 0 0 0 0 0 0 0 7,609,181 955,050 026,324000000003,241,588406,861 0000000000 00 0000000000 00 0000000000 00 018,405000000002,648,039332,363 0000000000 00 0000000000 00 0000000000 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 21,961 0 0 0 0 0 0 0 0 2,699,815 338,862 0 0 0 0 0 0 0 0 0 0 0 0 0000000000 00 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER TRIAL BALANCE EXPENSES ANCILLARY COST CENTERS 37.00 Operating Room 38.00 Recovery Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 41.01 41.02 42.00 Radiology - Therapeutic 43.00 Radioisotope 44.00 Laboratory 44.01 Pathological Lab 46.00 Whole Blood 47.00 Blood Storing and Processing 48.00 Intravenous Therapy 49.00 Respiratory Therapy 50.00 Physical Therapy 51.00 Occupational Therapy 52.00 Speech Pathology 53.00 Electrocardiology 54.00 Electroencephalography 55.00 Medical Supplies Charged to Patients 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 58.00 ASC (Non-Distinct Part) 59.00 59.01 59.02 59.03 60.00 Clinic 60.01 Other Clinic Services 61.00 Emergency 62.00 Observation Beds 71.00 82.00 83.00 84.00 85.00 86.00 NONREIMBURSABLE COST CENTER 96.00 Gift, Flower, Coffee Shop & Canteen 97.00 Research 98.00 Physicians' Private Office 99.00 Nonpaid Workers 99.01 Marketing 99.02 99.03 99.04 99.05 100.00 M.O.S.T 100.01 Outpatient Dailysis 100.02 Whittier - NRCC 100.03 El Monte - NRCC 100.04 Garfield - NRCC TOTAL SCHEDULE 8.1 Fiscal Period Ended: JUNE 30, 2007 ADMINIS- ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE & COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00 COMPUTATION OF COST ALLOCATION (W/S B) 0 17,074 0 0 0 0 0 0 0 0 2,168,770 272,209 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 09,538000000001,710,477214,687 0000000000 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000000369,49146,376 014,747000000002,525,786317,019 0000000000 00 0000000000772,06596,904 0000000000 00 0000000000 00 015,914000000002,055,624258,007 0 0 0 0 0 0 0 0 0 0 464,604 58,314 0 0 0 0 0 0 0 0 0 0 0 0 000000000053,8816,763 01,10900000000564,69870,877 000000000037,3894,693 00000000002,123,993266,588 00000000002,113,763265,304 0 0 0 0 0 0 0 0 0 0 389,381 48,872 0 0 0 0 0 0 0 0 0 0 0 0 0000000000 00 0000000000 00 0000000000 00 0000000000 00 0000000000 00 0 0 0 0 0 0 0 0 0 0 0 0 0 14,115 0 0 0 0 0 0 0 0 2,412,395 302,787 0000000000 00 0000000000 00 0000000000 00 0000000000 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00000000009,2221,158 0000000000 00 0000000000 00 0000000000 00 0 0 0 0 0 0 0 0 0 0 3,843 482 0 0 0 0 0 0 0 0 0 0 0 0 0000000000 00 0000000000 00 0000000000 00 034100000000120,82015,165 000000000041,5775,218 0000000000 00 0 0 0 0 0 0 0 0 0 0 0 0 0000000000 00 0 280,580 0 0 0 0 0 0 0 0 48,043,790 5,357,658 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER TRIAL BALANCE EXPENSES GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs-Bldg & Fixtures 2.00 Old Cap Rel Costs-Movable Equipmen 3.00 New Cap Rel Costs-Bldg & Fixtures 4.00 New Cap Rel Costs-Movable Equipme 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 Employee Benefits 6.01 Non-Patient Telephones 6.02 Data Processing 6.03 Purchasing/Receiving 6.04 Patient Admitting 6.05 Patient Business Office 6.06 6.07 6.08 6.00 Administrative and General 7.00 Maintenance and Repairs 8.00 Operation of Plant 9.00 Laundry and Linen Service 10.00 Housekeeping 11.00 Dietary 12.00 Cafeteria 13.00 Maintenance of Personnel 14.00 Nursing Administration 15.00 Central Services & Supply 16.00 Pharmacy 17.00 Medical Records and Library 18.00 Social Service 19.00 19.02 19.03 20.00 21.00 Nursing School 22.00 Intern & Res Service-Salary & Fringes 23.00 Intern & Res Other Program 24.00 Paramedical Ed Program INPATIENT ROUTINE COST CENTER 25.00 Adults & Pediatrics (Gen Routine) 26.00 Intensive Care Unit 27.00 Coronary Care Unit 28.00 Neonatal Intensive Care Unit 29.00 Surgical Intensive Care 31.00 Subprovider I 0.00 32.00 33.00 Nursery 34.00 Medicare Certified Nursing Facility 35.00 Distinct Part Nursing Facility 36.00 Adult Subacute Care Unit 36.01 Subacute Care Unit II 36.02 Transitional Care Unit SCHEDULE 8.2 Fiscal Period Ended: JUNE 30, 2007 CENTRAL MEDICAL MAINT & OPER LAUNDRY & MAINT OF NURSING SERVICE RECORDS SOCIAL REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN & SUPPLY PHARMACY & LIBRARY SERVICE 7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 COMPUTATION OF COST ALLOCATION (W/S B) 0 0 30,552 0 33,168 0 0 59,446 0 2,813 0 152,119 0 7,198 0 0 0 0 0 0 0 0 42,877 0 2,029 0 62,187 0 0 337,725 1,720 15,981 0 9,643 0 0 037,90601,794038,851001 067,41103,190025,9430000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000000000000 000000000000 0 0 0 0 0 0 0 0 0 0 0 0 000000000000 000000000000 0 438,711 142,793 20,759 741,190 248,421 0 548,308 4,289 0 170,878 40,439 0 153,136 35,436 7,246 58,164 58,821 0 274,154 2,689 0 43,462 1,665 000000000000 000000000000 000000000000 0 255,924 34,000 12,110 175,297 72,717 0 274,154 57000 000000000000 000000000000 000000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 475,280 77,928 22,490 64,749 92,332 0 0 4,392 0 44,666 22,864 0 0 0 0 0 0 0 0 0 0 0 0 000000000000 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER TRIAL BALANCE EXPENSES ANCILLARY COST CENTERS 37.00 Operating Room 38.00 Recovery Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 41.01 41.02 42.00 Radiology - Therapeutic 43.00 Radioisotope 44.00 Laboratory 44.01 Pathological Lab 46.00 Whole Blood 47.00 Blood Storing and Processing 48.00 Intravenous Therapy 49.00 Respiratory Therapy 50.00 Physical Therapy 51.00 Occupational Therapy 52.00 Speech Pathology 53.00 Electrocardiology 54.00 Electroencephalography 55.00 Medical Supplies Charged to Patients 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 58.00 ASC (Non-Distinct Part) 59.00 59.01 59.02 59.03 60.00 Clinic 60.01 Other Clinic Services 61.00 Emergency 62.00 Observation Beds 71.00 82.00 83.00 84.00 85.00 86.00 NONREIMBURSABLE COST CENTER 96.00 Gift, Flower, Coffee Shop & Canteen 97.00 Research 98.00 Physicians' Private Office 99.00 Nonpaid Workers 99.01 Marketing 99.02 99.03 99.04 99.05 100.00 M.O.S.T 100.01 Outpatient Dailysis 100.02 Whittier - NRCC 100.03 El Monte - NRCC 100.04 Garfield - NRCC TOTAL SCHEDULE 8.2 Fiscal Period Ended: JUNE 30, 2007 CENTRAL MEDICAL MAINT & OPER LAUNDRY & MAINT OF NURSING SERVICE RECORDS SOCIAL REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN & SUPPLY PHARMACY & LIBRARY SERVICE 7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 COMPUTATION OF COST ALLOCATION (W/S B) 0 288,714 11,462 13,662 0 63,504 0 274,154 0 0 75,499 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 397,317 4,793 18,800 0 34,852 0 0 35 0 53,893 0 000000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 05,81402750000009,2930 0 102,527 7,911 4,851 0 56,493 0 0 52,254 0 108,925 0 000000000000 01,2500590000003,1250 000000000000 000000000000 0 29,476 0 1,395 0 53,228 0 0 38,224 0 95,975 358 0 141,218 3,374 6,682 0 0 0 0 1,058 0 19,831 4,604 0 0 0 0 0 0 0 0 0 0 0 0 013,95306600000002,6580 051,80102,451024,703000020,5950 031,16201,4750000005300 00000000737,476030,9760 0000000001,555,697142,5500 0 0 0 0 0 0 0 0 0 0 8,965 0 0 0 0 0 0 0 0 0 0 0 0 0 000000000000 000000000000 000000000000 000000000000 000000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 182,205 27,337 8,622 0 33,637 0 0 4,602 0 31,227 780 000000000000 000000000000 000000000000 000000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 013,953066000000000 000000000000 000000000000 000000000000 0 5,814 0 275 0 5,745 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000000000000 000000000000 000000000000 08,808041702,809000000 062,90602,97700000000 000000000000 0 0 0 0 0 0 0 0 0 0 0 0 000000000000 0 3,421,172 346,753 158,870 1,039,400 883,887 0 1,370,770 845,077 1,555,697 863,048 70,710 This is trial version www.adultpdf.com [...]...1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4. 05 4.06 4.07 4.08 5. 00 6.01 6.02 6.03 6.04 6. 05 6.06 6.07 6.08 6.00 7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15. 00 16.00 17.00 18.00 19.00 19.02 19.03 20.00 21.00 22.00 23.00 24.00 25. 00 26.00 27.00 28.00 29.00 31.00 0.00 32.00 33.00 34.00 35. 00 36.00 36.01 36.02 Nursery Medicare Certified Nursing Facility Distinct Part... Paramedical Ed Program INPATIENT ROUTINE COST CENTER Adults & Pediatrics (Gen Routine) Intensive Care Unit Coronary Care Unit Neonatal Intensive Care Unit Surgical Intensive Care Subprovider I Administrative and General Maintenance and Repairs Operation of Plant Laundry and Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services & Supply Pharmacy Medical. .. Social Service Employee Benefits Non- Patient Telephones Data Processing Purchasing/Receiving Patient Admitting Patient Business Office GENERAL SERVICE COST CENTER Old Cap Rel Costs-Bldg & Fixtures Old Cap Rel Costs-Movable Equipmen New Cap Rel Costs-Bldg & Fixtures New Cap Rel Costs-Movable Equipme TRIAL BALANCE EXPENSES Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version... COST 19.02 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 19.03 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 NONPHYSICIAN ANESTH 20.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 NURSING SCHOOL 21.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 INT & RES SALARY & FRINGES 22.00 COMPUTATION OF COST ALLOCATION (W/S B) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 INT & RES PROGRAM 23.00 0 0 0 0 0 0 0 0 0 0 0 0... EDUCAT 24.00 10,920,018 4,283,221 0 0 0 3,804,662 0 0 0 0 0 3,843,377 0 0 (3,804,662) 3,804,662 POST STEP-DOWN SUBTOTAL ADJUSTMENT (Adj 4, 12) 25. 00 26.00 14,724,680 4,283,221 0 0 0 0 0 0 0 0 0 3,843,377 0 0 27.00 TOTAL COST Fiscal Period Ended: JUNE 30, 2007 SCHEDULE 8.3 . Respiratory Therapy 2 ,53 2,287 19, 155 ,59 0 0.132196 5, 319, 759 703,249 50 .00 Physical Therapy 699,6 85 3, 958 ,002 0.176777 45, 027 7,960 52 .00 Speech Pathology 77,916 53 0 ,59 3 0.146847 15, 960 2,344 53 .00 Electrocardiology. Electrocardiology 7 35, 1 25 4,110,438 0.178843 0 0 54 .00 Electroencephalography 75, 249 1 05, 813 0.711 151 0 0 55 .00 Med Supply Charged to Patients 3, 159 ,034 6,182 ,53 7 0 .51 0961 1,371,8 95 700,9 85 56.00 Drugs. 1,3 95 0 53 ,228 0 0 38,224 0 95, 9 75 358 0 141,218 3,374 6,682 0 0 0 0 1, 058 0 19,831 4,604 0 0 0 0 0 0 0 0 0 0 0 0 013, 953 06600000002, 658 0 051 ,80102, 451 024,703000020 ,59 50 031,16201,4 750 0000 053 00 00000000737,476030,9760 0000000001 ,55 5,697142 ,55 00 0 0 0 0 0 0 0 0 0 0 8,9 65 0 0 0 0 0 0 0 0 0 0 0 0 0 000000000000 000000000000 000000000000 000000000000 000000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 182,2 05 27,337 8,622 0 33,637 0 0 4,602 0 31,227 780 000000000000 000000000000 000000000000 000000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 013, 953 066000000000 000000000000 000000000000 000000000000 0 5, 814 0 2 75 0 5, 7 45 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000000000000 000000000000 000000000000 08,808041702,809000000 062,90602,97700000000 000000000000 0 0 0 0 0 0 0 0 0 0 0 0 000000000000 0 3,421,172 346, 753 158 ,870 1,039,400 883,887 0 1,370,770 8 45, 077 1 ,55 5,697 863,048 70,710 This