audit basic of STATE OF CALIFORNIA_part4 potx

State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 18 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted MEMORANDUM ADJUSTMENTS 1 To reconcile provider's reported costs on page 10.5 to provider's reported cost on page 10.1 column 14. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 2 To reconcile provider’s reported statistics on page 10.7 to provider’s reported statistics on page 11.1. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 Page 1 Adjustments ESCONDIDO CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZT06040K Cost Report Explanation of Audit Adjustments Report References Audit Report This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 18 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustments ESCONDIDO CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZT06040K Cost Report Explanation of Audit Adjustments Report References Audit Report RECLASSIFICATIONS OF REPORTED COSTS 3 10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor $355,858 ($9,289) $346,569 * 10.5 140 4 8A-2 140 4 Beauty and Barber - Other - Nonlabor 0 9,289 9,289 To reclassify beauty and barber expenses to a nonreimbursable cost center. 42 CFR 413.9, 413.20 and 413.24 CMS Pub. 15-1, Section 2328 CCR, Title 22, Section 51511(d) 4 10.5 005 4 8A-2 005 4 Plant Operations and Maintenance - Other - Nonlabor $336,451 ($1,157) $335,294 10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor * 346,569 (26,582) 319,987 * 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor 1,124,807 (11,803) 1,113,004 * 10.5 035 4 8A-2 035 4 Leases and Rentals 1,178,587 39,542 1,218,129 To reclassify leases and rental expenses to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 5 10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor * $319,987 ($12,609) $307,378 * 10.5 100 4 8A-2 100 4 Other Ancillary Services - Other - Nonlabor 36,477 12,609 49,086 To reclassify physician services from Skilled Nursing to an ancillary cost center. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Section 2203.2 CCR, Title 22, Section 51511 6 10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor * $307,378 ($10,800) $296,578 * 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * 1,113,004 10,800 1,123,804 * To reclassify medical director fees to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 CCR, Title 22, Section 52000(b) *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 18 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustments ESCONDIDO CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZT06040K Cost Report Explanation of Audit Adjustments Report References Audit Report ADJUSTMENTS TO REPORTED COSTS 7 10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor * $296,578 $9,941 $306,519 * To reverse the provider's abatement of revenue against nonreimbursable costs. 42 CFR 413.9, 413.20 and 413.24 CMS Pub. 15-1, Section 2328 8 10.5 165 1 8A-2 165 1 Administration - Salaries and Wages $379,107 ($83,063) $296,044 * 10.5 165 2 8A-2 165 2 Administration - Fringe Benefits 115,954 (18,574) 97,380 * To adjust administrator's compensation based on the Department of Health Care Services guidelines. 42 CFR 413.102 CMS Pub. 15-1, Sections 901, 902.3, 904 and 1005 9 10.5 165 1 8A-2 165 1 Administration - Salaries and Wages * $296,044 ($34,033) $262,011 10.5 165 2 8A-2 165 2 Administration - Fringe Benefits * 97,380 (7,610) 89,770 To eliminate assistant administrator's compensation due to insufficient documentation. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 10 10.5 055 4 8A-2 055 4 Interest - Other $5,725 ($5,725) $0 To eliminate interest expenses due to insufficient documentation. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 11 10.5 040 4 8A-2 040 4 Property Taxes $26,403 ($1,787) $24,616 To eliminate personal property tax expenses due to insufficient documentation. 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 18 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustments ESCONDIDO CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZT06040K Cost Report Explanation of Audit Adjustments Report References Audit Report ADJUSTMENTS TO REPORTED COSTS 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * $1,123,804 12 To eliminate legal cost not related to Escondido Care Center. ($2,112) 42 CFR 405.2468(a) and 413.9(b)(2) CMS Pub. 15-1, Sections 2102.3 and 2135.2 13 To eliminate investigations legal fees due to insufficient (1,260) documentation. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 14 To eliminate P PINT legal fees due to lack of documentation. (31,343) 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 15 To adjust home office costs to agree with the filed Home Office (21,056) Cost Report. ($55,771) $1,068,033 42 CFR 413.17 / CMS Pub. 15-1, Sections 2150.2 and 2304 16 10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor * $306,519 ($3,000) $303,519 To eliminate state and/or federal income taxes. 42 CFR 413.9 and 413.20 CMS Pub. 15-1, Sections 2122.2A and 2122.2B *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 18 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustments ESCONDIDO CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZT06040K Cost Report Explanation of Audit Adjustments Report References Audit Report ADJUSTMENT TO REPORTED STATISTICS 17 10.7 005 1 7 005 Plant Operations and Maintenance (Square Feet) 0 1,258 1,258 10.7 010 1, 2 7 010 Housekeeping 02525 10.7 060 1, 2, 3 7 060 Laundry and Linen 0 690 690 10.7 065 1, 2, 3 7 065 Dietary 0 3,666 3,666 10.7 080 1, 2, 3 7 080 Physical Therapy 152 1,000 1,152 10.7 105 1, 2, 3 7 105 Skilled Nursing Care 33,122 (7,595) 25,527 10.7 155 1, 2, 3 7 155 Social Services 0 192 192 10.7 160 1, 2, 3 7 160 Activities 0 208 208 10.7 165 1, 2, 3 7 165 Administration 0 1,764 1,764 10.7 166 1, 2, 3 7 166 Medical Records 0 256 256 10.7 170 1, 2, 3 7 170 Inservice Education - Nursing 0 315 315 10.7 175 1 7 N/A Total Statistics - Square Feet 34,285 1,779 36,064 10.7 175 2 7 N/A Total Statistics - Square Feet 34,285 521 34,806 10.7 175 3 7 N/A Total Statistics - Square Feet 34,285 496 34,781 To adjust square footage statistics to agree with prior year's audited amount. 42 CFR 413.24 and 413.50 / CMS Pub. 15-1, Sections 2304 and 2306 Page 5 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 18 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustments ESCONDIDO CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZT06040K Cost Report Explanation of Audit Adjustments Report References Audit Report ADJUSTMENT TO OTHER MATTERS 18 Not Reported 1 14.00 Credit Balances $0 $39,959 $39,959 To recover outstanding Medi-Cal credit balances. CCR, Title 22, Sections 50761 and 51458.1 Page 6 This is trial version www.adultpdf.com . ZZT06040K Cost Report Explanation of Audit Adjustments Report References Audit Report This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name. prior year's audited amount. 42 CFR 413.24 and 413.50 / CMS Pub. 15-1, Sections 2304 and 2306 Page 5 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider. THROUGH DECEMBER 31, 2009 ZZT06040K Cost Report Explanation of Audit Adjustments Report References Audit Report RECLASSIFICATIONS OF REPORTED COSTS 3 10.5 105 4 8A-2 105 4 Skilled Nursing Care