STATE OF CALIFORNIA CONTRACT SCH 5 Provider Name: Fiscal Period Ended: ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008 Provider No: HSC 30616I RATIO COST TO CHARGES ANCILLARY COST CENTERS 37.00 Operating Room $ 5,113,492 $ 54,808,109 0.093298 $ 828,670 $ 77,313 38.00 Recovery Room 0 0 0.000000 0 0 39.00 Delivery Room and Labor Room 137,285 1,479,613 0.092785 208,082 19,307 40.00 Anesthesiology 0 0 0.000000 0 0 41.00 Radiology - Diagnostic 3,592,122 14,713,725 0.244134 134,282 32,783 42.00 Radiology - Therapeutic 0 0 0.000000 0 0 42.01 Ultrasound 435,198 2,322,099 0.187416 27,387 5,133 42.02 CAT Scan 829,868 14,621,127 0.056758 167,503 9,507 43.00 Radioisotope 345,042 1,571,726 0.219531 17,763 3,900 44.00 Laboratory 4,380,098 35,372,413 0.123828 854,289 105,785 44.01 Pathological Lab 0 0 0.000000 0 0 46.00 Whole Blood 0 0 0.000000 0 0 47.00 Blood Storing and Processing 0 0 0.000000 0 0 48.00 Intravenous Therapy 0 0 0.000000 0 0 49.00 Respiratory Therapy 2,668,925 44,775,936 0.059606 455,419 27,146 49.01 Hyperbaric Chamber 1,399,828 10,624,124 0.131759 0 0 50.00 Physical Therapy 1,612,854 3,947,415 0.408585 57,121 23,339 51.00 Occupational Therapy 305,168 1,291,834 0.236228 6,303 1,489 52.00 Speech Pathology 129,738 569,919 0.227643 12,528 2,852 53.00 Electrocardiology 870,858 5,487,247 0.158706 155,700 24,711 54.00 Electroencephalography 0 0 0.000000 0 0 55.00 Medical Supplies Charged to Patients 3,462,472 15,268,493 0.226772 255,778 58,003 55.01 Implants Charged to Patients 3,287,181 3,246,746 1.012454 19,982 20,231 56.00 Drugs Charged to Patients 4,525,666 34,060,494 0.132871 1,174,697 156,084 57.00 Renal Dialysis 590,817 1,556,728 0.379525 82,556 31,332 58.00 ASC (Non-Distinct Part) 0 0 0.000000 0 0 59.00 0 0 0.000000 0 0 59.01 0 0 0.000000 0 0 60.00 Clinic 0 0 0.000000 0 0 60.01 Other Clinic Services 0 0 0.000000 0 0 61.00 Emergency 4,660,533 14,447,754 0.322578 243,569 78,570 62.00 Observation Beds 0 0 0.000000 0 0 TOTAL $ 38,347,145 $ 260,165,502 $ 4,701,629 $ 677,485 (To Contract Sch 3) * From Schedule 8, Column 27 SCHEDULE OF MEDI-CAL ANCILLARY COSTS TOTAL MEDI-CAL CHARGES TOTAL ANCILLARY MEDI-CAL ANCILLARY COST* COST (Contract Sch 6) CHARGES (Adj ) This is trial version www.adultpdf.com STATE OF CALIFORNIA CONTRACT SCH 6 Provider Name: Fiscal Period Ended: ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008 Provider No: HSC 30616I ANCILLARY CHARGES 37.00 Operating Room $ 927,451 $ (98,781) $ 828,670 38.00 Recovery Room 0 0 39.00 Delivery Room and Labor Room 273,192 (65,110) 208,082 40.00 Anesthesiology 0 0 41.00 Radiology - Diagnostic 193,808 (59,526) 134,282 42.00 Radiology - Therapeutic 0 0 42.01 Ultrasound 47,082 (19,695) 27,387 42.02 CAT Scan 226,454 (58,951) 167,503 43.00 Radioisotope 15,308 2,455 17,763 44.00 Laboratory 997,503 (143,214) 854,289 44.01 Pathological Lab 0 0 46.00 Whole Blood 0 0 47.00 Blood Storing and Processing 0 0 48.00 Intravenous Therapy 0 0 49.00 Respiratory Therapy 1,049,495 (594,076) 455,419 49.01 Hyperbaric Chamber 60,146 (60,146) 0 50.00 Physical Therapy 97,283 (40,162) 57,121 51.00 Occupational Therapy 22,879 (16,576) 6,303 52.00 Speech Pathology 5,738 6,790 12,528 53.00 Electrocardiology 139,964 15,736 155,700 54.00 Electroencephalography 0 0 55.00 Medical Supplies Charged to Patients 56,845 198,933 255,778 55.01 Implants Charged to Patients 0 19,982 19,982 56.00 Drugs Charged to Patients 1,556,001 (381,304) 1,174,697 57.00 Renal Dialysis 145,590 (63,034) 82,556 58.00 ASC (Non-Distinct Part) 0 0 59.00 0 0 59.01 0 0 60.00 Clinic 0 0 60.01 Other Clinic Services 0 0 61.00 Emergency 162,721 80,848 243,569 62.00 Observation Beds 0 0 TOTAL MEDI-CAL ANCILLARY CHARGES $ 5,977,460 $ (1,275,831) $ 4,701,629 (To Contract Sch 5) ADJUSTMENTS TO MEDI-CAL CHARGES (Adj 18) AUDITEDADJUSTMENTSREPORTED This is trial version www.adultpdf.com STATE OF CALIFORNIA CONTRACT SCH 7 Provider Name: Fiscal Period Ended: ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008 Provider No: HSC 30616I PROFESSIONAL SERVICE COST CENTERS 40.00 Anesthesiology $ 0 $ 0 0.000000 $ $ 0 41.00 Radiology - Diagnostic 0 0 0.000000 0 43.00 Radioisotope 0 0 0.000000 0 44.00 Laboratory 0 0 0.000000 0 53.00 Electrocardiology 0 0 0.000000 0 54.00 Electroencephalography 0 0 0.000000 0 61.00 Emergency 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 0 0 0.000000 0 TOTAL $ 0 $ 0 $ 0 $ 0 (To Contract Sch 3) (Adj )(Adj ) (Adj ) PHYSICIAN'S REMUNERATION TO CHARGES MEDI-CAL CHARGES MEDI-CAL COSTREMUNERATION COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED TO ALL PATIENTS RATIO OF REMUNERATION TOTAL CHARGES HBP This is trial version www.adultpdf.com STATE OF CALIFORNIA ADULT SUBACUTE SCH 1 Provider Name: Fiscal Period Ended: ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008 Provider No: LTC 70024G REPORTED AUDITED DIFFERENCE COMPUTATION OF SUBACUTE PER DIEM 1. Adult Subacute Ancillary Cost (Adult Subacute Sch 3) $ 828,465 $ 2,829,037 $ 2,000,572 2. Adult Subacute Routine Cost (Adult Subacute Sch 2) $ 10,060,321 $ 9,497,283 $ (563,038) 3. Total Adult Subacute Facility Cost (Lines 1 & 2) $ 10,888,786 $ 12,326,320 $ 1,437,534 4. Total Adult Subacute Patient Days (Adj 15) 15,517 15,525 8 5. Average Adult Subacute Per Diem Cost (L3 / L4) $ 701.73 $ 793.97 $ 92.24 ADULT SUBACUTE OVERPAYMENT & OVERBILLINGS 6. Medi-Cal Overpayments (Adj 26) $ 0 $ (2,811) $ (2,811) 6. Medi-Cal Overpayments (Adj 27) $ 0 $ (100,197) $ (100,197) 8. MEDI-CAL SETTLEMENT Due Provider (State) $ 0 $ (103,008) $ (103,008) (To Summary of Findings) GENERAL INFORMATION 9. Contracted Number of Adult Subacute Beds (Adj 23) 0 48 48 10. Total Licensed Nursing Facility Beds (Adj ) 99 99 * 0 11. Total Licensed Capacity (All levels of care)(Adj ) 180 180 0 12. Total Medi-Cal Adult Subacute Patient Days (Adj 21) 3,756 8,661 4,905 * 51 of 99 Licensed Nursing Facility beds are unstaffed. Hospital stopped providing Distinct Part Nursing services effective June 30, 2006. CAPITAL RELATED COST 13. Direct Capital Related Cost N/A $ 0 N/A 14. Indirect Capital Related Cost (Adult Subacute Sch 5) N/A $ 789,762 N/A 15. Total Capital Related Cost (Lines 13 & 14) N/A $ 789,762 N/A TOTAL SALARY & BENEFITS 16. Direct Salary & Benefits Expenses N/A $ 0 N/A 17. Alloc Salary & Benefits Expenses (Adult Subacute Sch 5) N/A $ 2,828,018 N/A 18. Total Salary & Benefits Expenses (Lines 16 & 17) N/A $ 2,828,018 N/A AUDITED ADULT SUBACUTE COST-VENTILATOR AND NONVENTILATOR AUDITED AUDITED AUDITED COSTS TOTAL DAYS MEDI-CAL DAYS (Adj 24) (Adj 16) (Adj 21) 19. Ventilator (Equipment Cost Only) $ 68,167 6,426 3,410 20. Nonventilator N/A 9,099 N/A 21. TOTAL N/A 15,525 N/A COMPUTATION OF ADULT SUBACUTE PER DIEM This is trial version www.adultpdf.com STATE OF CALIFORNIA ADULT SUBACUTE SCH 2 Provider Name: Fiscal Period Ended: ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008 Provider No: LTC 70024G COST CENTER COL. DIRECT AND ALLOCATED EXPENSE 0.00 Adult Subacute $ 4,732,619 $ 4,725,861 $ (6,758) 1.00 Old Cap Rel Costs-Bldg and Fixtures 0 0 0 2.00 Old Cap Rel Costs-Movable Equipment 0 0 0 3.00 New Cap Rel Costs-Bldg and Fixtures 227,029 190,490 (36,539) 4.00 New Cap Rel Costs-Movable Equipment 303,372 290,629 (12,743) 4.01 0 0 0 4.02 0 0 0 4.03 0 0 0 4.04 0 0 0 4.05 0 0 0 4.06 0 0 0 4.07 0 0 0 4.08 0 0 0 5.00 Employee Benefits 1,368,117 1,184,100 (184,017) 6.01 Non-Patient Telephones 0 0 0 6.02 Data Processing 0 0 0 6.03 Purchasing/Receiving 0 0 0 6.04 Patient Admitting 0 0 0 6.05 Patient Business Office 0 0 0 6.06 0 0 0 6.07 0 0 0 6.08 0 0 0 6.00 Administrative and General 1,315,485 1,100,635 (214,850) 7.00 Maintenance and Repairs 364,978 511,213 146,235 8.00 Operation of Plant 235,400 221,063 (14,337) 9.00 Laundry and Linen Service 182,550 98,450 (84,100) 10.00 Housekeeping 174,695 182,609 7,914 11.00 Dietary 82,871 87,526 4,655 12.00 Cafeteria 373,417 348,579 (24,838) 13.00 Maintenance of Personnel 0 0 0 14.00 Nursing Administration 574,567 440,451 (134,116) 15.00 Central Services and Supply 10,214 8,106 (2,108) 16.00 Pharmacy 0 0 0 17.00 Medical Records and Library 115,007 107,571 (7,436) 18.00 Social Service 0 0 0 19.00 0 0 0 19.02 0 0 0 19.03 0 0 0 20.00 0 0 0 21.00 Nursing School 0 0 0 22.00 Intern & Res Service-Salary & Fringes 0 0 0 23.00 Intern & Res Other Program 0 0 0 24.00 Paramedical Ed Program 0 0 0 TOTAL DIRECT AND 101.00 ALLOCATED EXPENSES $ 10,060,321 $ 9,497,283 $ (563,038) (To Adult Subacute Sch 1) * From Schedule 8, Part I, Line 36.00 REPORTED AUDITED * DIFFERENCE SUMMARY OF ADULT SUBACUTE FACILITY EXPENSES This is trial version www.adultpdf.com STATE OF CALIFORNIA ADULT SUBACUTE SCH 3 Provider Name: Fiscal Period Ended: ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008 Provider No: LTC 70024G TOTAL RATIO TOTAL SUBACUTE SUBACUTE ANCILLARY CHARGES COST TO ANCILLARY ANCILLARY COST * CHARGES CHARGES ** COSTS*** ANCILLARY COST CENTERS (Adult SA Sch 4) 37.00 Operating Room $ 5,113,492 $ 54,808,109 0.093298 $ 0 $ 0 41.00 Radiology - Diagnostic 3,592,122 14,713,725 0.244134 344,652 84,141 42.01 Ultrasound 435,198 2,322,099 0.187416 27,281 5,113 42.02 CAT Scan 829,868 14,621,127 0.056758 101,131 5,740 43.00 Radioisotope 345,042 1,571,726 0.219531 14,584 3,202 44.00 Laboratory 4,380,098 35,372,413 0.123828 2,252,908 278,973 49.00 Respiratory Therapy 2,668,925 44,775,936 0.059606 31,212,887 1,860,483 49.01 Hyperbaric Chamber 1,399,828 10,624,124 0.131759 0 0 50.00 Physical Therapy 1,612,854 3,947,415 0.408585 768,722 314,088 51.00 Occupational Therapy 305,168 1,291,834 0.236228 604,314 142,756 52.00 Speech Pathology 129,738 569,919 0.227643 449,989 102,437 53.00 Electrocardiology 870,858 5,487,247 0.158706 0 0 55.00 Med Supplies Charged to Patients 3,462,472 15,268,493 0.226772 109,145 24,751 56.00 Drugs Charged to Patients 4,525,666 34,060,494 0.132871 55,337 7,353 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 0.000000 0 0 101.00 TOTAL $ 29,671,329 $ 239,434,661 $ 35,940,950 $ 2,829,037 * From Schedule 8, Column 27 ** Total Other Allowable Ancillary Charges included in the rate. *** Total Other Ancillary Costs included in the rate. (To Adult Subacute Sch 1) TOTAL ANCILLARY SCHEDULE OF TOTAL OTHER ALLOWABLE ADULT SUBACUTE ANCILLARY COSTS** This is trial version www.adultpdf.com STATE OF CALIFORNIA ADULT SUBACUTE SCH 4 Provider Name: Fiscal Period Ended: ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008 Provider No: LTC 70024G ANCILLARY CHARGES 37.00 Operating Room $ 1,741 $ (1,741) $ 0 41.00 Radiology - Diagnostic 95,832 248,820 344,652 42.01 Ultrasound 3,637 23,644 27,281 42.02 CAT Scan 27,162 73,969 101,131 43.00 Radioisotope 4,316 10,268 14,584 44.00 Laboratory 520,362 1,732,546 2,252,908 49.00 Respiratory Therapy 6,136,680 25,076,207 31,212,887 49.01 Hyperbaric Chamber 38,401 (38,401) 0 50.00 Physical Therapy 127,728 640,994 768,722 51.00 Occupational Therapy 114,094 490,220 604,314 52.00 Speech Pathology 77,755 372,234 449,989 53.00 Electrocardiology 8,655 (8,655) 0 55.00 Med Supplies Charged to Patients 22,360 86,785 109,145 56.00 Drugs Charged to Patients 1,653,655 (1,598,318) 55,337 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 101.00 TOTAL ANCILLARY CHARGES $ 8,832,378 $ 27,108,572 $ 35,940,950 (To Adult Subacute Sch 3) REPORTED ADJUSTMENTS ADULT SUBACUTE ANCILLARY CHARGES ADJUSTMENTS TO OTHER ALLOWABLE (Adj 22) AUDITED This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: Fiscal Period Ended: ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008 Provider No: LTC 70024G COL. 1.00 Old Cap Rel Costs-Bldg and Fixtures $ 0 $ N/A 2.00 Old Cap Rel Costs-Movable Equipment 0 N/A 3.00 New Cap Rel Costs-Bldg and Fixtures 190,490 N/A 4.00 New Cap Rel Costs-Movable Equipment 290,629 N/A 4.01 0N/A 4.02 0N/A 4.03 0N/A 4.04 0N/A 4.05 0N/A 4.06 0N/A 4.07 0N/A 4.08 0N/A 5.00 Employee Benefits 1,557 1,182,543 6.01 Non-Patient Telephones 0 0 6.02 Data Processing 0 0 6.03 Purchasing/Receiving 0 0 6.04 Patient Admitting 0 0 6.05 Patient Business Office 0 0 6.06 00 6.07 00 6.08 00 6.00 Administrative and General 118,219 631,336 7.00 Maintenance and Repairs 119,986 188,904 8.00 Operation of Plant 3,488 18,629 9.00 Laundry and Linen Service 1,554 8,297 10.00 Housekeeping 10,898 113,497 11.00 Dietary 7,923 50,391 12.00 Cafeteria 31,554 200,686 13.00 Maintenance of Personnel 0 0 14.00 Nursing Administration 7,943 377,966 15.00 Central Services and Supply 632 5,138 16.00 Pharmacy 0 0 17.00 Medical Records and Library 4,889 50,631 18.00 Social Service 0 0 19.00 00 19.02 00 19.03 00 20.00 00 21.00 Nursing School 0 0 22.00 Intern & Res Service-Salary & Fringes 0 0 23.00 Intern & Res Other Program 0 0 24.00 Paramedical Ed Program 0 0 101.00 TOTAL ALLOCATED INDIRECT EXPENSES $ 789,762 $ 2,828,018 (To Adult Subacute Sch 1) (COL 2) RELATED (COL 1)ALLOCATED EXPENSES ADULT SUBACUTE SCH 5 COST CENTER EMP BENEFITS AUDITED SAL &AUDITED CAP ALLOCATION OF INDIRECT EXPENSES ADULT SUBACUTE This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 8 Provider Name: Fiscal Period Ended: ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008 NET EXP FOR OLD CAPITAL OLD NEW CAP REL NEW CAP REL COST ALLOC BLDG & MOVABLE BLDG & MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC TRIAL BALANCE (From Sch 10) FIXTURES EQUIP FIXTURES EQUIPMENT COST COST COST COST COST COST COST EXPENSES 0.00 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 COMPUTATION OF COST ALLOCATION (W/S B) GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs-Bldg and Fixtures 0 2.00 Old Cap Rel Costs-Movable Equipmen 0 0 3.00 New Cap Rel Costs-Bldg and Fixtures 1,871,259 0 0 4.00 New Cap Rel Costs-Movable Equipme 2,854,962 0 0 0 4.01 0 0 0 0 0 4.02 0 0 0 0 0 0 4.03 0 0 0 0 0 0 0 4.04 0 0 0 0 0 0 0 0 4.05 0 0 0 0 0 0 0 0 0 4.06 0 0 0 0 0 0 0 0 0 0 4.07 0 0 0 0 0 0 0 0 0 0 0 4.08 0 0 0 0 0 0 0 0 0 0 0 0 5.00 Employee Benefits 8,958,700 0 0 4,671 7,126 0 0 0 0 0 0 0 6.01 Non-Patient Telephones 0 0 0 0 0 0 0 0 0 0 0 0 6.02 Data Processing 0 0 0 0 0 0 0 0 0 0 0 0 6.03 Purchasing/Receiving 0 0 0 0 0 0 0 0 0 0 0 0 6.04 Patient Admitting 0 0 0 0 0 0 0 0 0 0 0 0 6.05 Patient Business Office 0 0 0 0 0 0 0 0 0 0 0 0 6.06 0 0 0 0 0 0 0 0 0 0 0 0 6.07 0 0 0 0 0 0 0 0 0 0 0 0 6.08 0 0 0 0 0 0 0 0 0 0 0 0 6.00 Administrative and General 7,859,489 0 0 432,829 660,363 0 0 0 0 0 0 0 7.00 Maintenance and Repairs 1,791,058 0 0 270,502 412,702 0 0 0 0 0 0 0 8.00 Operation of Plant 1,151,626 0 0 0 0 0 0 0 0 0 0 0 9.00 Laundry and Linen Service 368,835 0 0 0 0 0 0 0 0 0 0 0 10.00 Housekeeping 726,000 0 0 15,463 23,591 0 0 0 0 0 0 0 11.00 Dietary 1,333,927 0 0 52,691 80,390 0 0 0 0 0 0 0 12.00 Cafeteria 0 0 0 0 0 0 0 0 0 0 0 0 13.00 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 14.00 Nursing Administration 899,620 0 0 0 0 0 0 0 0 0 0 0 15.00 Central Services and Supply 389,402 0 0 12,392 18,9060000000 16.00 Pharmacy 1,034,335 0 0 6,654 10,1520000000 17.00 Medical Records and Library 1,049,956 0 0 13,277 20,2560000000 18.00 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 19.00 0 0 0 0 0 0 0 0 0 0 0 0 19.02 0 0 0 0 0 0 0 0 0 0 0 0 19.03 0 0 0 0 0 0 0 0 0 0 0 0 20.00 000000000000 21.00 Nursing School 000000000000 22.00 Intern & Res Service-Salary & Fringes 0 0 0 0 0 0 0 0 0 0 0 0 23.00Intern & Res Other Program 000000000000 24.00Paramedical Ed Program 000000000000 INPATIENT ROUTINE COST CENTERS 25.00 Adults and Pediatrics (Gen Routine) 6,815,127 0 0 307,677 469,419 0 0 0 0 0 0 0 26.00 Intensive Care Unit 3,143,645 0 0 55,303 84,3760000000 27.00 Coronary Care Unit 000000000000 28.00 Neonatal Intensive Care Unit 000000000000 29.00Surgical Intensive Care 000000000000 30.00 Subprovider I 000000000000 31.00 Subprovider II 000000000000 32.00 000000000000 33.00 Nursery 418,116 0 0 4,617 7,0450000000 34.00 Distinct Part Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 35.00 0 0 0 0 0 0 0 0 0 0 0 0 36.00 Subacute Care Unit 4,725,861 0 0 190,490 290,629 0 0 0 0 0 0 0 36.01 Subacute Care Unit II 0 0 0 0 0 0 0 0 0 0 0 0 36.02 Transitional Care Unit 000000000000 This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 8 Provider Name: Fiscal Period Ended: ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008 NET EXP FOR OLD CAPITAL OLD NEW CAP REL NEW CAP REL COST ALLOC BLDG & MOVABLE BLDG & MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC TRIAL BALANCE (From Sch 10) FIXTURES EQUIP FIXTURES EQUIPMENT COST COST COST COST COST COST COST EXPENSES 0.00 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 COMPUTATION OF COST ALLOCATION (W/S B) ANCILLARY COST CENTERS 37.00 Operating Room 2,700,117 0 0 67,354 102,761 0 0 0 0 0 0 0 38.00 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 39.00 Delivery Room and Labor Room 53,437 0 0 6,537 9,973 0 0 0 0 0 0 0 40.00 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 41.00 Radiology - Diagnostic 2,093,899 0 0 79,596 121,4390000000 42.00 Radiology - Therapeutic 000000000000 42.01 Ultrasound 291,890 0 0 2,645 4,035 0 0 0 0 0 0 0 42.02 CAT Scan 534,436 0 0 4,436 6,768 0 0 0 0 0 0 0 43.00 Radioisotope 216,545 0 0 6,142 9,3710000000 44.00 Laboratory 2,846,419 0 0 44,000 67,1300000000 44.01Pathological Lab 000000000000 46.00Whole Blood 000000000000 47.00 Blood Storing and Processing 000000000000 48.00 Intravenous Therapy 000000000000 49.00 Respiratory Therapy 1,597,262 0 0 6,974 10,6410000000 49.01 Hyperbaric Chamber 829,750 0 0 3,999 6,101 0 0 0 0 0 0 0 50.00 Physical Therapy 884,209 0 0 27,822 42,448 0 0 0 0 0 0 0 51.00 Occupational Therapy 188,163 0 0 1,450 2,2130000000 52.00 Speech Pathology 95,28500000000000 53.00 Electrocardiology 402,709 0 0 33,943 51,7870000000 54.00 Electroencephalography 000000000000 55.00 Medical Supplies Charged to Patients 2,729,48500000000000 55.01 Implants Charged to Patients 2,625,601 0 0 0 0 0 0 0 0 0 0 0 56.00 Drugs Charged to Patients 2,334,155 0 0 0 0 0 0 0 0 0 0 0 57.00 Renal Dialysis 497,96100000000000 58.00ASC (Non-Distinct Part) 000000000000 59.00 000000000000 59.01 000000000000 60.00Clinic 000000000000 60.01 Other Clinic Services 0 0 0 0 0 0 0 0 0 0 0 0 61.00 Emergency 2,612,538 0 0 55,037 83,969 0 0 0 0 0 0 0 62.00Observation Beds 000000000000 71.00 000000000000 82.00 000000000000 83.00 000000000000 84.00 0 0 0 0 0 0 0 0 0 0 0 0 85.00 0 0 0 0 0 0 0 0 0 0 0 0 86.00 0 0 0 0 0 0 0 0 0 0 0 0 NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop & Canteen 0 0 0 5,023 7,6630000000 97.00Research 000000000000 98.00Physicians' Private Office 000000000000 99.00 Nonpaid Workers 000000000000 99.01 0 0 0 0 0 0 0 0 0 0 0 0 99.02 0 0 0 0 0 0 0 0 0 0 0 0 99.03 000000000000 99.04 000000000000 100.00 Community Benefits 378,09900000000000 100.01 Unused Space 0 0 0 151,695 231,4390000000 100.10 Medical Transporation Services 76,87100000000000 100.20 Non-Patient Meals 000000000000 100.30 Foundation 0 0 0 1,066 1,627 0 0 0 0 0 0 0 100.40 Doctor's Lounge 0 0 0 6,974 10,6410000000 TOTAL 69,380,749 0 0 1,871,259 2,854,962 0 0 0 0 0 0 0 This is trial version www.adultpdf.com [...]... Administrative and General Maintenance and Repairs Operation of Plant Laundry and Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Social Service Employee Benefits Non-Patient Telephones Data Processing Purchasing/Receiving Patient Admitting Patient Business Office GENERAL SERVICE COST CENTER Old Cap Rel... Costs-Bldg and Fixtures Old Cap Rel Costs-Movable Equipmen New Cap Rel Costs-Bldg and Fixtures New Cap Rel Costs-Movable Equipme TRIAL BALANCE EXPENSES Provider Name: ST JOHN'S PLEASANT VALLEY HOSPITAL STATE OF CALIFORNIA This is trial version www.adultpdf.com 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1,547,101 708,308 0 0 0 0 0 0 104,751 0 0 1,184,100 0 0 0 0 0 0 0 0 0 0 1,240,294 188,902 0 0 122,891 217,988 0 0 217,093... 6.03 ALLOC COST 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6.04 ALLOC COST 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 COMPUTATION OF COST ALLOCATION (W/S B) 6.05 ALLOC COST 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6.06 ALLOC COST 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0... 0 92,053 0 0 1,100,635 0 0 458,635 198,326 63,519 152,917 290,180 0 0 192,314 84,703 228,186 206,586 0 0 0 0 0 0 0 0 0 6.00 Fiscal Period Ended: JUNE 30, 2008 ADMINISACCUMULATE TRATIVE & COST GENERAL SCHEDULE 8.1 . 4,701,629 $ 677,485 (To Contract Sch 3) * From Schedule 8, Column 27 SCHEDULE OF MEDI-CAL ANCILLARY COSTS TOTAL MEDI-CAL CHARGES TOTAL ANCILLARY MEDI-CAL ANCILLARY COST* COST (Contract Sch 6) CHARGES (Adj. ) PHYSICIAN'S REMUNERATION TO CHARGES MEDI-CAL CHARGES MEDI-CAL COSTREMUNERATION COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED TO ALL PATIENTS RATIO OF REMUNERATION TOTAL CHARGES HBP This. From Schedule 8, Column 27 ** Total Other Allowable Ancillary Charges included in the rate. *** Total Other Ancillary Costs included in the rate. (To Adult Subacute Sch 1) TOTAL ANCILLARY SCHEDULE