SCHEDULE 5 PROGRAM: NON CONTRACT SCHEDULE OF MEDICAL ANCILLARY COSTS_part6 doc

STATE OF CALIFORNIA SCHEDULE 10A Provider Name: Fiscal Period Ended: ALHAMBRA HOSPITAL MEDICAL CENTER JUNE 30, 2007 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ 24567891012 GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs-Bldg & Fixtures $0 2.00 Old Cap Rel Costs-Movable Equipment 0 3.00 New Cap Rel Costs-Bldg & Fixtures 444,389 224,408 380,992 (37,746) (16,507) (106,758) 4.00 New Cap Rel Costs-Movable Equipment 0 4.01 0 4.02 0 4.03 0 4.04 0 4.05 0 4.06 0 4.07 0 4.08 0 5.00 Employee Benefits (11,546) (11,546) 6.01 Non-Patient Telephones 0 6.02 Data Processing 0 6.03 Purchasing/Receiving 0 6.04 Patient Admitting 0 6.05 Patient Business Office 0 6.06 0 6.07 0 6.08 0 6.00 Administrative and General (136,906) (224,408) (8,000) 103,576 (8,074) 7.00 Maintenance and Repairs 0 8.00 Operation of Plant 0 9.00 Laundry and Linen Service 0 10.00 Housekeeping 0 11.00 Dietary 0 12.00 Cafeteria 0 13.00 Maintenance of Personnel 0 14.00 Nursing Administration 0 15.00 Central Services & Supply 0 16.00 Pharmacy 59,217 59,217 17.00 Medical Records and Library 0 18.00 Social Service 0 19.00 0 19.02 0 19.03 0 20.00 0 21.00 Nursing School 0 22.00 Intern & Res Service-Salary & Fringes 0 23.00 Intern & Res Other Program 0 24.00 Paramedical Ed Program 0 INPATIENT ROUTINE COST CENTERS 25.00 Adults & Pediatrics (Gen Routine) 0 26.00 Intensive Care Unit 0 27.00 Coronary Care Unit 0 28.00 Neonatal Intensive Care Unit 0 29.00 Surgical Intensive Care 0 31.00 Subprovider I 0 0.00 Subprovider II 0 32.00 0 33.00 Nursery 0 34.00 Medicare Certified Nursing Facility 0 35.00 Distinct Part Nursing Facility 0 36.00 Adult Subacute Care Unit 0 36.01 Subacute Care Unit II 0 36.02 Transitional Care Unit 0 ADJUSTMENTS TO REPORTED COSTS This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 10A Provider Name: Fiscal Period Ended: ALHAMBRA HOSPITAL MEDICAL CENTER JUNE 30, 2007 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ 24567891012 ADJUSTMENTS TO REPORTED COSTS ANCILLARY COST CENTERS 37.00 Operating Room 0 38.00 Recovery Room 0 39.00 Delivery Room and Labor Room 0 40.00 Anesthesiology 0 41.00 Radiology - Diagnostic 0 41.01 0 41.02 0 42.00 Radiology - Therapeutic 0 43.00 Radioisotope 0 44.00 Laboratory 0 44.01 Pathological Lab 0 46.00 Whole Blood 0 47.00 Blood Storing and Processing 0 48.00 Intravenous Therapy 0 49.00 Respiratory Therapy 0 50.00 Physical Therapy 0 51.00 Occupational Therapy 0 52.00 Speech Pathology 0 53.00 Electrocardiology 0 54.00 Electroencephalography 0 55.00 Medical Supplies Charged to Patients 0 56.00 Drugs Charged to Patients (59,217) (59,217) 57.00 Renal Dialysis 0 58.00 ASC (Non-Distinct Part) 0 59.00 0 59.01 0 59.02 0 59.03 0 60.00 Clinic 0 60.01 Other Clinic Services 0 61.00 Emergency 0 62.00 Observation Beds 0 71.00 0 82.00 0 83.00 0 84.00 0 85.00 0 86.00 0 NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop & Canteen 0 97.00 Research 0 98.00 Physicians' Private Office 0 99.00 Nonpaid Workers 0 99.01 Marketing 0 99.02 0 99.03 0 99.04 0 99.05 0 100.00 M.O.S.T 0 100.01 Outpatient Dailysis 0 100.02 Whittier - NRCC 0 100.03 El Monte - NRCC 0 100.04 Garfield - NRCC 0 101.00 TOTAL $295,937 0 0 380,992 (37,746) (16,507) (106,758) (8,000) 103,576 (19,620) 0 0 0 (To Sch 10) This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs-Bldg & Fixtures 2.00 Old Cap Rel Costs-Movable Equipment 3.00 New Cap Rel Costs-Bldg & Fixtures 4.00 New Cap Rel Costs-Movable Equipment 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 CENTERS 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 Subprovider II 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 10A Page 2 Fiscal Period Ended: JUNE 30, 2007 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ ADJUSTMENTS TO REPORTED COSTS This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ALHAMBRA HOSPITAL MEDICAL CENTER 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 CENTERS 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 101.00 TOTAL SCHEDULE 10A Page 2 Fiscal Period Ended: JUNE 30, 2007 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ ADJUSTMENTS TO REPORTED COSTS 0000000000000 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number JULY 1, 2006 THROUGH JUNE 30, 2007 29 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted MEMORANDUM ADJUSTMENT 1 The Adult Subacute Unit costs and statistics reported in the cost report on the Nursing Facility cost center, Line 35.00, have been reclassified to the Adult Subacute Unit cost center, line 36.00. This was done in accordance with CMS Pub. 15-2, Section 3610. Page 1 Report References ALHAMBRA HOSPITAL MEDICAL CENTER Adjustments Explanation of Audit Adjustments HSC 30281H Cost Report This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number JULY 1, 2006 THROUGH JUNE 30, 2007 29 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References ALHAMBRA HOSPITAL MEDICAL CENTER Adjustments Explanation of Audit Adjustments HSC 30281H Cost Report RECLASSIFICATIONS OF REPORTED COSTS 2 10A A 6.00 7 Administrative and General $5,267,374 ($224,408) $5,042,966 * 10A A 3.00 7 New Capital Related Costs - Building and Fixtures 2,324,939 224,408 2,549,347 * To reclassify property taxes to the proper cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.8 and 2304 3 10A A 56.00 7 Drugs Charged to Patients $2,172,980 ($59,217) $2,113,763 10A A 16.00 7 Pharmacy 1,217,448 59,217 1,276,665 To adjust provider's reclassification to agree with the general ledger. 42 CFR 413.20, 413.24 and 413.50 CMS Pub. 15-1, Sections 2300 and 2304 4 8.3 B I 31.00 26 Subprovider I $3,804,662 ($3,804,662) $0 8.3 B I 25.00 26 Adults and Pediatrics 10,920,018 3,804,662 14,724,680 To reclassify Subprovider I (Rehabilitation) costs to Adults and Pediatrics after step-down. The Rehabilitation unit does not meet the separate cost center requirements. 42 CFR 413.20, 413.24, and 413.53(b)(c) CMS Pub. 15-1, Sections 2336.1, 2336.2, 2336.3 and 2306 *Balance carried forward from prior/to subsequent adjustments Page 2 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number JULY 1, 2006 THROUGH JUNE 30, 2007 29 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References ALHAMBRA HOSPITAL MEDICAL CENTER Adjustments Explanation of Audit Adjustments HSC 30281H Cost Report ADJUSTMENTS TO REPORTED COSTS 10A A 3.00 7 New Capital Related Costs - Building and Fixtures * $2,549,347 5 To adjust the reported cost of ownership to agree with Calmed's Profit $380,992 and Loss Statement for the period ending June 30, 2007. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 6 To eliminate tax penalties and/or fines not related to patient care. (37,746) 42 CFR 413.9(c)(3) / CMS Pub. 15-1, Sections 2102.3 and 2122.1 7 To adjust depreciation to agree with the provider's detailed (16,507) depreciation schedules. 42 CFR 413.20, 413.24, 413.50, and 413.134 CMS Pub. 15-1, Sections 102, 2300, 2302.4, and 2304 8 To adjust depreciation for a change in useful life to agree with the (106,758) American Hospital Association Guidelines. $219,981 $2,769,328 42 CFR 413.20, 413.24 and 413.134 CMS Pub. 15-1, Sections 2300 and 2304 10A A 6.00 7 Administrative and General * $5,042,966 9 To adjust nonallowable management fees to agree with the provider's (8,000) general ledger. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 10 To reverse the provider's duplicate adjustment of goodwill 103,576 amortization cost. $95,576 $5,138,542 * 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 3 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number JULY 1, 2006 THROUGH JUNE 30, 2007 29 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References ALHAMBRA HOSPITAL MEDICAL CENTER Adjustments Explanation of Audit Adjustments HSC 30281H Cost Report ADJUSTMENTS TO REPORTED COSTS 11 10A A 5.00 7 Employee Benefits $284,883 ($11,546) $273,337 10A A 6.00 7 Administrative and General * 5,138,542 (8,074) 5,130,468 To eliminate nonreimbursable employee benefits and payroll expenses related to the nonreimbursable cost identified in adjustment number 12. 42 CFR 413.5, 413.9, and 413.24 CMS Pub. 15-1, Sections 2102.3, 2304, and 2328 12 8.3 Not Reported El Monte - NRCC $0 $74,094 $74,094 8.3 Not Reported Garfield - NRCC 0 213 213 8.3 Not Reported DHMCM - NRCC 0 610,971 610,971 To include the nonreimbursable cost identified in the general ledger and the cost identified in adjustment number 11 after step-down. 42 CFR 413.9, 413. 20 and 413.24 / CMS Pub. 15-1, Section 2328 *Balance carried forward from prior/to subsequent adjustments Page 4 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number JULY 1, 2006 THROUGH JUNE 30, 2007 29 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References ALHAMBRA HOSPITAL MEDICAL CENTER Adjustments Explanation of Audit Adjustments HSC 30281H Cost Report ADJUSTMENT TO REPORTED STATISTICS 13 9 B-1 18.00 17 Social Service (Gross Revenue) 50,804 (50,804) 0 9 B-1 25.00 17 Adults & Pediatrics 5,517,521 28,587,729 34,105,250 9 B-1 26.00 17 Intensive Care Unit 2,192,256 6,482,244 8,674,500 9 B-1 31.00 17 Subprovider I 1,532,748 (1,532,748) 0 9 B-1 36.00 17 Adult Subacute Care Unit 1,828,926 7,085,874 8,914,800 9 B-1 37.00 17 Operating Room 1,421,943 13,646,801 15,068,744 9 B-1 41.00 17 Radiology - Diagnostic 794,334 9,962,015 10,756,349 9 B-1 43.00 17 Radioisotope 0 1,854,743 1,854,743 9 B-1 44.00 17 Laboratory 1,228,107 20,512,075 21,740,182 9 B-1 46.00 17 Whole Blood & Packed Red 0 623,641 623,641 9 B-1 49.00 17 Respiratory Therapy 1,325,290 17,830,300 19,155,590 9 B-1 50.00 17 Physical Therapy 0 3,958,002 3,958,002 9 B-1 52.00 17 Speech Pathology 0 530,593 530,593 9 B-1 53.00 17 Electrocardiology 92,325 4,018,113 4,110,438 9 B-1 54.00 17 Electroencephalography 0 105,813 105,813 9 B-1 55.00 17 Medical Supplies Charged To Patients 0 6,182,537 6,182,537 9 B-1 56.00 17 Drugs Charged to Patients 0 28,451,429 28,451,429 9 B-1 57.00 17 Renal Dialysis 0 1,789,364 1,789,364 9 B-1 61.00 17 Emergency 1,175,508 5,057,080 6,232,588 9 B-1 100.00 17 M.O.S.T 28,386 (28,386) 0 9 B-1 17.00 17 Total - Gross Revenue 17,188,148 155,066,415 172,254,563 To adjust reported statistics to agree with the general ledger. 42 CFR 413.20, 413.24 and 413.50 CMS Pub. 15-1, Sections 2300 and 2304 Page 5 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number JULY 1, 2006 THROUGH JUNE 30, 2007 29 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References ALHAMBRA HOSPITAL MEDICAL CENTER Adjustments Explanation of Audit Adjustments HSC 30281H Cost Report ADJUSTMENT TO REPORTED PATIENT DAYS 14 4,Contract 4 D-1 I XIX 1.00 1 Adult and Pediatrics (Inpatient Days) 18,923 3,721 22,644 4,Contract 4 D-1 I XIX 4.00 1 Adult and Pediatrics (Semi-Private Room Days) 18,923 3,721 22,644 4-1 D-1 I XVIII 1.00 1 Subprovider (Inpatient Days) 3,721 (3,721) 0 4-1 D-1 I XVIII 4.00 1 Subprovider (Semi-Private Room Days) 3,721 (3,721) 0 To reclassify Subprovider (Rehabilitation) total inpatient days in the Adults and Pediatrics in conjunction with adjustment number 4. 42 CFR 413.20 and 413.50 CMS Pub. 15-1, Sections 2300 and 2336.1 Page 6 This is trial version www.adultpdf.com [...]... 413 .50 CMS Pub 15- 1, Sections 2300 and 2336.1 Explanation of Audit Adjustments ADJUSTMENT TO REPORTED TOTAL CHARGES JULY 1, 2006 THROUGH JUNE 30, 2007 ALHAMBRA HOSPITAL MEDICAL CENTER Line Fiscal Period Provider Name State of California This is trial version www.adultpdf.com $28,137, 750 28,137, 750 5, 967 ,50 0 5, 967 ,50 0 As Reported HSC 30281H As Adjusted 29 Page 7 Adjustments $5, 967 ,50 0 $34,1 05, 250 5, 967 ,50 0... trial version www.adultpdf.com $28,137, 750 28,137, 750 5, 967 ,50 0 5, 967 ,50 0 As Reported HSC 30281H As Adjusted 29 Page 7 Adjustments $5, 967 ,50 0 $34,1 05, 250 5, 967 ,50 0 34,1 05, 250 (5, 967 ,50 0) 0 (5, 967 ,50 0) 0 Increase (Decrease) Provider Number Department of Health Care Services ... 15 Adj No Work Sheet D-1 D-1 D-1 D-1 Audit Report 4 ,Contract 4 4 ,Contract 4 4-1 4-1 I I I I Part XIX XIX XVIII Title Cost Report Report References Col 28.00 30.00 28.00 30.00 1 1 1 1 Adult and Pediatrics (General Inpatient Charges) Adult . 3, 958 ,002 9 B-1 52 .00 17 Speech Pathology 0 53 0 ,59 3 53 0 ,59 3 9 B-1 53 .00 17 Electrocardiology 92,3 25 4,018,113 4,110,438 9 B-1 54 .00 17 Electroencephalography 0 1 05, 813 1 05, 813 9 B-1 55 .00 17 Medical. (50 ,804) 0 9 B-1 25. 00 17 Adults & Pediatrics 5, 517 ,52 1 28 ,58 7,729 34,1 05, 250 9 B-1 26.00 17 Intensive Care Unit 2,192, 256 6,482,244 8,674 ,50 0 9 B-1 31.00 17 Subprovider I 1 ,53 2,748 (1 ,53 2,748) 0 9. 6,182 ,53 7 6,182 ,53 7 9 B-1 56 .00 17 Drugs Charged to Patients 0 28, 451 ,429 28, 451 ,429 9 B-1 57 .00 17 Renal Dialysis 0 1,789,364 1,789,364 9 B-1 61.00 17 Emergency 1,1 75, 508 5, 057 ,080 6,232 ,58 8 9