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 9.3 Fiscal Period Ended: JUNE 30, 2008 STAT STAT NONPHY NURSE I&R-SAL I&R-PRG PARAMED ANESTH SCHOOL & FRINGES COST EDUCAT (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 19.02 19.03 20.00 21.00 22.00 23.00 24.00 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) 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 9.3 Fiscal Period Ended: JUNE 30, 2008 STAT STAT NONPHY NURSE I&R-SAL I&R-PRG PARAMED ANESTH SCHOOL & FRINGES COST EDUCAT (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 19.02 19.03 20.00 21.00 22.00 23.00 24.00 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) STATISTICS FOR COST ALLOCATION (W/S B-1) 0000000 0000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 10 Provider Name: Fiscal Period Ended: ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008 GENERAL SERVICE COST CENTERS 1.00 Old Cap Rel Costs-Bldg and Fixtures $ $ 0 $ 0 2.00 Old Cap Rel Costs-Movable Equipment 0 0 3.00 New Cap Rel Costs-Bldg and Fixtures 1,830,559 40,700 1,871,259 4.00 New Cap Rel Costs-Movable Equipment 2,446,117 408,845 2,854,962 4.01 00 4.02 00 4.03 00 4.04 00 4.05 00 4.06 00 4.07 00 4.08 00 5.00 Employee Benefits 10,345,270 (1,386,570) 8,958,700 6.01 Non-Patient Telephones 0 0 6.02 Data Processing 00 6.03 Purchasing/Receiving 0 0 6.04 Patient Admitting 00 6.05 Patient Business Office 0 0 6.06 00 6.07 00 6.08 00 6.00 Administrative and General 10,036,811 (2,177,322) 7,859,489 7.00 Maintenance and Repairs 1,789,769 1,289 1,791,058 8.00 Operation of Plant 1,151,626 0 1,151,626 9.00 Laundry and Linen Service 368,835 0 368,835 10.00 Housekeeping 721,259 4,741 726,000 11.00 Dietary 1,331,510 2,417 1,333,927 12.00 Cafeteria 00 13.00 Maintenance of Personnel 0 0 14.00 Nursing Administration 953,680 (54,060) 899,620 15.00 Central Services and Supply 381,381 8,021 389,402 16.00 Pharmacy 980,467 53,868 1,034,335 17.00 Medical Records and Library 1,049,956 0 1,049,956 18.00 Social Service 00 19.00 00 19.02 00 19.03 00 20.00 00 21.00 Nursing School 00 22.00 Intern & Res Service-Salary & Fringes 0 0 23.00 Intern & Res Other Program 0 0 24.00 Paramedical Ed Program 0 0 INPATIENT ROUTINE COST CENTERS 25.00 Adults and Pediatrics (Gen Routine) 6,844,500 (29,373) 6,815,127 26.00 Intensive Care Unit 3,159,281 (15,636) 3,143,645 27.00 Coronary Care Unit 0 0 28.00 Neonatal Intensive Care Unit 0 0 29.00 Surgical Intensive Care 0 0 30.00 Subprovider I 00 31.00 Subprovider II 00 32.00 00 33.00 Nursery 418,131 (15) 418,116 34.00 Distinct Part Nursing Facility 0 0 35.00 00 36.00 Subacute Care Unit 4,732,619 (6,758) 4,725,861 36.01 Subacute Care Unit II 0 0 36.02 Transitional Care Unit 0 0 (From Sch 10A) AUDITEDREPORTED ADJUSTMENTS TRIAL BALANCE OF EXPENSES This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 10 Provider Name: Fiscal Period Ended: ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008 (From Sch 10A) AUDITEDREPORTED ADJUSTMENTS TRIAL BALANCE OF EXPENSES ANCILLARY COST CENTERS 37.00 Operating Room $ 2,727,126 $ (27,009) $ 2,700,117 38.00 Recovery Room 00 39.00 Delivery Room and Labor Room 60,266 (6,829) 53,437 40.00 Anesthesiology 00 41.00 Radiology - Diagnostic 2,133,511 (39,612) 2,093,899 42.00 Radiology - Therapeutic 0 0 42.01 Ultrasound 291,892 (2) 291,890 42.02 CAT Scan 540,520 (6,084) 534,436 43.00 Radioisotope 216,545 0 216,545 44.00 Laboratory 2,847,223 (804) 2,846,419 44.01 Pathological Lab 00 46.00 Whole Blood 00 47.00 Blood Storing and Processing 0 0 48.00 Intravenous Therapy 0 0 49.00 Respiratory Therapy 1,597,318 (56) 1,597,262 49.01 Hyperbaric Chamber 839,790 (10,040) 829,750 50.00 Physical Therapy 884,209 0 884,209 51.00 Occupational Therapy 188,163 0 188,163 52.00 Speech Pathology 95,285 0 95,285 53.00 Electrocardiology 403,419 (710) 402,709 54.00 Electroencephalography 0 0 55.00 Medical Supplies Charged to Patients 2,621,964 107,521 2,729,485 55.01 Implants Charged to Patients 2,625,601 0 2,625,601 56.00 Drugs Charged to Patients 2,323,804 10,351 2,334,155 57.00 Renal Dialysis 497,961 0 497,961 58.00 ASC (Non-Distinct Part) 0 0 59.00 00 59.01 00 60.00 Clinic 00 60.01 Other Clinic Services 0 0 61.00 Emergency 2,658,866 (46,328) 2,612,538 62.00 Observation Beds 0 0 71.00 00 82.00 00 83.00 00 84.00 00 85.00 00 86.00 00 SUBTOTAL $ 72,095,234 $ (3,169,455) $ 68,925,779 NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop & Canteen 0 0 97.00 Research 00 98.00 Physicians' Private Office 0 0 99.00 Nonpaid Workers 0 0 99.01 00 99.02 00 99.03 00 99.04 00 100.00 Community Benefits 378,099 0 378,099 100.01 Unused Space 00 100.10 Medical Transporation Services 76,871 0 76,871 100.20 Non-Patient Meals 0 0 100.30 Foundation 00 100.40 Doctor's Lounge 00 100.99 SUBTOTAL $ 454,970 $ 0 $ 454,970 101 TOTAL $ 72,550,204 $ (3,169,455) $ 69,380,749 (To Schedule 8) This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 10A Page 1 Provider Name: Fiscal Period Ended: ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 & 2)123456789 GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs-Bldg and Fixtures $0 2.00 Old Cap Rel Costs-Movable Equipment 0 3.00 New Cap Rel Costs-Bldg and Fixtures 40,700 40,700 4.00 New Cap Rel Costs-Movable Equipment 408,845 408,845 4.01 0 4.02 0 4.03 0 4.04 0 4.05 0 4.06 0 4.07 0 4.08 0 5.00 Employee Benefits (1,386,570) 11 (1,386,581) 6.01 Non-Patient Telephones 0 6.02 Data Processing 0 6.03 Purchasing/Receiving 0 6.04 Patient Admitting 0 6.05 Patient Business Office 0 6.06 0 6.07 0 6.08 0 6.00 Administrative and General (2,177,322) 1,046 (42,003) (1,289) (29,383) (5,953) (24,676) (963) (71,112) (2,002,989) 7.00 Maintenance and Repairs 1,289 1,289 8.00 Operation of Plant 0 9.00 Laundry and Linen Service 0 10.00 Housekeeping 4,741 4,741 11.00 Dietary 2,417 2,417 12.00 Cafeteria 0 13.00 Maintenance of Personnel 0 14.00 Nursing Administration (54,060) (54,060) 15.00 Central Services and Supply 8,021 8,021 16.00 Pharmacy 53,868 53,868 17.00 Medical Records and Library 0 18.00 Social Service 0 19.00 0 19.02 0 19.03 0 20.00 0 21.00 Nursing School 0 22.00 Intern & Res Service-Salary & Fringes 0 23.00 Intern & Res Other Program 0 24.00 Paramedical Ed Program 0 INPATIENT ROUTINE COST CENTERS 25.00 Adults and Pediatrics (Gen Routine) (29,373) (29,373) 26.00 Intensive Care Unit (15,636) (15,636) 27.00 Coronary Care Unit 0 28.00 Neonatal Intensive Care Unit 0 29.00 Surgical Intensive Care 0 30.00 Subprovider I 0 31.00 Subprovider II 0 32.00 0 33.00 Nursery (15) (15) 34.00 Distinct Part Nursing Facility 0 35.00 0 36.00 Subacute Care Unit (6,758) (6,758) 36.01 Subacute Care Unit II 0 36.02 Transitional Care Unit 0 ADJUSTMENTS TO REPORTED COSTS This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 10A Page 1 Provider Name: Fiscal Period Ended: ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 & 2)123456789 ADJUSTMENTS TO REPORTED COSTS ANCILLARY COST CENTERS 37.00 Operating Room (27,009) (27,009) 38.00 Recovery Room 0 39.00 Delivery Room and Labor Room (6,829) (6,829) 40.00 Anesthesiology 0 41.00 Radiology - Diagnostic (39,612) (39,612) 42.00 Radiology - Therapeutic 0 42.01 Ultrasound (2) (2) 42.02 CAT Scan (6,084) (6,084) 43.00 Radioisotope 0 44.00 Laboratory (804) (804) 44.01 Pathological Lab 0 46.00 Whole Blood 0 47.00 Blood Storing and Processing 0 48.00 Intravenous Therapy 0 49.00 Respiratory Therapy (56) (56) 49.01 Hyperbaric Chamber (10,040) (10,040) 50.00 Physical Therapy 0 51.00 Occupational Therapy 0 52.00 Speech Pathology 0 53.00 Electrocardiology (710) (710) 54.00 Electroencephalography 0 55.00 Medical Supplies Charged to Patients 107,521 107,521 55.01 Implants Charged to Patients 0 56.00 Drugs Charged to Patients 10,351 10,351 57.00 Renal Dialysis 0 58.00 ASC (Non-Distinct Part) 0 59.00 0 59.01 0 60.00 Clinic 0 60.01 Other Clinic Services 0 61.00 Emergency (46,328) (46,328) 62.00 Observation Beds 0 71.00 0 82.00 0 83.00 0 84.00 0 85.00 0 86.00 0 NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop & Canteen 0 97.00 Research 0 98.00 Physicians' Private Office 0 99.00 Nonpaid Workers 0 99.01 0 99.02 0 99.03 0 99.04 0 100.00 Community Benefits 0 100.01 Unused Space 0 100.10 Medical Transporation Services 0 100.20 Non-Patient Meals 0 100.30 Foundation 0 100.40 Doctor's Lounge 0 101.00 TOTAL ($3,169,455) 9 (42,003) (1,289) (29,383) (5,953) (24,676) (963) (125,172) (2,940,025) 0 0 0 (To Sch 10) This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ST. JOHN'S PLEASANT VALLEY HOSPITAL GENERAL SERVICE COST CENTER 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 10A Page 2 Fiscal Period Ended: JUNE 30, 2008 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ ADJUSTMENTS TO REPORTED COSTS 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 101.00 TOTAL SCHEDULE 10A Page 2 Fiscal Period Ended: JUNE 30, 2008 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ ADJUSTMENTS TO REPORTED COSTS 0000000000000 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 27 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted ADJUSTMENTS TO REPORTED COSTS 1 10A A 5.00 7 Employee Benefits $10,345,270 $11 $10,345,281 * 10A A 6.00 7 Administrative and General 10,036,811 1,046 10,037,857 * 10A A 7.00 7 Maintenance and Repairs 1,789,769 1,289 1,791,058 10A A 10.00 7 Housekeeping 721,259 4,741 726,000 10A A 11.00 7 Dietary 1,331,510 2,417 1,333,927 10A A 15.00 7 Central Services and Supply 381,381 8,021 389,402 10A A 16.00 7 Pharmacy 980,467 53,868 1,034,335 10A A 25.00 7 Adults and Pediatrics 6,844,500 (29,373) 6,815,127 10A A 26.00 7 Intensive Care Unit 3,159,281 (15,636) 3,143,645 10A A 33.00 7 Nursery 418,131 (15) 418,116 10A A 36.00 7 Subacute Care Unit 4,732,619 (6,758) 4,725,861 10A A 37.00 7 Operating Room 2,727,126 (27,009) 2,700,117 10A A 39.00 7 Delivery Room and Labor Room 60,266 (6,829) 53,437 10A A 41.00 7 Radiology - Diagnostic 2,133,511 (39,612) 2,093,899 10A A 42.01 7 Ultrasound 291,892 (2) 291,890 10A A 42.02 7 CAT Scan 540,520 (6,084) 534,436 10A A 44.00 7 Laboratory 2,847,223 (804) 2,846,419 10A A 49.00 7 Respiratory Therapy 1,597,318 (56) 1,597,262 10A A 49.01 7 Hyperbaric Chamber 839,790 (10,040) 829,750 10A A 53.00 7 Electrocardiology 403,419 (710) 402,709 10A A 55.00 7 Medical Supplies Charged to Patients 2,621,964 107,521 2,729,485 10A A 56.00 7 Drugs Charged to Patients 2,323,804 10,351 2,334,155 10A A 61.00 7 Emergency 2,658,866 (46,328) 2,612,538 To adjust provider’s reclassification of chargeable medical supplies to the general ledger. 42 CFR 413.20, 413.24 and 413.50 CMS Pub. 5-1, Sections 2300, 2304 and 2306 *Balance carried forward from prior/to subsequent adjustments Page 1 Report References ST. JOHN'S PLEASANT VALLEY HOSPITAL Adjustments Explanation of Audit Adjustments JULY 1, 2007 THROUGH JUNE 30, 2008 HSC 30616I Cost Report This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 27 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References ST. JOHN'S PLEASANT VALLEY HOSPITAL Adjustments Explanation of Audit Adjustments JULY 1, 2007 THROUGH JUNE 30, 2008 HSC 30616I Cost Report ADJUSTMENTS TO REPORTED COSTS 10A A 6.00 7 Administrative and General * $10,037,857 2 To eliminate legal fees not related to patient care. ($42,003) 42 CFR 413.9(c)(3) CMS Pub. 15-1, Sections 2102.3 and 2183 3 To eliminate construction planning costs that should have been capitalized. (1,289) 42 CFR 413.9(c)(3) CMS Pub. 15-1, Sections 2102.3 and 2132.2 4 To eliminate inter-company community grant expenses not related to (29,383) patient care. 42 CFR 413.9(c)(3) CMS Pub. 15-1, Section 2102.3 5 To eliminate costs associated with a charity class action settlement not (5,953) related to patient care. 42 CFR 413.9(c)(3) CMS Pub. 15-1, Section 2102.3 6 To eliminate promotional/marketing items, country club membership fees, (24,676) movie tickets and gift cards that are not related to patient care. 413.5, 413.5(c)(7) and 413.9 CMS Pub. 15-1, Sections 2102.3 and 2138.3 7 To abate other operating revenue against the related costs. (963) 42 CFR 413.5 and 413.9 ($104,267) $9,933,590 * CMS Pub. 15-1, Section 2328 *Balance carried forward from prior/to subsequent adjustments Page 2 This is trial version www.adultpdf.com [...]... related to patient care 413.5(c)(7) and 413.9(b)(2) CMS Pub 15-1, Sections 2102.3 and 2136.2 ADJUSTMENTS TO REPORTED COSTS Explanation of Audit Adjustments ST JOHN'S PLEASANT VALLEY HOSPITAL Col Fiscal Period JULY 1, 2007 THROUGH JUNE 30, 2008 Provider Name State of California This is trial version www.adultpdf.com * * * $1,830,559 2,446,117 10,345,281 9,862,478 $9,933,590 953,680 As Reported HSC 30616I... adjustments New Capital Related Costs - Building and Fixtures New Capital Related Costs - Movable Equipment Employee Benefits Administrative and General To adjust reported home office costs to agree with the Catholic Healthcare West filed Home Office Cost Report for fiscal period ended June 30, 2008 42 CFR 413.17 and 413.24 CMS Pub 15-1, Sections 2150.2 and 2304 Administrative and General Nursing Administration... $40,700 408,845 (1,386,581) (2,002,989) ($71,112) (54,060) Increase (Decrease) Provider Number Page $1,871,259 2,854,962 8,958,700 7,859,489 $9,862,478 * 899,620 As Adjusted 27 3 Adjustments Department of Health Care Services . 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. version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 10 Provider Name: Fiscal Period Ended: ST. JOHN'S PLEASANT VALLEY HOSPITAL JUNE 30, 2008 GENERAL SERVICE COST CENTERS 1.00 Old Cap Rel Costs- Bldg. 0 0 (From Sch 10A) AUDITEDREPORTED ADJUSTMENTS TRIAL BALANCE OF EXPENSES This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 10 Provider Name: Fiscal Period Ended: ST. JOHN'S