STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS_part4 potx

STATE OF CALIFORNIA Schedule 8A-2 Page 1 Provider Name: Provider Number: Provider NPI: OSHPD Facility Number: Fiscal Period: VILLA SCALABRINI LTC90058F 1538221288 206194113 JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1) 10 11 12 13 14 15 16 ADJUSTMENTS TO REPORTED COSTS 130.00 Hospice Inpatient Care 0 135.00 Other Routine Services 0 136.00 Residential Care 0 140.00 Beauty and Barber 0 145.00 Other Nonreimbursable 0 155.00 Social Services 0 155.01 Social Services - Salaries and Wages 0 155.02 Social Services - Fringe Benefits 0 155.03 Social Services - Agency Staff 0 155.04 Social Services - Other - Nonlabor 0 160.00 Activities 0 160.01 Activities - Salaries and Wages 0 160.02 Activities - Fringe Benefits 0 160.03 Activities - Agency Staff 0 160.04 Activities - Other - Nonlabor 0 165.00 Administration 0 165.01 Administration - Salaries and Wages (3,780) (3,780) 165.02 Administration - Fringe Benefits (872) (872) 165.03 Administration - Medical Records - Salaries and Wages 0 165.04 Administration - Medical Records - Fringe Benefits 0 165.05 Administration - Medical Records - Agency Staff 0 165.06 Administration - Medical Records - Other - Nonlabor 0 165.07 Administration - Facility License Fees 14,654 14,654 165.08 Administration - Liability Insurance 5,710 5,710 165.09 Administration - Caregiver Training 0 165.10 Administration - Quality Assurance Fees 0 165.11 Administration - Other - Nonlabor (14,172) (14,654) (5,710) 6,687 (495) 170.00 Inservice Education - Nursing 0 170.01 Inservice Education - Nursing - Salaries and Wages 0 170.02 Inservice Education - Nursing - Fringe Benefits 0 170.03 Inservice Education - Nursing - Agency Staff 0 170.04 Inservice Education - Nursing - Other - Nonlabor 0 175.00 Total $74,302000(4,652) 184,449 (105,000) (495) 0 0 (To Sch 8) This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 17 MC530 Adj. 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Sch Line Reported (Decrease) Adjusted RECONCILIATION OF THE PROVIDER'S RECORDS TO THE AUDIT REPORT 1 10.1(4) 05 14 8A-1 5.00 Plant Operations and Maintenance $303,013 ($303,013) $0 Not Reported 8A-1 5.01 Plant Operations and Maintenance - Salaries and Wages 0 41,313 41,313 Not Reported 8A-1 5.02 Plant Operations and Maintenance - Fringe Benefits 0 13,941 13,941 Not Reported 8A-1 5.04 Plant Operations and Maintenance - Other - Nonlabor 0 247,759 247,759 * 2 10.1(4) 10 14 8A-1 10.00 Housekeeping $198,735 ($198,735) $0 Not Reported 8A-1 10.01 Housekeeping - Salaries and Wages 0 119,417 119,417 Not Reported 8A-1 10.02 Housekeeping - Fringe Benefits 0 40,296 40,296 Not Reported 8A-1 10.04 Housekeeping - Other - Nonlabor 0 39,022 39,022 3 10.1(4) 60 14 8A-1 60.00 Laundry and Linen $118,200 ($118,200) $0 Not Reported 8A-1 60.04 Laundry and Linen - Other - Nonlabor 0 118,200 118,200 4 10.1(4) 65 14 8A-1 65.00 Dietary $354,407 ($354,407) $0 Not Reported 8A-1 65.01 Dietary - Salaries and Wages 0 152,727 152,727 Not Reported 8A-1 65.02 Dietary - Fringe Benefits 0 51,536 51,536 Not Reported 8A-1 65.04 Dietary - Other - Nonlabor 0 150,144 150,144 5 10.1(4) 105 14 8A-1 105.00 Skilled Nursing Care $1,641,591 ($1,641,591) $0 Not Reported 8A-1 105.01 Skilled Nursing Care - Salaries and Wages 0 1,173,925 1,173,925 Not Reported 8A-1 105.02 Skilled Nursing Care - Fringe Benefits 0 396,128 396,128 Not Reported 8A-1 105.04 Skilled Nursing Care - Other - Nonlabor 0 71,538 71,538 6 10.1(4) 155 14 8A-1 155.00 Social Services $41,352 ($41,352) $0 Not Reported 8A-1 155.01 Social Services - Salaries and Wages 0 17,850 17,850 Not Reported 8A-1 155.02 Social Services - Fringe Benefits 0 6,023 6,023 Not Reported 8A-1 155.04 Social Services - Other - Nonlabor 0 17,479 17,479 7 10.1(4) 160 14 8A-1 160.00 Activities $26,953 ($26,953) $0 Not Reported 8A-1 160.01 Activities - Salaries and Wages 0 17,850 17,850 Not Reported 8A-1 160.02 Activities - Fringe Benefits 0 6,023 6,023 Not Reported 8A-1 160.04 Activities - Other - Nonlabor 0 3,080 3,080 -Continued on next page- *Balance carried forward from prior/to subsequent adjustments Page 1 Adjustments VILLA SCALABRINI JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 LTC90058F Report References Cost Report Audit Report Explanation of Audit Adjustments This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 17 MC530 Adj. 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Sch Line Reported (Decrease) Adjusted Adjustments VILLA SCALABRINI JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 LTC90058F Report References Cost Report Audit Report Explanation of Audit Adjustments RECONCILIATION OF THE PROVIDER'S RECORDS TO THE AUDIT REPORT -Continued from previous page- 8 10.1(4) 165 14 8A-1 165.00 Administration $521,271 ($521,271) $0 Not Reported 8A-1 165.01 Administration - Salaries and Wages 0 264,375 264,375 * Not Reported 8A-1 165.02 Administration - Fringe Benefits 0 89,209 89,209 * Not Reported 8A-1 165.06 Administration - Medical Records - Other - Nonlabor 0 793 793 Not Reported 8A-1 165.11 Administration - Other - Nonlabor 0 166,894 166,894 * 9 10.1(4) 170 14 8A-1 170.00 Inservice Education - Nursing $37,800 ($37,800) $0 Not Reported 8A-1 170.01 Inservice Education - Nursing - Salaries and Wages 0 27,373 27,373 Not Reported 8A-1 170.02 Inservice Education - Nursing - Fringe Benefits 0 9,237 9,237 Not Reported 8A-1 170.04 Inservice Education - Nursing - Other - Nonlabor 0 1,190 1,190 To reclassify reported expenses for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 *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 17 MC530 Adj. 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Sch Line Reported (Decrease) Adjusted Adjustments VILLA SCALABRINI JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 LTC90058F Report References Cost Report Audit Report Explanation of Audit Adjustments RECLASSIFICATIONS OF REPORTED COSTS 10 Not Reported 8A-2 165.07 Administration - Facility License Fees $0 $14,654 $14,654 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 166,894 (14,654) 152,240 * To reclassify facility licensing fees to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 11 Not Reported 8A-2 165.08 Administration - Liability Insurance $0 $5,710 $5,710 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 152,240 (5,710) 146,530 * To reclassify professional liability insurance expense to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 12 Not Reported 8A-2 5.04 Plant Operations and Maintenance - Other - Nonlabor * $247,759 ($6,687) $241,072 * Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 146,530 6,687 153,217 * To reclassify telephone expenses to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 *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 17 MC530 Adj. 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Sch Line Reported (Decrease) Adjusted Adjustments VILLA SCALABRINI JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 LTC90058F Report References Cost Report Audit Report Explanation of Audit Adjustments ADJUSTMENTS TO REPORTED COSTS 13 Not Reported 8A-2 165.01 Administration - Salaries and Wages * $264,375 ($3,780) $260,595 Not Reported 8A-2 165.02 Administration - Fringe Benefits * 89,209 (872) 88,337 To adjust administrator's compensation based on the department survey. 42 CFR 413.102 CMS Pub. 15-1, Sections 901, 902.3, 904 and 1005 SPA 05-005, Section (III)(J) / W&I Code, Section 14126.023(f) 14 10.1(4) 15 14 8A-2 15.00 Depreciation - Buildings and Improvements ($104,778) $147,090 $42,312 10.1(4) 25 14 8A-2 25.00 Depreciation - Equipment (16,041) 37,359 21,318 To adjust depreciation expense to agree with the provider's depreciation schedule. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 15 Not Reported 8A-2 5.04 Plant Operations and Maintenance - Other - Nonlabor * $241,072 ($105,000) $136,072 To eliminate capital related expense for assets that should have been capitalized. 42 CFR 413.20 and 413.134 / CMS Pub. 15-1, Section 108 16 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $153,217 ($495) $152,722 To eliminate contribution expenses not related to patient care. 42 CFR 413.9(c)(3) / CMS Pub. 15-1, Sections 2102.3 and 2105.7 *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 17 MC530 Adj. 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Sch Line Reported (Decrease) Adjusted Adjustments VILLA SCALABRINI JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 LTC90058F Report References Cost Report Audit Report Explanation of Audit Adjustments ADJUSTMENT TO REPORTED STATISTICS 17 Not Reported 7 5.00 Plant Operations and Maintenance (Square Feet) 0 439 439 Not Reported 7 10.00 Housekeeping 02222 Not Reported 7 60.00 Laundry and Linen 02929 Not Reported 7 65.00 Dietary 0 1,076 1,076 11.1(1 of 3) 10 2 7 75.00 Patient Supplies 0 253 253 11.1(1 of 3) 15 2 7 80.00 Physical Therapy 0 348 348 11.1(1 of 3) 40 2 7 105.00 Skilled Nursing Care 11,762 (4,808) 6,954 Not Reported 7 155.00 Social Services 0 902 902 Not Reported 7 160.00 Activities 0 741 741 Not Reported 7 165.00 Administration 0 517 517 Not Reported 7 165.00 Medical Records 0 105 105 11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 11,762 (376) 11,386 11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 11,762 (815) 10,947 11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 11,762 (837) 10,925 To adjust square footage to agree with the audited totals for the fiscal year ended December 31, 2007. 42 CFR 413.24 / CMS Pub. 15-1, Sections 2300 and 2306 Page 5 This is trial version www.adultpdf.com . Adjusted Adjustments VILLA SCALABRINI JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 LTC90058F Report References Cost Report Audit Report Explanation of Audit Adjustments ADJUSTMENTS TO REPORTED COSTS 13. Adjusted Adjustments VILLA SCALABRINI JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 LTC90058F Report References Cost Report Audit Report Explanation of Audit Adjustments RECLASSIFICATIONS OF REPORTED COSTS 10. Nursing - Other - Nonlabor 0 175.00 Total $74,302000(4,652) 184,449 (105,000) (495) 0 0 (To Sch 8) This is trial version www.adultpdf.com State of California Department of Health Care Services Provider