STATE OF CALIFORNIA SCHEDULE OF MEDI-CAL ANCILLARY COSTS_part2 pot

STATE OF CALIFORNIA Provider Name: ST. JOHN'S PLEASANT VALLEY HOSPITAL TRIAL BALANCE EXPENSES ANCILLARY COST CENTERS 37.00 Operating Room 38.00 Recovery Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 42.00 Radiology - Therapeutic 42.01 Ultrasound 42.02 CAT Scan 43.00 Radioisotope 44.00 Laboratory 44.01 Pathological Lab 46.00 Whole Blood 47.00 Blood Storing and Processing 48.00 Intravenous Therapy 49.00 Respiratory Therapy 49.01 Hyperbaric Chamber 50.00 Physical Therapy 51.00 Occupational Therapy 52.00 Speech Pathology 53.00 Electrocardiology 54.00 Electroencephalography 55.00 Medical Supplies Charged to Patients 55.01 Implants Charged to Patients 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 58.00 ASC (Non-Distinct Part) 59.00 59.01 60.00 Clinic 60.01 Other Clinic Services 61.00 Emergency 62.00 Observation Beds 71.00 82.00 83.00 84.00 85.00 86.00 NONREIMBURSABLE COST CENTER 96.00 Gift, Flower, Coffee Shop & Canteen 97.00 Research 98.00 Physicians' Private Office 99.00 Nonpaid Workers 99.01 99.02 99.03 99.04 100.00 Community Benefits 100.01 Unused Space 100.10 Medical Transporation Services 100.20 Non-Patient Meals 100.30 Foundation 100.40 Doctor's Lounge TOTAL SCHEDULE 8.1 Fiscal Period Ended: JUNE 30, 2008 ADMINIS- ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE & COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00 COMPUTATION OF COST ALLOCATION (W/S B) 0 645,055 0 0 0 0 0 0 0 0 3,515,286 605,382 0 0 0 0 0 0 0 0 0 0 0 0 0 4,756 0 0 0 0 0 0 0 0 74,704 12,865 0 0 0 0 0 0 0 0 0 0 0 0 0 282,237000000002,577,171443,825 0000000000 00 0 45,083 0 0 0 0 0 0 0 0 343,653 59,182 0 74,463 0 0 0 0 0 0 0 0 620,104 106,791 022,50200000000254,56143,839 0 350,526000000003,308,074569,697 0000000000 00 0000000000 00 0000000000 00 0000000000 00 0 360,289000000001,975,165340,152 0 210,575 0 0 0 0 0 0 0 0 1,050,425 180,898 0 237,764 0 0 0 0 0 0 0 0 1,192,243 205,321 049,78800000000241,61441,609 011,53600000000106,82118,396 081,40500000000569,84598,135 0000000000 00 00000000002,729,485470,056 0 0 0 0 0 0 0 0 0 0 2,625,601 452,166 0 0 0 0 0 0 0 0 0 0 2,334,155 401,975 0000000000497,96185,756 0000000000 00 0000000000 00 0000000000 00 0000000000 00 0 0 0 0 0 0 0 0 0 0 0 0 0 566,876 0 0 0 0 0 0 0 0 3,318,420 571,479 0000000000 00 0000000000 00 0000000000 00 0000000000 00 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 000000000012,6862,185 0000000000 00 0000000000 00 0000000000 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000000 00 0000000000 00 035,10300000000413,20271,159 0000000000383,13465,981 000000000076,87113,238 0000000000 00 0 0 0 0 0 0 0 0 0 0 2,693 464 000000000017,6153,034 0 8,970,497 0 0 0 0 0 0 0 0 69,380,749 10,192,975 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ST. JOHN'S PLEASANT VALLEY HOSPITAL TRIAL BALANCE EXPENSES GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs-Bldg and Fixtures 2.00 Old Cap Rel Costs-Movable Equipmen 3.00 New Cap Rel Costs-Bldg and Fixtures 4.00 New Cap Rel Costs-Movable Equipme 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 Employee Benefits 6.01 Non-Patient Telephones 6.02 Data Processing 6.03 Purchasing/Receiving 6.04 Patient Admitting 6.05 Patient Business Office 6.06 6.07 6.08 6.00 Administrative and General 7.00 Maintenance and Repairs 8.00 Operation of Plant 9.00 Laundry and Linen Service 10.00 Housekeeping 11.00 Dietary 12.00 Cafeteria 13.00 Maintenance of Personnel 14.00 Nursing Administration 15.00 Central Services and Supply 16.00 Pharmacy 17.00 Medical Records and Library 18.00 Social Service 19.00 19.02 19.03 20.00 21.00 Nursing School 22.00 Intern & Res Service-Salary & Fringes 23.00 Intern & Res Other Program 24.00 Paramedical Ed Program INPATIENT ROUTINE COST CENTER 25.00 Adults and Pediatrics (Gen Routine) 26.00 Intensive Care Unit 27.00 Coronary Care Unit 28.00 Neonatal Intensive Care Unit 29.00 Surgical Intensive Care 30.00 Subprovider I 31.00 Subprovider II 32.00 33.00 Nursery 34.00 Distinct Part Nursing Facility 35.00 36.00 Subacute Care Unit 36.01 Subacute Care Unit II 36.02 Transitional Care Unit SCHEDULE 8.2 Fiscal Period Ended: JUNE 30, 2008 MAINTENANCE MAINTENANCE NURSING CENTRAL MEDICAL AND OPERAION LAUNDRY & OF ADMINI- SERVICE RECORDS SOCIAL REPAIRS OF PLANT LINEN HOUSEKEEPING DIETARY CAFETERIA PERSONNEL STRATION & SUPPLY PHARMACY & LIBRARY SERVICE 7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 COMPUTATION OF COST ALLOCATION (W/S B) 0 0 0 41,497 17,944 0 141,404 61,147 0 50,511 0 0 0 0 1,618,678 0 0 0 0 0 0 0 0 0 0 0 36,746 0 33,255 14,380 0 11,879 0 28,916 0 52 17,8587,72206,379049,042000 35,630 15,407 0 12,727 0 34,488 0 0 503 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 0 0 0 0 0 0 0 0 000 000000000 000 000000000 0 0 0 0 0 0 0 0 0 0 0 0 000 000000000 000 000000000 825,703 357,057 96,422 294,946 400,876 344,976 0 429,244 5,336 0 145,545 0 148,416 64,179 67,107 53,015 29,791 128,441 0 161,780 4,454 0 61,791 0 000 000000000 000 000000000 000 000000000 000 000000000 000 000000000 000 000000000 12,3925,3595,3024,42600008903,4800 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 511,213 221,063 98,450 182,609 87,526 348,579 0 440,451 8,106 0 107,571 0 0 0 0 0 0 0 0 0 0 0 0 0 000 000000000 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ST. JOHN'S PLEASANT VALLEY HOSPITAL TRIAL BALANCE EXPENSES ANCILLARY COST CENTERS 37.00 Operating Room 38.00 Recovery Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 42.00 Radiology - Therapeutic 42.01 Ultrasound 42.02 CAT Scan 43.00 Radioisotope 44.00 Laboratory 44.01 Pathological Lab 46.00 Whole Blood 47.00 Blood Storing and Processing 48.00 Intravenous Therapy 49.00 Respiratory Therapy 49.01 Hyperbaric Chamber 50.00 Physical Therapy 51.00 Occupational Therapy 52.00 Speech Pathology 53.00 Electrocardiology 54.00 Electroencephalography 55.00 Medical Supplies Charged to Patients 55.01 Implants Charged to Patients 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 58.00 ASC (Non-Distinct Part) 59.00 59.01 60.00 Clinic 60.01 Other Clinic Services 61.00 Emergency 62.00 Observation Beds 71.00 82.00 83.00 84.00 85.00 86.00 NONREIMBURSABLE COST CENTER 96.00 Gift, Flower, Coffee Shop & Canteen 97.00 Research 98.00 Physicians' Private Office 99.00 Nonpaid Workers 99.01 99.02 99.03 99.04 100.00 Community Benefits 100.01 Unused Space 100.10 Medical Transporation Services 100.20 Non-Patient Meals 100.30 Foundation 100.40 Doctor's Lounge TOTAL SCHEDULE 8.2 Fiscal Period Ended: JUNE 30, 2008 MAINTENANCE MAINTENANCE NURSING CENTRAL MEDICAL AND OPERAION LAUNDRY & OF ADMINI- SERVICE RECORDS SOCIAL REPAIRS OF PLANT LINEN HOUSEKEEPING DIETARY CAFETERIA PERSONNEL STRATION & SUPPLY PHARMACY & LIBRARY SERVICE 7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 COMPUTATION OF COST ALLOCATION (W/S B) 180,755 78,163 0 64,567 0 120,948 0 119,069 179,357 0 249,964 0 0 0 0 0 0 0 0 0 0 0 0 0 17,543 7,586 9,164 6,267 0 576 0 37 1,795 0 6,748 0 0 0 0 0 0 0 0 0 0 0 0 0 213,609 92,370 37,597 76,302 0 76,037 0 222 7,883 0 67,105 0 000 000000000 7,097 3,069 0 2,535 0 8,310 0 0 761 0 10,590 0 11,905 5,148 0 4,253 0 13,209 0 0 1,775 0 66,683 0 16,484 7,128 0 5,888 0 3,939 0 0 6,034 0 7,168 0 118,080 51,061 0 42,179 0 86,940 0 751 41,991 0 161,323 0 000 000000000 000 000000000 000 000000000 000 000000000 18,717 8,094 5,465 6,686 0 98,084 0 0 12,353 0 204,210 0 10,732 4,641 13,316 3,834 0 42,606 0 43,866 1,058 0 48,454 0 74,666 32,288 7,240 26,671 0 45,776 0 10,478 169 0 18,003 0 3,8921,68301,39009,07800905,8920 000 001,92100002,5990 91,093 39,391 0 32,539 0 14,266 0 299 265 0 25,026 0 000 000000000 000 00000193,296069,6350 0 0 0 0 0 0 0 0 194,606 0 14,807 0 0 0 0 0 0 0 0 0 0 1,634,197 155,340 0 000 00000007,1000 000 000000000 000 000000000 000 000000000 000 000000000 0 0 0 0 0 0 0 0 0 0 0 0 147,700 63,870 92,290 52,760 85,458 118,114 0 139,525 5,025 0 65,892 0 000 000000000 000 000000000 000 000000000 000 000000000 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 13,4795,82904,81500000000 000 000000000 000 000000000 000 000000000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 000 000000000 000 000000000 000 007,68500166000 407,099 176,041 0 145,41800000000 000 000000000 000 05,9070000000 2,862 1,238 0 1,022 0 0 0 0 0 0 0 0 18,7178,09406,68600000000 3,121,799 1,349,952 432,354 1,100,303 2,228,237 1,618,678 0 1,345,772 665,032 1,634,197 1,504,927 0 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ST. JOHN'S PLEASANT VALLEY HOSPITAL TRIAL BALANCE EXPENSES GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs-Bldg and Fixtures 2.00 Old Cap Rel Costs-Movable Equipmen 3.00 New Cap Rel Costs-Bldg and Fixtures 4.00 New Cap Rel Costs-Movable Equipme 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 Employee Benefits 6.01 Non-Patient Telephones 6.02 Data Processing 6.03 Purchasing/Receiving 6.04 Patient Admitting 6.05 Patient Business Office 6.06 6.07 6.08 6.00 Administrative and General 7.00 Maintenance and Repairs 8.00 Operation of Plant 9.00 Laundry and Linen Service 10.00 Housekeeping 11.00 Dietary 12.00 Cafeteria 13.00 Maintenance of Personnel 14.00 Nursing Administration 15.00 Central Services and Supply 16.00 Pharmacy 17.00 Medical Records and Library 18.00 Social Service 19.00 19.02 19.03 20.00 21.00 Nursing School 22.00 Intern & Res Service-Salary & Fringes 23.00 Intern & Res Other Program 24.00 Paramedical Ed Program INPATIENT ROUTINE COST CENTER 25.00 Adults and Pediatrics (Gen Routine) 26.00 Intensive Care Unit 27.00 Coronary Care Unit 28.00 Neonatal Intensive Care Unit 29.00 Surgical Intensive Care 30.00 Subprovider I 31.00 Subprovider II 32.00 33.00 Nursery 34.00 Distinct Part Nursing Facility 35.00 36.00 Subacute Care Unit 36.01 Subacute Care Unit II 36.02 Transitional Care Unit SCHEDULE 8.3 Fiscal Period Ended: JUNE 30, 2008 NON- INT & RES POST ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY & INT & RES PARAMED SUBTOTAL STEP-DOWN TOTAL COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT ADJUSTMENT COST 19.00 19.02 19.03 20.00 21.00 22.00 23.00 24.00 25.00 26.00 27.00 COMPUTATION OF COST ALLOCATION (W/S B) 0 0 0 000 0000 0 0 0 0 0 000000 0000000 0 0 0 0 0 0 0 0 13,613,351 13,613,351 000000005,398,022 5,398,022 000000000 0 000000000 0 000000000 0 000000000 0 000000000 0 000000000 0 00000000657,630 657,630 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 9,497,283 9,497,283 0 0 0 0 0 0 0 0 0 0 000000000 0 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ST. JOHN'S PLEASANT VALLEY HOSPITAL TRIAL BALANCE EXPENSES ANCILLARY COST CENTERS 37.00 Operating Room 38.00 Recovery Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 42.00 Radiology - Therapeutic 42.01 Ultrasound 42.02 CAT Scan 43.00 Radioisotope 44.00 Laboratory 44.01 Pathological Lab 46.00 Whole Blood 47.00 Blood Storing and Processing 48.00 Intravenous Therapy 49.00 Respiratory Therapy 49.01 Hyperbaric Chamber 50.00 Physical Therapy 51.00 Occupational Therapy 52.00 Speech Pathology 53.00 Electrocardiology 54.00 Electroencephalography 55.00 Medical Supplies Charged to Patients 55.01 Implants Charged to Patients 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 58.00 ASC (Non-Distinct Part) 59.00 59.01 60.00 Clinic 60.01 Other Clinic Services 61.00 Emergency 62.00 Observation Beds 71.00 82.00 83.00 84.00 85.00 86.00 NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop & Canteen 97.00 Research 98.00 Physicians' Private Office 99.00 Nonpaid Workers 99.01 99.02 99.03 99.04 100.00 Community Benefits 100.01 Unused Space 100.10 Medical Transporation Services 100.20 Non-Patient Meals 100.30 Foundation 100.40 Doctor's Lounge TOTAL SCHEDULE 8.3 Fiscal Period Ended: JUNE 30, 2008 NON- INT & RES POST ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY & INT & RES PARAMED SUBTOTAL STEP-DOWN TOTAL COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT ADJUSTMENT COST 19.00 19.02 19.03 20.00 21.00 22.00 23.00 24.00 25.00 26.00 27.00 COMPUTATION OF COST ALLOCATION (W/S B) 000000005,113,492 5,113,492 000000000 0 00000000137,285 137,285 000000000 0 000000003,592,122 3,592,122 000000000 0 00000000435,198 435,198 00000000829,868 829,868 00000000345,042 345,042 000000004,380,098 4,380,098 000000000 0 000000000 0 000000000 0 000000000 0 000000002,668,925 2,668,925 000000001,399,828 1,399,828 000000001,612,854 1,612,854 00000000305,168 305,168 00000000129,738 129,738 00000000870,858 870,858 000000000 0 000000003,462,472 3,462,472 000000003,287,181 3,287,181 000000004,525,666 4,525,666 00000000590,817 590,817 000000000 0 000000000 0 000000000 0 000000000 0 000000000 0 000000004,660,533 4,660,533 000000000 0 000000000 0 000000000 0 000000000 0 000000000 0 000000000 0 000000000 0 0000000038,994 38,994 000000000 0 000000000 0 000000000 0 000000000 0 000000000 0 000000000 0 000000000 0 00000000492,212 492,212 000000001,177,674 1,177,674 0000000090,109 90,109 000000005,907 5,907 000000008,279 8,279 0000000054,144 54,144 0 0 0 0 0 0 0 0 69,380,749 0 69,380,749 This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 9 Provider Name: Fiscal Period Ended: ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008 OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT & FIXTURES EQUIPMENT & FIXTURES EQUIPMENT (SQ FT) (SQ FT) (SQ FT) (SQ FT) 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 (Adj ) (Adj ) (Adj 10) (Adj 10) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) GENERAL SERVICE COST CENTERS 1.00 Old Cap Rel Costs-Bldg and Fixtures 2.00 Old Cap Rel Costs-Movable Equipment 3.00 New Cap Rel Costs-Bldg and Fixtures 4.00 New Cap Rel Costs-Movable Equipment 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 Employee Benefits 438 438 6.01 Non-Patient Telephones 6.02 Data Processing 6.03 Purchasing/Receiving 6.04 Patient Admitting 6.05 Patient Business Office 6.06 6.07 6.08 6.00 Administrative and General 40,588 40,588 7.00 Maintenance and Repairs 25,366 25,366 8.00 Operation of Plant 0 0 9.00 Laundry and Linen Service 0 0 10.00 Housekeeping 1,450 1,450 11.00 Dietary 4,941 4,941 12.00 Cafeteria 00 13.00 Maintenance of Personnel 14.00 Nursing Administration 0 0 15.00 Central Services and Supply 1,162 1,162 16.00 Pharmacy 624 624 17.00 Medical Records and Library 1,245 1,245 18.00 Social Service 19.00 19.02 19.03 20.00 21.00 Nursing School 22.00 Intern & Res Service-Salary & Fringes 23.00 Intern & Res Other Program 24.00 Paramedical Ed Program INPATIENT ROUTINE COST CENTERS 25.00 Adults and Pediatrics (Gen Routine) 28,852 28,852 26.00 Intensive Care Unit 5,186 5,186 27.00 Coronary Care Unit 28.00 Neonatal Intensive Care Unit 29.00 Surgical Intensive Care 30.00 Subprovider I 31.00 Subprovider II 32.00 33.00 Nursery 433 433 34.00 Distinct Part Nursing Facility 35.00 36.00 Subacute Care Unit 17,863 17,863 36.01 Subacute Care Unit II 36.02 Transitional Care Unit STATISTICS FOR COST ALLOCATION (W/S B-1) This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 9 Provider Name: Fiscal Period Ended: ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008 OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE STAT STAT STAT STAT STAT STAT STAT STAT & FIXTURES EQUIPMENT & FIXTURES EQUIPMENT (SQ FT) (SQ FT) (SQ FT) (SQ FT) 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 (Adj ) (Adj ) (Adj 10) (Adj 10) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) STATISTICS FOR COST ALLOCATION (W/S B-1) ANCILLARY COST CENTERS 37.00 Operating Room 6,316 6,316 38.00 Recovery Room 39.00 Delivery Room and Labor Room 613 613 40.00 Anesthesiology 41.00 Radiology - Diagnostic 7,464 7,464 42.00 Radiology - Therapeutic 42.01 Ultrasound 248 248 42.02 CAT Scan 416 416 43.00 Radioisotope 576 576 44.00 Laboratory 4,126 4,126 44.01 Pathological Lab 46.00 Whole Blood 47.00 Blood Storing and Processing 48.00 Intravenous Therapy 49.00 Respiratory Therapy 654 654 49.01 Hyperbaric Chamber 375 375 50.00 Physical Therapy 2,609 2,609 51.00 Occupational Therapy 136 136 52.00 Speech Pathology 53.00 Electrocardiology 3,183 3,183 54.00 Electroencephalography 55.00 Medical Supplies Charged to Patients 55.01 Implants Charged to Patients 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 58.00 ASC (Non-Distinct Part) 59.00 59.01 60.00 Clinic 60.01 Other Clinic Services 61.00 Emergency 5,161 5,161 62.00 Observation Beds 71.00 82.00 83.00 84.00 85.00 86.00 NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop & Canteen 471 471 97.00 Research 98.00 Physicians' Private Office 99.00 Nonpaid Workers 99.01 99.02 99.03 99.04 100.00 Community Benefits 100.01 Unused Space 14,225 14,225 100.10 Medical Transporation Services 100.20 Non-Patient Meals 100.30 Foundation 100 100 100.40 Doctor's Lounge 654 654 TOTAL 0 0 175,475 175,47500000000 COST TO BE ALLOCATED 0 0 1,871,259 2,854,96200000000 UNIT COST MULTIPLIER - SCH 8 0.000000 0.000000 10.663964 16.269907 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ST. JOHN'S PLEASANT VALLEY HOSPITAL GENERAL SERVICE COST CENTERS 1.00 Old Cap Rel Costs-Bldg and Fixtures 2.00 Old Cap Rel Costs-Movable Equipment 3.00 New Cap Rel Costs-Bldg and Fixtures 4.00 New Cap Rel Costs-Movable Equipment 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 Employee Benefits 6.01 Non-Patient Telephones 6.02 Data Processing 6.03 Purchasing/Receiving 6.04 Patient Admitting 6.05 Patient Business Office 6.06 6.07 6.08 6.00 Administrative and General 7.00 Maintenance and Repairs 8.00 Operation of Plant 9.00 Laundry and Linen Service 10.00 Housekeeping 11.00 Dietary 12.00 Cafeteria 13.00 Maintenance of Personnel 14.00 Nursing Administration 15.00 Central Services and Supply 16.00 Pharmacy 17.00 Medical Records and Library 18.00 Social Service 19.00 19.02 19.03 20.00 21.00 Nursing School 22.00 Intern & Res Service-Salary & Fringes 23.00 Intern & Res Other Program 24.00 Paramedical Ed Program INPATIENT ROUTINE COST CENTERS 25.00 Adults and Pediatrics (Gen Routine) 26.00 Intensive Care Unit 27.00 Coronary Care Unit 28.00 Neonatal Intensive Care Unit 29.00 Surgical Intensive Care 30.00 Subprovider I 31.00 Subprovider II 32.00 33.00 Nursery 34.00 Distinct Part Nursing Facility 35.00 36.00 Subacute Care Unit 36.01 Subacute Care Unit II 36.02 Transitional Care Unit SCHEDULE 9.1 Fiscal Period Ended: JUNE 30, 2008 EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM & GEN MAINTENANCE (GROSS (ACCUMMU- AND REPAIRS SALARIES) LATED COSTS) (SQ FT) 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 7.00 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 10) 4,608,141 701,838 2,663,164 1,151,626 0 368,835 0 456,584 887,945 1,450 809,903 1,684,995 4,941 00 0 806,578 1,116,713 0 264,338 491,846 1,162 1,017,519 1,325,010 624 431,341 1,199,585 1,245 0 0 0 0 0 0 0 0 0 5,748,041 9,139,324 28,852 2,631,620 3,991,632 5,186 0 0 0 0 0 0 389,186 534,529 433 0 0 4,399,359 6,391,081 17,863 0 0 STATISTICS FOR COST ALLOCATION (W/S B-1) This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ST. JOHN'S PLEASANT VALLEY HOSPITAL ANCILLARY COST CENTERS 37.00 Operating Room 38.00 Recovery Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 42.00 Radiology - Therapeutic 42.01 Ultrasound 42.02 CAT Scan 43.00 Radioisotope 44.00 Laboratory 44.01 Pathological Lab 46.00 Whole Blood 47.00 Blood Storing and Processing 48.00 Intravenous Therapy 49.00 Respiratory Therapy 49.01 Hyperbaric Chamber 50.00 Physical Therapy 51.00 Occupational Therapy 52.00 Speech Pathology 53.00 Electrocardiology 54.00 Electroencephalography 55.00 Medical Supplies Charged to Patients 55.01 Implants Charged to Patients 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 58.00 ASC (Non-Distinct Part) 59.00 59.01 60.00 Clinic 60.01 Other Clinic Services 61.00 Emergency 62.00 Observation Beds 71.00 82.00 83.00 84.00 85.00 86.00 NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop & Canteen 97.00 Research 98.00 Physicians' Private Office 99.00 Nonpaid Workers 99.01 99.02 99.03 99.04 100.00 Community Benefits 100.01 Unused Space 100.10 Medical Transporation Services 100.20 Non-Patient Meals 100.30 Foundation 100.40 Doctor's Lounge TOTAL COST TO BE ALLOCATED UNIT COST MULTIPLIER - SCH 8 SCHEDULE 9.1 Fiscal Period Ended: JUNE 30, 2008 EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT ADM & GEN MAINTENANCE (GROSS (ACCUMMU- AND REPAIRS SALARIES) LATED COSTS) (SQ FT) 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 7.00 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj 10) STATISTICS FOR COST ALLOCATION (W/S B-1) 2,396,613 3,515,286 6,316 0 17,672 74,704 613 0 1,048,613 2,577,171 7,464 0 167,501 343,653 248 276,658 620,104 416 83,603 254,561 576 1,302,331 3,308,074 4,126 0 0 0 0 1,338,603 1,975,165 654 782,361 1,050,425 375 883,379 1,192,243 2,609 184,980 241,614 136 42,861 106,821 302,449 569,845 3,183 0 2,729,485 2,625,601 2,334,155 497,961 0 0 0 0 0 2,106,150 3,318,420 5,161 0 0 0 0 0 0 0 12,686 471 0 0 0 0 0 0 0 130,419 413,202 383,134 14,225 76,871 0 2,693 100 17,615 654 33,328,6410000000059,187,774 109,083 8,970,4970000000010,192,975 3,121,799 0.269153 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.172214 28.618565 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ST. JOHN'S PLEASANT VALLEY HOSPITAL GENERAL SERVICE COST CENTERS 1.00 Old Cap Rel Costs-Bldg and Fixtures 2.00 Old Cap Rel Costs-Movable Equipment 3.00 New Cap Rel Costs-Bldg and Fixtures 4.00 New Cap Rel Costs-Movable Equipment 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 Employee Benefits 6.01 Non-Patient Telephones 6.02 Data Processing 6.03 Purchasing/Receiving 6.04 Patient Admitting 6.05 Patient Business Office 6.06 6.07 6.08 6.00 Administrative and General 7.00 Maintenance and Repairs 8.00 Operation of Plant 9.00 Laundry and Linen Service 10.00 Housekeeping 11.00 Dietary 12.00 Cafeteria 13.00 Maintenance of Personnel 14.00 Nursing Administration 15.00 Central Services and Supply 16.00 Pharmacy 17.00 Medical Records and Library 18.00 Social Service 19.00 19.02 19.03 20.00 21.00 Nursing School 22.00 Intern & Res Service-Salary & Fringes 23.00 Intern & Res Other Program 24.00 Paramedical Ed Program INPATIENT ROUTINE COST CENTERS 25.00 Adults and Pediatrics (Gen Routine) 26.00 Intensive Care Unit 27.00 Coronary Care Unit 28.00 Neonatal Intensive Care Unit 29.00 Surgical Intensive Care 30.00 Subprovider I 31.00 Subprovider II 32.00 33.00 Nursery 34.00 Distinct Part Nursing Facility 35.00 36.00 Subacute Care Unit 36.01 Subacute Care Unit II 36.02 Transitional Care Unit SCHEDULE 9.2 Fiscal Period Ended: JUNE 30, 2008 OPERATION LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT OF PLANT & LINEN KEEPING (MEALS FULL TIME PERSONNEL ADMIN & SUPPLY (COSTS GROSS (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) EQUIVALENT (# HOUSED) (NURSE HR) (CST REQ) REQUIS) CHARGES) SPENT) 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 (Adj 10) (Adj 11) (Adj 10) (Adj 12) (Adj ) (Adj ) (Adj 13) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) 0 0 1,450 4,941 4,941 0 0 212,936 0 0 765 1,162 1,162 602 17 624 624 1,021 1,245 1,245 718 6,789 28,852 149,315 28,852 52,735 7,182 139,413 71,990 31,912,887 5,186 103,919 5,186 3,919 2,674 52,544 60,091 13,548,581 433 8,211 433 1,205 762,963 17,863 152,456 17,863 11,514 7,257 143,053 109,366 23,586,443 STATISTICS FOR COST ALLOCATION (W/S B-1) This is trial version www.adultpdf.com [...]... HOSPITAL STATE OF CALIFORNIA This is trial version www.adultpdf.com 7,464 471 5,161 14,225 669,526 432,354 0.645761 142,917 100 654 107,633 1,100,303 10.222729 14,225 471 5,161 3,183 654 375 2,609 136 654 375 2,609 136 3,183 248 416 576 4,126 248 416 576 4,126 8,463 20,621 11,211 58,222 613 7,464 613 14,191 HOUSEKEEPING (SQ FT) 10.00 (Adj 10) 6,316 LAUNDRY & LINEN (LB LNDRY) 9.00 (Adj 11) 6,316 OPERATION OF. .. Benefits Unused Space Medical Transporation Services Non-Patient Meals Foundation Doctor's Lounge NONREIMBURSABLE COST CENTERS Gift, Flower, Coffee Shop & Canteen Research Physicians' Private Office Nonpaid Workers Clinic Other Clinic Services Emergency Observation Beds ANCILLARY COST CENTERS Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic Radiology - Therapeutic... 11.00 (Adj 12) 33,699 1,618,678 48.033425 160 2,459 2,042 887 953 189 40 297 173 275 82 1,810 1,583 12 2,518 0 0 0.000000 437,090 1,345,772 3.078936 45,316 97 14,247 3,403 244 72 12 38,672 CAFETERIA MAINT OF NURSING FULL TIME PERSONNEL ADMIN EQUIVALENT (# HOUSED) (NURSE HR) 12.00 13.00 14.00 (Adj ) (Adj ) (Adj 13) STATISTICS FOR COST ALLOCATION (W/S B-1) 8,972,517 665,032 0.074119 2,235 67,792 2,607,923... 1,571,726 35,372,413 14,713,725 1,479,613 54,808,109 MED REC GROSS CHARGES) 17.00 (Adj ) 0 0 0.000000 SOC SERV (TIME SPENT) 18.00 (Adj ) 0 0 0.000000 19.00 (Adj ) STAT Fiscal Period Ended: JUNE 30, 2008 SCHEDULE 9.2 . version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ST. JOHN'S PLEASANT VALLEY HOSPITAL TRIAL BALANCE EXPENSES GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs- Bldg and Fixtures 2.00 Old Cap Rel Costs- Movable. version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ST. JOHN'S PLEASANT VALLEY HOSPITAL TRIAL BALANCE EXPENSES GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs- Bldg and Fixtures 2.00 Old Cap Rel Costs- Movable. version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ST. JOHN'S PLEASANT VALLEY HOSPITAL GENERAL SERVICE COST CENTERS 1.00 Old Cap Rel Costs- Bldg and Fixtures 2.00 Old Cap Rel Costs- Movable