STATE OF CALIFORNIA SCHEDULE 4B PROGRAM: NONCONTRACT COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST _part4 doc

STATE OF CALIFORNIA Provider Name: SAN FRANCISCO GENERAL HOSPITAL ANCILLARY COST CENTERS 37.00 Operating Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 43.00 Radioisotope 44.00 Laboratory 44.01 Laboratory Pathology 46.00 Whole Blood 49.00 Respiratory Therapy 50.00 Physical Therapy 51.00 Occupational Therapy 53.00 Electrocardiology 54.00 Electroencephalography 55.00 Medical Supplies Charged to Patients 55.01 Implantable Devices 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 59.00 Other Ancillary Services 59.01 59.02 59.03 59.04 59.05 59.06 59.07 59.08 59.09 59.10 60.00 Clinic 61.00 Emergency 61.01 Psych Emergency 62.00 Observation Beds 63.60 Adult Medical Center FQHC I 63.61 Women's Health Center FQHC II 63.62 Family Health Center FQHC III 63.63 Children's Health Center FQHC IV 63.64 Urgent Care FQHC V 64.00 Home Program Dialysis NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop and Canteen 96.01 Other Than Hospital 98.00 99.00 99.01 99.02 99.03 99.04 99.05 99.06 99.07 99.08 99.09 99.10 TOTAL COST TO BE ALLOCATED UNIT COST MULTIPLIER - SCH 8 STATISTICS FOR COST ALLOCATION (W/S B-1) Fiscal Period Ended: JUNE 30, 2009 SCHEDULE 9.3 HOUSEKEEP DIETARY CAFETERIA NURSING ADM CTRL SERV PHARMACY MED REC SOC SERV I&R-SAL (MEALS (NURSING SUPPLIES (COSTS (GROSS (GROSS & FRINGES (SQ FT) SERVED) (FTE) FTE) (COST REQ) REQUIS) CHARGES) CHARGES) (ASG TIME) 10.01 11.00 12.00 14.00 15.00 16.00 17.00 18.00 22.00 (Adj 13) (Adj 14) (Adjs 15, 16) (Adj 17) (Adj 18) (Adj 18) (Adj 19) 23,401 10,587 6,902 8,872,693 36,969 77,824,637 77,824,637 7,804 5,430 2,603 2,400 90,655 10,194 4,642,051 4,642,051 5,632 3,218 304,082 440,663 55,955,476 55,955,476 4,976 32,299 9,551 242 1,092,079 6,293 106,236,045 106,236,045 4,428 26,515 15,407 67,914 152 124,559,091 124,559,091 24,348 1,805 48,788 11,664,392 11,664,392 4,246 5,017,971 5,017,971 1,909 4,264 163,625 21,779,813 21,779,813 6,880 3,362 41,494 7 8,575,913 8,575,913 718 506 44,765 3,598,702 3,598,702 7,503 1,418 178 720,158 122,938 12,735,645 12,735,645 195 375 266 236 86,333 86,333 215 2,531,289 58,257,007 58,257,007 4,306,295 8,387,370 8,387,370 3,566 364,050 16,634,382 195,603,755 195,603,755 3,308 2,986 268,468 149 9,880,790 9,880,790 8,029 1,044 555 96,889 1,775 5,262,883 5,262,883 40,537 7,724 2,372 155,461 82,307 19,131,357 19,131,357 46,512 11,352 19,011 13,265 9,097 340,492 21,698 99,660,181 99,660,181 2,954 1,887 24,273 3,049 1,994 5,001 6,395 16,775,979 16,775,979 25,905 9,538 2,778 102,872 3,590,083 42,651,814 42,651,814 6,031 8,269 3,387 2,315 64,163 465,264 13,112,752 13,112,752 4,701 28,796 5,245 1,189 43,511 93,834 13,935,626 13,935,626 5,519 13,969 1,844 1,339 14,983 83,927 9,930,227 9,930,227 3,999 7,192 1,654 1,219 14,874 746 6,905,864 6,905,864 2,380 1,543,286 1,543,286 352,204 90,247 7,583 4,678 101,615 861,647 929,003 487,660 243,440 98,894 20,954,192 22,536,063 1,429,044,687 1,429,044,687 116,491 0 7,444,454 1,613,995 16,148,839 4,177,534 20,257,425 9,877,829 5,928,593 29,157,236 0.000000 15.265664 6.629950 163.294430 0.199365 0.898889 0.006912 0.004149 250.296039 This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 10 Provider Name: Fiscal Period Ended: SAN FRANCISCO GENERAL HOSPITAL JUNE 30, 2009 GENERAL SERVICE COST CENTERS 1.00 Old Cap Rel Cost - Buildings and Fixtures $ 0 $ 0 $ 0 1.01 Old Cap Rel Cost - Building 2 56,715 0 56,715 1.02 Old Cap Rel Cost - Building 3 0 0 0 1.03 Old Cap Rel Cost - Building 5 287,858 0 287,858 1.05 Old Cap Rel Cost - Building 10 448 0 448 1.06 Old Cap Rel Cost - Building 20 0 0 1.07 Old Cap Rel Cost - Building 30 0 0 1.09 Old Cap Rel Cost - MRI Building 0 0 0 1.10 Old Cap Rel Cost - Building 80 0 0 1.11 Old Cap Rel Cost - Building 90 0 0 0 1.13 Old Cap Rel Cost - Land Improvements 0 0 0 2.00 Old Cap Rel Cost - Moveable Equipment 0 0 3.00 New Cap Rel Cost - Buildings and Fixtures 6,319 0 6,319 3.01 New Cap Rel Cost - Building 2 21,223 0 21,223 3.02 New Cap Rel Cost - Building 3 15,587 0 15,587 3.03 New Cap Rel Cost - Building 5 1,862,470 0 1,862,470 3.04 New Cap Rel Cost - Building 9 7,617 0 7,617 3.05 New Cap Rel Cost - Building 10 21,950 0 21,950 3.06 New Cap Rel Cost - Building 20 61,016 0 61,016 3.07 New Cap Rel Cost - Building 30 12,374 0 12,374 3.08 New Cap Rel Cost - Building 40 390 0 390 3.09 New Cap Rel Cost - MRI Building 0 0 0 3.10 New Cap Rel Cost - Building 80 13,692 0 13,692 3.11 New Cap Rel Cost - Building 90 25,675 0 25,675 3.12 New Cap Rel Cost - Building 100 129,031 0 129,031 3.13 New Cap Rel Costs - Land Imp 17,581 0 17,581 3.14 New Cap Rel Costs - MHRF 1,083,165 0 1,083,165 4.00 New Cap Rel Costs - Moveable Equipment 3,079,983 39,064 3,119,047 4.01 New Cap Rel Costs - Moveable Equipment 0 0 5.00 Employee Benefits 8,968,395 0 8,968,395 6.00 Administrative and General 94,002,497 (8,911,136) 85,091,361 7.00 Maintenance and Repairs 17,309,415 0 17,309,415 8.00 Operation of Plant 12,933,989 0 12,933,989 9.00 Laundry and Linen Service 2,202,501 0 2,202,501 10.00 Housekeeping 12,976,153 0 12,976,153 10.01 Housekeeping 0 0 0 11.00 Dietary 5,103,379 0 5,103,379 12.00 Cafeteria 930,280 0 930,280 14.00 Nursing Administration 12,922,527 0 12,922,527 15.00 Central Services and Supply 2,441,584 539,100 2,980,684 16.00 Pharmacy 15,558,314 924,584 16,482,898 17.00 Medical Records and Library 6,882,411 0 6,882,411 18.00 Social Service 4,750,593 0 4,750,593 22.00 Intern and Res Services - Salary and Fringes 23,660,682 0 23,660,682 INPATIENT ROUTINE COST CENTER 25.00 Adults and Pediatrics 77,714,254 (533,960) 77,180,294 26.00 Intensive Care Unit 13,171,074 (22,247) 13,148,827 27.00 Coronary Care Unit 9,924,604 122,152 10,046,756 28.00 Subprovider I 00 29.00 Subprovider II 00 30.00 NICU 1,152,665 136,679 1,289,344 33.00 Nursery 4,704,466 (34,766) 4,669,700 34.00 Medicare Certified Nursing Facility 11,401,801 (934) 11,400,867 35.00 Distinct Part Nursing Facility 0 0 36.00 00 36.01 Subacute Care Unit 0 0 36.02 Transitional Care Unit 0 0 (From Sch 10A) AUDITEDREPORTED TRIAL BALANCE OF EXPENSES ADJUSTMENTS This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 10 Provider Name: Fiscal Period Ended: SAN FRANCISCO GENERAL HOSPITAL JUNE 30, 2009 (From Sch 10A) AUDITEDREPORTED TRIAL BALANCE OF EXPENSES ADJUSTMENTS ANCILLARY COST CENTERS 37.00 Operating Room $ 25,997,293 $ 581,839 $ 26,579,132 39.00 Delivery Room and Labor Room 4,758,443 113,869 4,872,312 40.00 Anesthesiology 5,068,243 (2,329) 5,065,914 41.00 Radiology - Diagnostic 22,056,998 (75,069) 21,981,929 43.00 Radioisotope 0 0 0 44.00 Laboratory 22,017,739 5,993 22,023,732 44.01 Laboratory Pathology 1,516,844 (2,431) 1,514,413 46.00 Whole Blood 3,118,600 0 3,118,600 49.00 Respiratory Therapy 4,554,704 (11,713) 4,542,991 50.00 Physical Therapy 5,418,058 (7,617) 5,410,441 51.00 Occupational Therapy 797,622 (9,341) 788,281 53.00 Electrocardiology 3,312,606 (4,926) 3,307,680 54.00 Electroencephalography 156,431 0 156,431 55.00 Medical Supplies Charged to Patients 2,942,693 (411,405) 2,531,288 55.01 Implantable Devices 4,306,295 0 4,306,295 56.00 Drugs Charged to Patients 17,505,076 (1,499,271) 16,005,805 57.00 Renal Dialysis 2,431,093 299,217 2,730,310 59.00 Other Ancillary Services 2,023,190 (3,819) 2,019,371 59.01 00 59.02 00 59.03 00 59.04 00 59.05 00 59.06 00 59.07 00 59.08 00 59.09 00 59.10 00 60.00 Clinic 8,110,588 (49,453) 8,061,135 61.00 Emergency 21,643,164 (29,932) 21,613,232 61.01 Psych Emergency 8,015,100 (1,568,392) 6,446,708 62.00 Observation Beds 0 0 63.60 Adult Medical Center FQHC I 15,850,573 3,583,204 19,433,777 63.61 Women's Health Center FQHC II 6,118,102 1,056,780 7,174,882 63.62 Family Health Center FQHC III 5,257,837 1,690,847 6,948,684 63.63 Children's Health Center FQHC IV 3,564,803 841,770 4,406,573 63.64 Urgent Care FQHC V 2,501,858 (10,117) 2,491,741 64.00 Home Program Dialysis 404,743 59,017 463,760 SUBTOTAL $ 544,863,374 $ (3,194,743) $ 541,668,631 NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop and Canteen 0 0 96.01 Other Than Hospital 20,722,323 10,242,123 30,964,446 98.00 00 99.00 00 99.01 00 99.02 00 99.03 00 99.04 00 99.05 00 99.06 00 99.07 00 99.08 00 99.09 00 99.10 00 99.99 SUBTOTAL $ 20,722,323 $ 10,242,123 $ 30,964,446 101 TOTAL $ 565,585,697 $ 7,047,380 $ 572,633,077 (To Schedule 8) This is trial version www.adultpdf.com STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1 Provider Name: Fiscal Period Ended: JUNE 30, 2009 SAN FRANCISCO GENERAL HOSPITAL 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 (Pages 1 & 2) 2 345 6 7891011 GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Cost - Buildings and Fixtures $0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 1.01 Old Cap Rel Cost - Building 2 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 1.02 Old Cap Rel Cost - Building 3 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 1.03 Old Cap Rel Cost - Building 5 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 1.05 Old Cap Rel Cost - Building 10 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 1.06 Old Cap Rel Cost - Building 20 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 1.07 Old Cap Rel Cost - Building 30 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 1.09 Old Cap Rel Cost - MRI Building 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 1.10 Old Cap Rel Cost - Building 80 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 1.11 Old Cap Rel Cost - Building 90 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 1.13 Old Cap Rel Cost - Land Improvements 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 2.00 Old Cap Rel Cost - Moveable Equipment 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 3.00 New Cap Rel Cost - Buildings and Fixtures 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 3.01 New Cap Rel Cost - Building 2 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 3.02 New Cap Rel Cost - Building 3 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 3.03 New Cap Rel Cost - Building 5 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 3.04 New Cap Rel Cost - Building 9 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 3.05 New Cap Rel Cost - Building 10 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 3.06 New Cap Rel Cost - Building 20 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 3.07 New Cap Rel Cost - Building 30 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 3.08 New Cap Rel Cost - Building 40 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 3.09 New Cap Rel Cost - MRI Building 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 3.10 New Cap Rel Cost - Building 80 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 3.11 New Cap Rel Cost - Building 90 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 3.12 New Cap Rel Cost - Building 100 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 3.13 New Cap Rel Costs - Land Imp 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 3.14 New Cap Rel Costs - MHRF 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 4.00 New Cap Rel Costs - Moveable Equipment 39,064 __________ __________ __________ __________ __________ __________ __________ __________ 39,064 __________ __________ __________ 4.01 New Cap Rel Costs - Moveable Equipment 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 5.00 Employee Benefits 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 6.00 Administrative and General (8,911,136) __________ (6,475) __________ __________ (8,703,429) __________ __________ (201,232) __________ __________ __________ __________ 7.00 Maintenance and Repairs 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 8.00 Operation of Plant 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 9.00 Laundry and Linen Service 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 10.00 Housekeeping 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 10.01 Housekeeping 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 11.00 Dietary 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 12.00 Cafeteria 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 14.00 Nursing Administration 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 15.00 Central Services and Supply 539,100 __________ (2,848) __________ __________ __________ 541,948 __________ __________ __________ __________ __________ __________ 16.00 Pharmacy 924,584 __________ 7,534 __________ __________ __________ __________ 917,050 __________ __________ __________ __________ __________ 17.00 Medical Records and Library 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 18.00 Social Service 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 22.00 Intern and Res Services - Salary and Fringes 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ INPATIENT ROUTINE COST CENTER ` 25.00 Adults and Pediatrics (533,960) __________ (371,136) __________ (162,824) __________ __________ __________ __________ __________ __________ __________ __________ 26.00 Intensive Care Unit (22,247) __________ (22,247) __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 27.00 Coronary Care Unit 122,152 __________ 122,152 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 28.00 Subprovider I 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 29.00 Subprovider II 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 30.00 NICU 136,679 __________ 136,679 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 33.00 Nursery (34,766) __________ (34,766) __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 34.00 Medicare Certified Nursing Facility (934) __________ (934) __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 35.00 Distinct Part Nursing Facility 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 36.00 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 36.01 Subacute Care Unit 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 36.02 Transitional Care Unit 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ This is trial version www.adultpdf.com STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1 Provider Name: Fiscal Period Ended: JUNE 30, 2009 SAN FRANCISCO GENERAL HOSPITAL 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 (Pages 1 & 2) 2 345 6 7891011 ANCILLARY COST CENTERS 37.00 Operating Room 581,839 __________ 581,839 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 39.00 Delivery Room and Labor Room 113,869 __________ (48,955) __________ 162,824 __________ __________ __________ __________ __________ __________ __________ __________ 40.00 Anesthesiology (2,329) __________ (2,329) __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 41.00 Radiology - Diagnostic (75,069) __________ (75,069) __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 43.00 Radioisotope 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 44.00 Laboratory 5,993 __________ 5,993 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 44.01 Laboratory Pathology (2,431) __________ (2,431) __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 46.00 Whole Blood 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 49.00 Respiratory Therapy (11,713) __________ (11,713) __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 50.00 Physical Therapy (7,617) __________ (7,617) __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 51.00 Occupational Therapy (9,341) __________ (9,341) __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 53.00 Electrocardiology (4,926) __________ (4,926) __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 54.00 Electroencephalography 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 55.00 Medical Supplies Charged to Patients (411,405) __________ 1,057 (412,462) __________ __________ __________ __________ __________ __________ __________ __________ __________ 55.01 Implantable Devices 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 56.00 Drugs Charged to Patients (1,499,271) __________ (40,273) __________ __________ __________ (541,948) (917,050) __________ __________ __________ __________ __________ 57.00 Renal Dialysis 299,217 __________ (54,228) 353,445 __________ __________ __________ __________ __________ __________ __________ __________ __________ 59.00 Other Ancillary Services (3,819) __________ (3,819) __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 59.01 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 59.02 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 59.03 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 59.04 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 59.05 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 59.06 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 59.07 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 59.08 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 59.09 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 59.10 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 60.00 Clinic (49,453) __________ (49,453) __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 61.00 Emergency (29,932) __________ (29,932) __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 61.01 Psych Emergency (1,568,392) (1,559,613) (8,779) __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 62.00 Observation Beds 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 63.60 Adult Medical Center FQHC I 3,583,204 __________ 49,867 __________ __________ __________ __________ __________ __________ __________ 3,533,337 __________ __________ 63.61 Women's Health Center FQHC II 1,056,780 __________ (49,344) __________ __________ __________ __________ __________ __________ __________ 1,106,124 __________ __________ 63.62 Family Health Center FQHC III 1,690,847 __________ (22,245) __________ __________ __________ __________ __________ __________ __________ 1,713,092 __________ __________ 63.63 Children's Health Center FQHC IV 841,770 __________ (15,225) __________ __________ __________ __________ __________ __________ __________ 856,995 __________ __________ 63.64 Urgent Care FQHC V (10,117) __________ (10,117) __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 64.00 Home Program Dialysis 59,017 __________ __________ 59,017 __________ __________ __________ __________ __________ __________ __________ __________ __________ NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop and Canteen 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 96.01 Other Than Hospital 10,242,123 1,559,613 (20,919) __________ __________ 8,703,429 __________ __________ __________ __________ __________ __________ __________ 98.00 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 99.00 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 99.01 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 99.02 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 99.03 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 99.04 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 99.05 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 99.06 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 99.07 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 99.08 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 99.09 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 99.10 0 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 101.00 TOTAL $7,047,380 0000 000(201,232) 39,064 7,209,548 0 0 (To Sch 10) This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: SAN FRANCISCO GENERAL HOSPITAL GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Cost - Buildings and Fixtures 1.01 Old Cap Rel Cost - Building 2 1.02 Old Cap Rel Cost - Building 3 1.03 Old Cap Rel Cost - Building 5 1.05 Old Cap Rel Cost - Building 10 1.06 Old Cap Rel Cost - Building 20 1.07 Old Cap Rel Cost - Building 30 1.09 Old Cap Rel Cost - MRI Building 1.10 Old Cap Rel Cost - Building 80 1.11 Old Cap Rel Cost - Building 90 1.13 Old Cap Rel Cost - Land Improvements 2.00 Old Cap Rel Cost - Moveable Equipment 3.00 New Cap Rel Cost - Buildings and Fixtures 3.01 New Cap Rel Cost - Building 2 3.02 New Cap Rel Cost - Building 3 3.03 New Cap Rel Cost - Building 5 3.04 New Cap Rel Cost - Building 9 3.05 New Cap Rel Cost - Building 10 3.06 New Cap Rel Cost - Building 20 3.07 New Cap Rel Cost - Building 30 3.08 New Cap Rel Cost - Building 40 3.09 New Cap Rel Cost - MRI Building 3.10 New Cap Rel Cost - Building 80 3.11 New Cap Rel Cost - Building 90 3.12 New Cap Rel Cost - Building 100 3.13 New Cap Rel Costs - Land Imp 3.14 New Cap Rel Costs - MHRF 4.00 New Cap Rel Costs - Moveable Equipment 4.01 New Cap Rel Costs - Moveable Equipment 5.00 Employee Benefits 6.00 Administrative and General 7.00 Maintenance and Repairs 8.00 Operation of Plant 9.00 Laundry and Linen Service 10.00 Housekeeping 10.01 Housekeeping 11.00 Dietary 12.00 Cafeteria 14.00 Nursing Administration 15.00 Central Services and Supply 16.00 Pharmacy 17.00 Medical Records and Library 18.00 Social Service 22.00 Intern and Res Services - Salary and Fringes INPATIENT ROUTINE COST CENTER 25.00 Adults and Pediatrics 26.00 Intensive Care Unit 27.00 Coronary Care Unit 28.00 Subprovider I 29.00 Subprovider II 30.00 NICU 33.00 Nursery 34.00 Medicare Certified Nursing Facility 35.00 Distinct Part Nursing Facility 36.00 36.01 Subacute Care Unit 36.02 Transitional Care Unit ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2 JUNE 30, 2009 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 __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ 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__________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: SAN FRANCISCO GENERAL HOSPITAL ANCILLARY COST CENTERS 37.00 Operating Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 43.00 Radioisotope 44.00 Laboratory 44.01 Laboratory Pathology 46.00 Whole Blood 49.00 Respiratory Therapy 50.00 Physical Therapy 51.00 Occupational Therapy 53.00 Electrocardiology 54.00 Electroencephalography 55.00 Medical Supplies Charged to Patients 55.01 Implantable Devices 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 59.00 Other Ancillary Services 59.01 59.02 59.03 59.04 59.05 59.06 59.07 59.08 59.09 59.10 60.00 Clinic 61.00 Emergency 61.01 Psych Emergency 62.00 Observation Beds 63.60 Adult Medical Center FQHC I 63.61 Women's Health Center FQHC II 63.62 Family Health Center FQHC III 63.63 Children's Health Center FQHC IV 63.64 Urgent Care FQHC V 64.00 Home Program Dialysis NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop and Canteen 96.01 Other Than Hospital 98.00 99.00 99.01 99.02 99.03 99.04 99.05 99.06 99.07 99.08 99.09 99.10 101.00 TOTAL ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2 JUNE 30, 2009 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 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Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted MEMORANDUM ADJUSTMENT 1 The provider's post step-down adjustments, Column 26, for Interns and Residents, Epoietin, and Aranesp will be reversed on the audit report as they are not applicable to the Medi-Cal Program. CMS Pub. 15-1, Sections 2300, 2302, 2304, and 2306 Page 1 Report References SAN FRANCISCO GENERAL HOSPITAL Adjustments Explanation of Audit Adjustments JULY 1, 2008 THROUGH JUNE 30, 2009 HSC00228W Cost Report This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 31 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References SAN FRANCISCO GENERAL HOSPITAL Adjustments Explanation of Audit Adjustments JULY 1, 2008 THROUGH JUNE 30, 2009 HSC00228W Cost Report RECLASSIFICATIONS OF REPORTED COSTS 2 10A A 61.01 7 Psych Emergency $8,015,100 ($1,559,613) $6,455,487 * 10A A 96.01 7 Other Than Hospital 20,722,323 1,559,613 22,281,936 * To reclassify reported expense to the proper cost center for proper cost determination. CMS Pub. 15-1, Sections 2300, 2304, and 2306 3 10A A 6.00 7 Administrative and General $94,002,497 ($6,475) $93,996,022 * 10A A 15.00 7 Central Services and Supply 2,441,584 (2,848) 2,438,736 * 10A A 25.00 7 Adults and Pediatrics 77,714,254 (371,136) 77,343,118 * 10A A 26.00 7 Intensive Care Unit 13,171,074 (22,247) 13,148,827 10A A 33.00 7 Nursery 4,704,466 (34,766) 4,669,700 10A A 34.00 7 Medicare Certified Nursing Facility 11,401,801 (934) 11,400,867 10A A 39.00 7 Delivery Room and Labor Room 4,758,443 (48,955) 4,709,488 * 10A A 40.00 7 Anesthesiology 5,068,243 (2,329) 5,065,914 10A A 41.00 7 Radiology - Diagnostic 22,056,998 (75,069) 21,981,929 10A A 44.01 7 Laboratory Pathology 1,516,844 (2,431) 1,514,413 10A A 49.00 7 Respiratory Therapy 4,554,704 (11,713) 4,542,991 10A A 50.00 7 Physical Therapy 5,418,058 (7,617) 5,410,441 10A A 51.00 7 Occupational Therapy 797,622 (9,341) 788,281 10A A 53.00 7 Electrocardiology 3,312,606 (4,926) 3,307,680 10A A 56.00 7 Drugs Charged to Patients 17,505,076 (40,273) 17,464,803 * 10A A 57.00 7 Renal Dialysis 2,431,093 (54,228) 2,376,865 * 10A A 59.00 7 Other Ancillary Services 2,023,190 (3,819) 2,019,371 10A A 60.00 7 Clinic 8,110,588 (49,453) 8,061,135 10A A 61.00 7 Emergency 21,643,164 (29,932) 21,613,232 10A A 61.01 7 Psych Emergency * 6,455,487 (8,779) 6,446,708 10A A 63.61 7 Women's Health Center FQHC II 6,118,102 (49,344) 6,068,758 * 10A A 63.62 7 Family Health Center FQHC III 5,257,837 (22,245) 5,235,592 * 10A A 63.63 7 Children's Health Center FQHC IV 3,564,803 (15,225) 3,549,578 * 10A A 63.64 7 Urgent Care FQHC V 2,501,858 (10,117) 2,491,741 10A A 96.01 7 Other Than Hospital * 22,281,936 (20,919) 22,261,017 * 10A A 16.00 7 Pharmacy 15,558,314 7,534 15,565,848 * -Continued on next page- *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 31 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References SAN FRANCISCO GENERAL HOSPITAL Adjustments Explanation of Audit Adjustments JULY 1, 2008 THROUGH JUNE 30, 2009 HSC00228W Cost Report RECLASSIFICATIONS OF REPORTED COSTS -Continued from previous page- 10A A 27.00 7 Coronary Care Unit $9,924,604 $122,152 $10,046,756 10A A 30.00 7 NICU 1,152,665 136,679 1,289,344 10A A 37.00 7 Operating Room 25,997,293 581,839 26,579,132 10A A 44.00 7 Laboratory 22,017,739 5,993 22,023,732 10A A 55.00 7 Medical Supplies Charged to Patients 2,942,693 1,057 2,943,750 * 10A A 63.60 7 Adult Medical Center FQHC I 15,850,573 49,867 15,900,440 * To adjust the provider's reclassification of medical supplies charged to patients to agree with the supporting documentations. CMS Pub. 15-1, Sections 2300, 2304, and 2306 4 10A A 55.00 7 Medical Supplies Charged to Patients * $2,943,750 ($412,462) $2,531,288 10A A 57.00 7 Renal Dialysis * 2,376,865 353,445 2,730,310 10A A 64.00 7 Home Program Dialysis 404,743 59,017 463,760 To reverse the provider's reclassification of medical supplies charged to patients to agree with the provider's general ledger. CMS Pub. 15-1, Sections 2300, 2304, and 2306 5 10A A 25.00 7 Adults and Pediatrics * $77,343,118 ($162,824) $77,180,294 10A A 39.00 7 Delivery Room and Labor Room * 4,709,488 162,824 4,872,312 To adjust the provider's reclassification to agree with the supporting documentations. CMS Pub. 15-1, Sections 2300, 2304, and 2306 6 10A A 6.00 7 Administrative and General * $93,996,022 ($8,703,429) $85,292,593 * 10A A 96.01 7 Other Than Hospital * 22,261,017 8,703,429 30,964,446 To adjust the provider's reclassification of Healthy San Francisco to agree with the supporting documentations. CMS Pub. 15-1, Sections 2300, 2304, and 2306 *Balance carried forward from prior/to subsequent adjustments Page 3 This is trial version www.adultpdf.com [...]... reclassify other and nonchargeable supply expenses to the appropriate cost center for proper cost determination CMS Pub 15-1, Sections 2300, 2302, 2304, and 2306 Explanation of Audit Adjustments RECLASSIFICATIONS OF REPORTED COSTS JULY 1, 2008 THROUGH JUNE 30, 2009 SAN FRANCISCO GENERAL HOSPITAL Line Fiscal Period Provider Name State of California This is trial version www.adultpdf.com * * * * $16,922,855... Sheet Audit Report Part Title Cost Report Report References Col 56.00 16.00 56.00 15.00 7 7 7 7 *Balance carried forward from prior/to subsequent adjustments Drugs Charged to Patients Pharmacy To reclassify Drugs Sold overhead expense to the appropriate cost center for proper cost determination CMS Pub 15-1, Sections 2300, 2302, 2304, and 2306 Drugs Charged to Patients Central Services and Supply To reclassify... 2,438,736 As Reported HSC00228W ($917,050) 917,050 ($541,948) 541,948 Increase (Decrease) Provider Number Page $16,005,805 16,482,898 $16,922,855 * 2,980,684 As Adjusted 31 4 Adjustments Department of Health Care Services . version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 10 Provider Name: Fiscal Period Ended: SAN FRANCISCO GENERAL HOSPITAL JUNE 30, 2009 GENERAL SERVICE COST CENTERS 1.00 Old Cap Rel Cost - Buildings. version www.adultpdf.com STATE OF CALIFORNIA Provider Name: SAN FRANCISCO GENERAL HOSPITAL GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Cost - Buildings and Fixtures 1.01 Old Cap Rel Cost - Building. TOTAL $ 565,585,697 $ 7,047,380 $ 572,633,077 (To Schedule 8) This is trial version www.adultpdf.com STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1 Provider Name: Fiscal Period