State of California Fiscal Period JANUARY 1, 2007 AUDIT REPORT ppt

State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 39 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments Adjustments SUNRAY HEALTHCARE CENTER JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05870H RECONCILIATION OF THE PROVIDER'S RECORDS TO THE AUDIT REPORT -Continued from previous page- 14 10.1(4) 125 14 8A-1 125.00 Subacute Care $1,487,558 ($1,487,558) $0 Not Reported 8A-1 125.01 Subacute Care - Salaries and Wages 0 782,831 782,831 * Not Reported 8A-1 125.02 Subacute Care - Fringe Benefits 0 225,562 225,562 * Not Reported 8A-1 125.03 Subacute Care - Agency Staff 0 149,752 149,752 Not Reported 8A-1 125.04 Subacute Care - Other - Nonlabor 0 329,413 329,413 * 15 10.1(4) 155 14 8A-1 155.00 Social Services $50,035 ($50,035) $0 Not Reported 8A-1 155.01 Social Services - Salaries and Wages 0 38,491 38,491 Not Reported 8A-1 155.02 Social Services - Fringe Benefits 0 7,829 7,829 Not Reported 8A-1 155.04 Social Services - Other - Nonlabor 0 3,715 3,715 16 10.1(4) 160 14 8A-1 160.00 Activities $105,177 ($105,177) $0 Not Reported 8A-1 160.01 Activities - Salaries and Wages 0 80,167 80,167 Not Reported 8A-1 160.02 Activities - Fringe Benefits 0 16,537 16,537 Not Reported 8A-1 160.04 Activities - Other - Nonlabor 0 8,473 8,473 17 10.1(4) 165 14 8A-1 165.00 Administration $1,342,031 ($1,342,031) $0 Not Reported 8A-1 165.01 Administration - Salaries and Wages 0 280,867 280,867 * Not Reported 8A-1 165.02 Administration - Fringe Benefits 0 71,388 71,388 Not Reported 8A-1 165.03 Administration - Medical Records - Salaries and Wages 0 44,757 44,757 Not Reported 8A-1 165.04 Administration - Medical Records - Fringe Benefits 0 9,925 9,925 Not Reported 8A-1 165.06 Administration - Medical Records - Other - Nonlabor 0 29,885 29,885 Not Reported 8A-1 165.07 Administration - DHS Licensing Fees 0 24,521 24,521 * Not Reported 8A-1 165.08 Administration - Liability Insurance 0 118,952 118,952 * Not Reported 8A-1 165.10 Administration - Quality Assurance Fees 0 266,064 266,064 Not Reported 8A-1 165.11 Administration - Other - Nonlabor 0 495,672 495,672 * -Continued on next page- *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 39 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments Adjustments SUNRAY HEALTHCARE CENTER JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05870H RECONCILIATION OF THE PROVIDER'S RECORDS TO THE AUDIT REPORT -Continued from previous page- 18 10.1(4) 170 14 8A-1 170.00 Inservice Education - Nursing $75,427 ($75,427) $0 Not Reported 8A-1 170.01 Inservice Education - Nursing - Salaries and Wages 0 59,737 59,737 Not Reported 8A-1 170.02 Inservice Education - Nursing - Fringe Benefits 0 11,661 11,661 Not Reported 8A-1 170.04 Inservice Education - Nursing - Other - Nonlabor 0 4,029 4,029 To reclassify the reported expenses for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 Page 4 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 39 MC530 Adj. 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Sch Line Reported (Decrease) Adjusted Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments Adjustments SUNRAY HEALTHCARE CENTER JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05870H RECLASSIFICATIONS OF REPORTED COSTS 19 10.1(4) 70 14 8A-2 70.00 Provision for Bad Debts $56,673 ($56,673) $0 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 495,672 56,673 552,345 * To reverse provider's elimination of bad debts expense to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 20 Not Reported 8A-2 165.07 Administration - DHS Licensing Fees * $24,521 ($3,047) $21,474 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 552,345 3,047 555,392 * To reclassify other license fees to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 21 Not Reported 8A-2 125.04 Subacute Care - Other - Nonlabor * $329,413 ($30,000) $299,413 * Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 555,392 30,000 585,392 * 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 72305 22 Not Reported 8A-2 75.04 Patient Supplies - Other - Nonlabor * $7,299 $111,857 $119,156 Not Reported 8A-2 105.01 Skilled Nursing Care - Salaries and Wages * 1,611,471 (75,044) 1,536,427 Not Reported 8A-2 105.02 Skilled Nursing Care - Fringe Benefits * 359,956 22,714 382,670 Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * 238,421 (140,441) 97,980 Not Reported 8A-2 125.01 Subacute Care - Salaries and Wages * 782,831 75,044 857,875 Not Reported 8A-2 125.02 Subacute Care - Fringe Benefits * 225,562 (22,714) 202,848 Not Reported 8A-2 125.04 Subacute Care - Other - Nonlabor * 299,413 28,584 327,997 To reclassify reported expense to agree with the provider's general ledger. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 5 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 39 MC530 Adj. 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Sch Line Reported (Decrease) Adjusted Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments Adjustments SUNRAY HEALTHCARE CENTER JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05870H ADJUSTMENTS TO REPORTED COSTS 23 Not Reported 8A-2 165.01 Administration - Salaries and Wages * $280,867 ($83,465) $197,402 To adjust administrator compensation based on the Department of Health Care Services guidelines. 42 CFR 413.102 CMS Pub. 15-1, Sections 901, 902.3, 904 and 905 24 10.1(4) 40 14 8A-2 40.00 Property Taxes $39,066 $27,576 $66,642 To adjust property taxes to agree with the provider's property tax bill. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 25 Not Reported 8A-2 165.08 Administration - Liability Insurance * $118,952 ($7,117) $111,835 To adjust liability insurance to agree with the provider's liability insurance cancelled checks. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $585,392 26 To eliminate meals expense not related to patient care. ($4,113) 42 CFR 413.9(c)(3) / CMS Pub. 15-1, Section 2102.3 27 To eliminate travel and entertainment expense not related (1,067) to patient care. 42 CFR 413.9(c)(3) / CMS Pub. 15-1, Section 2102.3 28 To adjust auto/gas expense to agree with the provider's (7,521) mileage report. ($12,701) $572,691 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 29 10.1(4) 35 14 8A-2 35.00 Leases and Rentals $609,313 $270 $609,583 To adjust home office costs to agree with the filed Home Office Cost Report. 42 CFR 413.17 / CMS Pub. 15-1, Sections 2150.2 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 6 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 39 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments Adjustments SUNRAY HEALTHCARE CENTER JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05870H ADJUSTMENTS TO REPORTED STATISTICS 30 Not Reported 7 5.00 Plant Operations and Maintenance (Square Feet) 0 195 195 Not Reported 7 60.00 Laundry and Linen 0 361 361 Not Reported 7 65.00 Dietary 0 768 768 11.1(1 of 3) 10 2 7 75.00 Patient Supplies 521 (248) 273 11.1(1 of 3) 15 2 7 80.00 Physical Therapy 460 (219) 241 11.1(1 of 3) 16 2 7 81.00 Respiratory Therapy 386 (184) 202 11.1(1 of 3) 17 2 7 82.00 Occupational Therapy 527 (251) 276 11.1(1 of 3) 20 2 7 85.00 Pharmacy 401 (191) 210 11.1(1 of 3) 40 2 7 105.00 Skilled Nursing Care 15,048 (7,167) 7,881 11.1(1 of 3) 60 2 7 125.00 Subacute Care 4,829 (2,300) 2,529 Not Reported 7 155.00 Social Services 0 297 297 Not Reported 7 160.00 Activities 0 924 924 Not Reported 7 165.00 Administration 0 672 672 Not Reported 7 165.00 Medical Records 0 491 491 11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 22,214 (6,852) 15,362 11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 22,214 (7,047) 15,167 11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 22,214 (7,047) 15,167 To establish the correct square footage in order to properly allocate indirect costs. 42 CFR 413.24 / CMS Pub. 15-1, Sections 2300 and 2306 31 11.1(1 of 3) 40 4 7 105.00 Skilled Nursing Care (Clean, Dry Pounds) 63,138 (1,188) 61,950 11.1(1 of 3) 60 4 7 125.00 Subacute Care 20,110 (1,883) 18,227 11.1(1 of 3) 85 4 7 N/A Total Statistics - Clean, Dry Pounds 83,248 (3,071) 80,177 To adjust laundry pounds statistics to properly allocate laundry costs. 42 CFR 413.24 / CMS Pub. 15-1, Sections 2304 and 2306 32 11.1(2 of 3) 40 6 7 105.00 Skilled Nursing Care (Number of Patient Meals) 75,765 (1,425) 74,340 11.1(2 of 3) 60 6 7 125.00 Subacute Care 24,132 (16,386) 7,746 11.1(2 of 3) 85 6 7 N/A Total Statistics - Number of Patient Meals 99,897 (17,811) 82,086 To adjust dietary meals statistics to properly allocate dietary costs. 42 CFR 413.24 / CMS Pub. 15-1, Sections 2304 and 2306 Page 7 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 39 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments Adjustments SUNRAY HEALTHCARE CENTER JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05870H ADJUSTMENT TO REPORTED PATIENT DAYS 33 4.1 5 6 1 12.00 Total Patient Days - Skilled Nursing Care 25,255 (3) 25,252 4.3(1) 120 1 SA 1 36.00 Total Patient Days - Subacute 8,044 (27) 8,017 4.3(1) 100 1 SA 1 48.00 Total Subacute Days - Ventilator 4,986 394 5,380 4.3(1) 115 1 SA 1 49.00 Total Subacute Days - Nonventilator 3,058 (421) 2,637 To adjust total patient days to agree with the provider's patient census reports. 42 CFR 413.20 and 413.50 CMS Pub. 15-1, Sections 2205 and 2304 Page 8 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 39 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments Adjustments SUNRAY HEALTHCARE CENTER JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05870H ADJUSTMENTS TO REPORTED TOTAL CHARGES 34 13.1 12 4 SA 2 22.00 Specialized Support Surfaces (Total Subacute Ancillary Charges) $3,065 ($3,065) $0 To eliminate Subacute ancillary charges not included in the rate. CCR, Title 22, Sections 51511(c) and 51511.5 35 13.1 20 4 SA 2 77.00 Pharmacy (Total Subacute Ancillary Charges) $99,446 ($34,683) $64,763 To exclude Subacute outlier drug charges from Subacute pharmacy charges for proper determination of Subacute costs. CMS Pub. 15-1, Section 2304 CCR, Title 22, Section 51511.5 Page 9 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 39 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments Adjustments SUNRAY HEALTHCARE CENTER JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05870H ADJUSTMENT TO REPORTED MEDI-CAL SETTLEMENT DATA - SUBACUTE 36 4.3(1) 100 2 SA 1 48.00 Medi-Cal Subacute Days - Ventilator 3,358 68 3,426 4.3(1) 120 2 SA 1 44.00 Medi-Cal Subacute Days - Total 5,441 32 5,473 To adjust Medi-Cal Settlement Data to agree with the following EDS Paid Claims Summary: Report Date: November 18, 2008 Payment Period: January 1, 2007 through November 18, 2008 Service Period: January 1, 2007 through December 31, 2007 42 CFR 413.20, 413.50, 413.53, 413.60 and 413.64 CMS Pub. 15-1, Sections 2304 and 2408 Page 10 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 39 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments Adjustments SUNRAY HEALTHCARE CENTER JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05870H ADJUSTMENTS TO OTHER MATTERS 37 Not Reported SA 1 41.00 Contracted Number of Subacute Beds 0 24 24 To reflect the number of contracted Subacute care beds on the audit report schedule. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 38 4.3(1) 20 1 1 15.00 Total Licensed Nursing Facility Beds 99 (24) 75 To adjust total available licensed nursing facility beds. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 39 Not Reported SA 1 48.00 Subacute Ventilator Equipment Cost $0 $41,514 $41,514 To include ventilator equipment expense. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 Page 11 This is trial version www.adultpdf.com . Adjusted Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments Adjustments SUNRAY HEALTHCARE CENTER JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05870H RECONCILIATION OF THE. Adjusted Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments Adjustments SUNRAY HEALTHCARE CENTER JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05870H RECONCILIATION OF THE. Adjusted Report References COST REPORT AUDIT REPORT Explanation of Audit Adjustments Adjustments SUNRAY HEALTHCARE CENTER JANUARY 1, 2007 THROUGH DECEMBER 31, 2007 ZZT05870H ADJUSTMENTS TO REPORTED