REPORT ON THE COST REPORT REVIEW CENTINELA HOSPITAL MEDICAL CENTER INGLEWOOD, CALIFORNIA PROVIDER NUMBER: HSC30240H NATIONAL PROVIDER IDENTIFIERS: 1336328244 AND 1619936440 FISCAL PERIOD FEBRUARY 1, 2008 TO DECEMBER 31, 2008_part1 docx

REPORT ON THE COST REPORT REVIEW CENTINELA HOSPITAL MEDICAL CENTER INGLEWOOD, CALIFORNIA PROVIDER NUMBER: HSC30240H NATIONAL PROVIDER IDENTIFIERS: 1336328244 AND 1619936440 FISCAL PERIOD FEBRUARY 1, 2008 TO DECEMBER 31, 2008 Audits Section - Gardena Financial Audits Branch Audits and Investigations Department of Health Care Services Section Chief: Cheryl Phillips Audit Supervisor: Maria Delgado Auditor: Myrtle Maghirang This is trial version www.adultpdf.com State of California—Health and Human Services Agency Department of Health Care Services DAVID MAXWELL-JOLLY Director ARNOLD SCHWARZENEGGER Governor July 13, 2010 Jeffrey N Brown Vice President Hospital Management Services, Inc 211 East Imperial Highway, Suite 102 Fullerton, CA 92835 PROVIDER: CENTINELA HOSPITAL MEDICAL CENTER PROVIDER NO.: HSC30240H NATIONAL PROVIDER INDENTIFIERS: 1336328244 AND 1619936440 FISCAL PERIOD: FEBRUARY 1, 2008 TO DECEMBER 31, 2008 We have examined the provider's Medi-Cal Cost Report for the above-referenced fiscal period Our examination was made under the authority of Section 14170 of the Welfare and Institutions Code and was limited to a review of the cost report and accompanying financial statements, Medi-Cal Paid Claims Summary Report, prior fiscal period's Medi-Cal program audit report, and Medicare audit report for the current fiscal period, if applicable and available In our opinion, the audited combined settlement for the fiscal period due the State in the amount of $8,771, and the audited costs presented in the Summary of Findings represent a proper determination in accordance with the reimbursement principles of applicable programs This audit report includes the: Summary of Findings Computation of Medi-Cal Reimbursement Settlement (NONCONTRACT Schedules) Computation of Medi-Cal Cost (CONTRACT Schedules) Audit Adjustments Schedule Financial Audits/Gardena/A & I, MS 2103, 19300 South Hamilton Avenue, Suite 280, Gardena, CA 90248 Telephone: (310) 516-4757 FAX: (310) 217-6918 Internet Address: www.dhcs.ca.gov This is trial version www.adultpdf.com Jeffrey N Brown Page The audited settlement will be incorporated into a Statement of Account Status, which may reflect tentative retroactive adjustment determinations, payments from the provider, and other financial transactions initiated by the Department The Statement of Account Status will be forwarded to the provider by the State fiscal intermediary Instructions regarding payment will be included with the Statement of Account Status Notwithstanding this audit report, overpayments to the provider are subject to recovery pursuant to Section 51458.1, Article of Division 3, Title 22, California Code of Regulations If you disagree with the decision of the Department, you may appeal by writing to: Chief Office of Administrative Appeals and Hearings 1029 J Street, Suite 200 Sacramento, CA 95814 (916) 322-5603 The written notice of disagreement must be received by the Department within 60 calendar days from the day you receive this letter A copy of this notice should be sent to: United States Postal Service (USPS) Assistant Chief Counsel Department of Health Care Services Office of Legal Services MS 0010 PO Box 997413 Sacramento, CA 95899-7413 Courier (UPS, FedEx, etc.) Assistant Chief Counsel Department of Health Care Services Office of Legal Services MS 0010 1501 Capitol Avenue, Suite 71.5001 Sacramento, CA 95814-5005 (916) 440-7700 The procedures that govern an appeal are contained in Welfare and Institutions Code, Section 14171, and California Code of Regulations, Title 22, Section 51016, et seq This is trial version www.adultpdf.com Jeffrey N Brown Page If you have questions regarding this report, you may call the Audits Section—Gardena at (310) 516-4757 Signed By: Cheryl Phillips, Chief Audits Section—Gardena Financial Audits Branch Certified cc: Matt Williams Finance Department Centinela Hospital Medical Center 555 East Hardy Street Inglewood, CA 90301 This is trial version www.adultpdf.com SUMMARY OF FINDINGS Provider Name: Fiscal Period Ended: CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008 SETTLEMENT COST Medi-Cal Noncontract Settlement (SCHEDULE 1) Provider No ZZT30240H Reported Net Change $ (8,771) Audited Amount Due Provider (State) $ $ (8,771) Subprovider I (SCHEDULE 1-1) Provider No Reported $ Audited Amount Due Provider (State) $ Reported $ Net Change $ Audited Amount Due Provider (State) Net Change $ $ Subprovider II (SCHEDULE 1-2) Provider No Medi-Cal Contract Cost (CONTRACT SCH 1) Provider No HSC30240H Reported $ 39,169,928 Net Change $ 58,255 Audited Cost $ 39,228,184 Reported $ 0.00 Net Change $ 0.00 Audited Cost Per Day $ 0.00 Reported $ 0.00 Net Change $ 0.00 Audited Cost Per Day $ 0.00 Reported $ 0.00 Net Change $ 0.00 Audited Cost Per Day $ 0.00 Audited Amount Due Provider (State) Audited Amount Due Provider (State) $ Distinct Part Nursing Facility (DPNF SCH 1-1) Provider No Audited Amount Due Provider (State) $ Distinct Part Nursing Facility (DPNF SCH 1) Provider No $ Adult Subacute (ADULT SUBACUTE SCH 1) Provider No Audited Amount Due Provider (State) $ Total Medi-Cal Settlement Due Provider (State) - (Lines through 7) $ (8,771) Total Medi-Cal Cost This is trial version www.adultpdf.com $ 39,228,184 SUMMARY OF FINDINGS Provider Name: Fiscal Period Ended: CENTINELA HOSPITAL MEDICAL CENTER DECEMBER 31, 2008 SETTLEMENT 10 COST Subacute (SUBACUTE SCH 1-1) Provider No Reported $ 0.00 Net Change $ 0.00 Audited Cost Per Day $ 0.00 Reported $ 0.00 Net Change $ 0.00 Audited Cost Per Day $ 0.00 Audited Amount Due Provider (State) $ $ $ Net Change $ Audited Amount Due Provider (State) $ Reported $ Net Change $ Audited Amount Due Provider (State) $ Reported $ Net Change $ Audited Amount Due Provider (State) 15 Reported 14 $ Audited Amount Due Provider (State) 13 Net Change 12 $ Reported 11 $ Rural Health Clinic (RHC SCH 1) Provider No Rural Health Clinic (RHC 95-210 SCH 1) Provider No Rural Health Clinic (RHC 95-210 SCH 1-1) Provider No County Medical Services Program (CMSP SCH 1) Provider No Transitional Care (TC SCH 1) Provider No Audited Amount Due Provider (State) 16 17 $ Total Other Settlement Due Provider - (Lines 10 through 15) $ Total Combined Audited Settlement Due Provider (State/CMSP/RHC) - (Line + Line 16) $ This is trial version www.adultpdf.com (8,771) STATE OF CALIFORNIA SCHEDULE PROGRAM: NONCONTRACT COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT Provider Name: CENTINELA HOSPITAL MEDICAL CENTER Fiscal Period Ended: DECEMBER 31, 2008 Provider No ZZT30240H REPORTED AUDITED Net Cost of Covered Services Rendered to Medi-Cal Patients (Schedule 3) $ $ 193,545 Excess Reasonable Cost Over Charges (Schedule 2) $ $ Medi-Cal Inpatient Hospital Based Physician Services $ $ $ $ N/A TOTAL COST-Reimbursable to Provider (Lines through 4) $ $ 193,545 Interim Payments (Adj 7) $ $ (202,316) Balance Due Provider (State) $ $ (8,771) Duplicate Payments (Adj ) $ $ $ $ 10 $ $ 11 TOTAL MEDI-CAL SETTLEMENT Due Provider (State) $ This is trial version www.adultpdf.com $ (8,771) (To Summary of Findings) STATE OF CALIFORNIA SCHEDULE PROGRAM: NONCONTRACT COMPUTATION OF LESSER OF MEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES Provider Name: CENTINELA HOSPITAL MEDICAL CENTER Fiscal Period Ended: DECEMBER 31, 2008 Provider No ZZT30240H REPORTED AUDITED REASONABLE COST OF MEDI-CAL INPATIENT SERVICES Cost of Covered Services (Schedule 3) $ $ 195,126 CHARGES FOR MEDI-CAL INPATIENT SERVICES Inpatient Routine Service Charges (Adj 6) $ $ 966,453 Inpatient Ancillary Service Charges (Adj 6) $ $ 899,326 Total Charges - Medi-Cal Inpatient Services $ $ 1,865,779 Excess of Customary Charges Over Reasonable Cost (Line minus Line 1) * $ $ 1,670,653 Excess of Reasonable Cost Over Customary Charges (Line minus Line 4) $ * If charges exceed reasonable cost, no further calculation necessary for this schedule This is trial version www.adultpdf.com $ (To Schedule 1) STATE OF CALIFORNIA SCHEDULE PROGRAM: NONCONTRACT COMPUTATION OF MEDI-CAL NET COSTS OF COVERED SERVICES Provider Name: CENTINELA HOSPITAL MEDICAL CENTER Fiscal Period Ended: DECEMBER 31, 2008 Provider No ZZT30240H REPORTED AUDITED Medi-Cal Inpatient Ancillary Services (Schedule 5) $ $ 73,274 Medi-Cal Inpatient Routine Services (Schedule 4) $ $ 121,852 Medi-Cal Inpatient Hospital Based Physician for Intern and Resident Services (Sch ) $ $ $ $ $ $ SUBTOTAL (Sum of Lines through 5) $ $ 195,126 Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Schedule 7) $ (See Schedule 1) $ SUBTOTAL $ Coinsurance (Adj 7) $ $ 10 Patient and Third Party Liability (Adj ) $ $ 11 Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ This is trial version www.adultpdf.com $ (To Schedule 2) $ (To Schedule 1) 195,126 (1,581) 193,545 STATE OF CALIFORNIA SCHEDULE PROGRAM: NONCONTRACT COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST Provider Name: CENTINELA HOSPITAL MEDICAL CENTER Fiscal Period Ended: DECEMBER 31, 2008 Provider No ZZT30240H GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED INPATIENT DAYS Total Inpatient Days (include private & swing-bed) (Adj ) Inpatient Days (include private, exclude swing-bed) Private Room Days (exclude swing-bed private room) (Adj ) Semi-Private Room Days (exclude swing-bed) (Adj ) Medicare NF Swing-Bed Days through Dec 31 (Adj ) Medicare NF Swing-Bed Days after Dec 31 (Adj ) Medi-Cal NF Swing-Bed Days through July 31 (Adj ) Medi-Cal NF Swing-Bed Days after July 31 (Adj ) Medi-Cal Days (excluding swing-bed) (Adj ) AUDITED 62,121 62,121 62,121 0 0 62,121 62,121 62,121 0 0 SWING-BED ADJUSTMENT 17 Medicare NF Swing-Bed Rates through Dec 31 (Adj ) 18 Medicare NF Swing-Bed Rates after Dec 31(Adj ) 19 Medi-Cal NF Swing-Bed Rates through July 31(Adj ) 20 Medi-Cal NF Swing-Bed Rates after July 31(Adj ) 21 Total Routine Serv Cost (Sch 8, Line 25, Col 27) 22 Medicare NF Swing-Bed Cost through Dec 31 (L x L 17) 23 Medicare NF Swing-Bed Cost after Dec 31 (L x L 18) 24 Medi-Cal NF Swing-Bed Cost through July 31 (L x L 19) 25 Medi-Cal NF Swing-Bed Cost after July 31 (L x L 20) 26 Total Swing-Bed Cost (Sum of Lines 22 to 25) 27 Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26) $ $ $ $ $ $ $ $ $ $ $ 0.00 0.00 0.00 0.00 64,008,208 0 0 64,008,208 $ $ $ $ $ $ $ $ $ $ $ 0.00 0.00 0.00 0.00 63,347,793 0 0 63,347,793 PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 Gen Inpatient Routine Serv Charges (excl swing-bed charges) 29 Private Room Charges (excluding swing-bed charges) 30 Semi-Private Room Charges (excluding swing-bed charges) 31 Gen Inpatient Routine Service Cost/Charge Ratio (L 27 / L 28) 32 Average Private Room Per Diem Charge (L 29 / L 3) 33 Average Semi-Private Room Per Diem Charge (L 30 / L 4) 34 Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33) 35 Average Per Diem Private Room Cost Differential (L 31 x L 34) 36 Private Room Cost Differential Adjustment (L 35 x L 3) 37 Inpatient Rout Cost Net of Swing-Bed & Prvt Rm (L 27 minus L 36) $ $ $ $ $ $ $ $ $ $ 369,411,300 369,411,300 0.173271 0.00 5,946.64 0.00 0.00 64,008,208 $ $ $ $ $ $ $ $ $ $ 369,411,300 369,411,300 0.171483 0.00 5,946.64 0.00 0.00 63,347,793 PROGRAM INPATIENT OPERATING COST 38 Adjusted General Inpatient Routine Cost Per Diem (L 37 / L 2) 39 Program General Inpatient Routine Service Cost (L x L 38) $ $ 1,030.38 $ $ 1,019.75 40 41 Cost Applicable to Medi-Cal (Sch 4A) Cost Applicable to Medi-Cal (Sch 4B) $ $ $ $ 121,852 42 TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 39,40 & 41) $ This is trial version www.adultpdf.com $ 121,852 ( To Schedule ) STATE OF CALIFORNIA SCHEDULE 4A PROGRAM: NONCONTRACT COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST Provider Name: CENTINELA HOSPITAL MEDICAL CENTER Fiscal Period Ended: DECEMBER 31, 2008 Provider No ZZT30240H SPECIAL CARE AND/OR NURSERY UNITS NURSERY Total Inpatient Routine Cost (Sch 8, Line 33, Col 27) Total Inpatient Days (Adj ) Average Per Diem Cost Medi-Cal Inpatient Days (Adj ) Cost Applicable to Medi-Cal INTENSIVE CARE UNIT Total Inpatient Routine Cost (Sch 8, Line 26, Col 27) Total Inpatient Days (Adj ) Average Per Diem Cost Medi-Cal Inpatient Days (Adj ) 10 Cost Applicable to Medi-Cal CORONARY CARE UNIT 11 Total Inpatient Routine Cost (Sch 8, Line 27, Col 27) 12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost 14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal NEONATAL INTENSIVE CARE UNIT 16 Total Inpatient Routine Cost (Sch 8, Line 30, Col 27) 17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost 19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal SURGICAL INTENSIVE CARE UNIT 21 Total Inpatient Routine Cost (Sch 8, Line 29, Col 27) 22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost 24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal ADMINISTRATIVE DAYS (FEBRUARY 1, 2008 TO JULY 31, 2008) 26 Per Diem Rate (Adj 4) 27 Medi-Cal Inpatient Days (Adj 4) 28 Cost Applicable to Medi-Cal ADMINISTRATIVE DAYS (AUGUST 1, 2008 TO DECEMBER 31, 2008) 29 Per Diem Rate (Adj 4) 30 Medi-Cal Inpatient Days (Adj 4) 31 Cost Applicable to Medi-Cal 32 Medi-Cal Routine Cost (Sum of Lines 5,10,15,20,25,28,31) REPORTED $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ This is trial version www.adultpdf.com AUDITED 1,244,249 $ 4,391 283.36 $ 0 $ 1,231,396 4,391 280.44 0 17,992,564 $ 9,258 1,943.46 $ 0 $ 17,806,741 9,258 1,923.39 0 $ 0.00 $ 0 $ 0 0.00 0 3,892,517 $ 2,789 1,395.67 $ 0 $ 3,852,313 2,789 1,381.25 0 $ 0.00 $ 0 $ 0 0.00 0 0.00 $ 0 $ 318.19 171 54,410 0.00 $ 0 $ 351.26 192 67,442 $ (To Schedule 4) 121,852 ... Fullerton, CA 92835 PROVIDER: CENTINELA HOSPITAL MEDICAL CENTER PROVIDER NO.: HSC30240H NATIONAL PROVIDER INDENTIFIERS: 1336328244 AND 1619936440 FISCAL PERIOD: FEBRUARY 1, 2008 TO DECEMBER 31, 2008. .. CUSTOMARY CHARGES Provider Name: CENTINELA HOSPITAL MEDICAL CENTER Fiscal Period Ended: DECEMBER 31, 2008 Provider No ZZT30240H REPORTED AUDITED REASONABLE COST OF MEDI-CAL INPATIENT SERVICES Cost. .. current fiscal period, if applicable and available In our opinion, the audited combined settlement for the fiscal period due the State in the amount of $8,7 71, and the audited costs presented in the