STATE OF CALIFORNIA Provider Name: MARIAN MEDICAL CENTER GENERAL SERVICE COST CENTERS 1.00 Old Cap Rel Costs-Bldg & Fixtures 2.00 Old Cap Rel Costs-Movable Equipment 3.00 New Cap Rel Costs-Bldg & 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 & 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 & 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 Medicare Certified Nursing Facility 35.00 Distinct Part Nursing Facility 36.00 Adult Subacute Care Unit 36.01 Subacute Care Unit II 36.02 Transitional Care Unit SCHEDULE 9.3 Fiscal Period Ended: JUNE 30, 2009 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 ) (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: MARIAN MEDICAL CENTER ANCILLARY COST CENTERS 37.00 Operating Room 37.01 Gastro Intestinal Service 37.20 Cardicac Cath Lab 38.00 Recovery Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 41.01 CT Scan and MRI 43.00 Radioisotope 44.00 Laboratory 44.01 Pathological Lab 46.00 Whole Blood & Packed Red Blood 47.00 Blood Storing and Processing 48.00 Intravenous Therapy 49.00 Respiratory Therapy 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 Medical Supplies Chrg. Pat. - IMP 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 58.00 ASC (Non-Distinct Part) 59.00 Ultrasound 59.02 59.03 60.00 Clinic 60.01 Other Clinic Services 61.00 Emergency 62.00 Observation Beds 71.00 Home Health Agency 89.00 Utilization Review 93.00 Hospice 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 99.05 100.00 100.01 Foundation 100.02 100.03 Community Relations 100.04 TOTAL COST TO BE ALLOCATED UNIT COST MULTIPLIER - SCH 8 SCHEDULE 9.3 Fiscal Period Ended: JUNE 30, 2009 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 ) (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: MARIAN MEDICAL CENTER JUNE 30, 2009 GENERAL SERVICE COST CENTERS 1.00 Old Cap Rel Costs-Bldg & Fixtures $ $ 0 $ 0 2.00 Old Cap Rel Costs-Movable Equipment 0 0 3.00 New Cap Rel Costs-Bldg & Fixtures 6,429,449 (1,969,656) 4,459,793 4.00 New Cap Rel Costs-Movable Equipment 5,342,064 1,633,874 6,975,938 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 23,297,357 (557,257) 22,740,100 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 28,987,953 (5,894,764) 23,093,189 7.00 Maintenance and Repairs 4,854,230 (25) 4,854,205 8.00 Operation of Plant 2,605,898 (197,296) 2,408,602 9.00 Laundry and Linen Service 886,908 0 886,908 10.00 Housekeeping 2,165,800 0 2,165,800 11.00 Dietary 1,403,139 0 1,403,139 12.00 Cafeteria 1,369,291 106,572 1,475,863 13.00 Maintenance of Personnel 0 0 14.00 Nursing Administration 1,806,659 0 1,806,659 15.00 Central Services & Supply 402,079 (560) 401,519 16.00 Pharmacy 2,576,016 (180,254) 2,395,762 17.00 Medical Records and Library 1,132,829 0 1,132,829 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 & Pediatrics (Gen Routine) 13,791,449 (166,060) 13,625,389 26.00 Intensive Care Unit 3,454,404 (40,874) 3,413,530 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 1,433,129 45,940 1,479,069 34.00 Medicare Certified Nursing Facility 4,705,466 (6,283) 4,699,183 35.00 Distinct Part Nursing Facility 0 0 36.00 Adult Subacute Care Unit 0 0 36.01 Subacute Care Unit II 0 0 36.02 Transitional Care Unit 0 0 REPORTED ADJUSTMENTS TRIAL BALANCE OF EXPENSES (From Sch 10A) AUDITED This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 10 Provider Name: Fiscal Period Ended: MARIAN MEDICAL CENTER JUNE 30, 2009 REPORTED ADJUSTMENTS TRIAL BALANCE OF EXPENSES (From Sch 10A) AUDITED ANCILLARY COST CENTERS 37.00 Operating Room $ 4,955,402 $ (45,173) $ 4,910,229 37.01 Gastro Intestinal Service 212,687 (766) 211,921 37.20 Cardicac Cath Lab 1,117,357 (21,331) 1,096,026 38.00 Recovery Room 00 39.00 Delivery Room and Labor Room 4,136,680 (40,547) 4,096,133 40.00 Anesthesiology 146,802 (11,303) 135,499 41.00 Radiology - Diagnostic 3,328,053 (11,292) 3,316,761 41.01 CT Scan and MRI 516,039 (2,195) 513,844 43.00 Radioisotope 1,291,377 (4,371) 1,287,006 44.00 Laboratory 5,140,846 (12,720) 5,128,126 44.01 Pathological Lab 00 46.00 Whole Blood & Packed Red Blood 1,555,570 0 1,555,570 47.00 Blood Storing and Processing 0 0 48.00 Intravenous Therapy 103,855 0 103,855 49.00 Respiratory Therapy 1,854,927 (3) 1,854,924 50.00 Physical Therapy 1,686,912 (20) 1,686,892 51.00 Occupational Therapy 655,034 0 655,034 52.00 Speech Pathology 0 0 53.00 Electrocardiology 1,090,149 (542) 1,089,607 54.00 Electroencephalography 63,219 0 63,219 55.00 Medical Supplies Charged to Patients 6,334,741 449,446 6,784,187 55.01 Medical Supplies Chrg. Pat. - IMP 8,335,663 0 8,335,663 56.00 Drugs Charged to Patients 3,527,163 175,154 3,702,317 57.00 Renal Dialysis 290,849 (557) 290,292 58.00 ASC (Non-Distinct Part) 0 0 59.00 Ultrasound 345,883 (5,902) 339,981 59.02 00 59.03 00 60.00 Clinic 504,893 (816) 504,077 60.01 Other Clinic Services 0 0 61.00 Emergency 5,328,437 (118,512) 5,209,925 62.00 Observation Beds 0 0 71.00 Home Health Agency 10,130,828 0 10,130,828 89.00 Utilization Review 0 0 93.00 Hospice 2,138,604 0 2,138,604 00 00 00 SUBTOTAL $ 171,436,090 $ (6,878,093) $ 164,557,997 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 99.05 00 100.00 00 100.01 Foundation 00 100.02 00 100.03 Community Relations 1,133,607 1,111,595 2,245,202 100.04 00 100.99 SUBTOTAL $ 1,133,607 $ 1,111,595 $ 2,245,202 101 TOTAL $ 172,569,697 $ (5,766,498) $ 166,803,199 (To Schedule 8) This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 10A Page 1 Provider Name: Fiscal Period Ended: MARIAN MEDICAL CENTER JUNE 30, 2009 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)6234578910111213 GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs-Bldg & Fixtures $0 2.00 Old Cap Rel Costs-Movable Equipment 0 3.00 New Cap Rel Costs-Bldg & Fixtures (1,969,656) (53,218) 101,989 (1,818,188) 4.00 New Cap Rel Costs-Movable Equipment 1,633,874 1,633,874 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 (557,257) (557,257) 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 (5,894,764) (434) (290,976) (47,737) (80,760) (5,474,857) 7.00 Maintenance and Repairs (25) (25) 8.00 Operation of Plant (197,296) (197,296) 9.00 Laundry and Linen Service 0 10.00 Housekeeping 0 11.00 Dietary 0 12.00 Cafeteria 106,572 106,572 13.00 Maintenance of Personnel 0 14.00 Nursing Administration 0 15.00 Central Services & Supply (560) (560) 16.00 Pharmacy (180,254) (5,116) (175,138) 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 & Pediatrics (Gen Routine) (166,060) (116,521) (49,539) 26.00 Intensive Care Unit (40,874) (40,874) 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 45,940 (3,583) 49,539 (16) 34.00 Medicare Certified Nursing Facility (6,283) (6,283) 35.00 Distinct Part Nursing Facility 0 36.00 Adult Subacute Care Unit 0 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: MARIAN MEDICAL CENTER JUNE 30, 2009 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)6234578910111213 ADJUSTMENTS TO REPORTED COSTS ANCILLARY COST CENTERS 37.00 Operating Room (45,173) (45,173) 37.01 Gastro Intestinal Service (766) (766) 37.20 Cardicac Cath Lab (21,331) (21,331) 38.00 Recovery Room 0 39.00 Delivery Room and Labor Room (40,547) (40,547) 40.00 A nesthesiolog y (11,303) (11,303) 41.00 Radiology - Diagnostic (11,292) (11,292) 41.01 CT Scan and MRI (2,195) (2,195) 43.00 Radioisotope (4,371) (4,371) 44.00 Laborator y (12,720) (12,720) 44.01 Pathological Lab 0 46.00 Whole Blood & Packed Red Blood 0 47.00 Blood Storing and Processing 0 48.00 Intravenous Therapy 0 49.00 Respiratory Therapy (3) (3) 50.00 Physical Therapy (20) (20) 51.00 Occupational Therapy 0 52.00 Speech Pathology 0 53.00 Electrocardiolog y (542) (542) 54.00 Electroencephalograph y 0 55.00 Medical Supplies Charged to Patients 449,446 449,446 55.01 Medical Supplies Chrg. Pat. - IMP 0 56.00 Drugs Charged to Patients 175,154 175,154 57.00 Renal Dialysis (557) (557) 58.00 ASC (Non-Distinct Part) 0 59.00 Ultrasound (5,902) (5,902) 59.02 0 59.03 0 60.00 Clinic (816) (816) 60.01 Other Clinic Services 0 61.00 Emergency (118,512) (118,512) 62.00 Observation Beds 0 71.00 Home Health Agenc y 0 89.00 Utilization Review 0 93.00 Hospice 0 0 0 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 99.05 0 100.00 0 100.01 Foundation 0 100.02 0 100.03 Community Relations 1,111,595 290,976 47,737 772,882 100.04 0 101.00 TOTAL ($5,766,498) 00000772,882106,572(197,296) (53,218) (80,760) (4,296,251) (1,818,188) (To Sch 10) This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: MARIAN MEDICAL CENTER GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs-Bldg & Fixtures 2.00 Old Cap Rel Costs-Movable Equipment 3.00 New Cap Rel Costs-Bldg & 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 & 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 & 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 Medicare Certified Nursing Facility 35.00 Distinct Part Nursing Facility 36.00 Adult Subacute Care Unit 36.01 Subacute Care Unit II 36.02 Transitional Care Unit SCHEDULE 10A Page 2 Fiscal Period Ended: 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 14 (200,239) ADJUSTMENTS TO REPORTED COSTS This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: MARIAN MEDICAL CENTER ANCILLARY COST CENTERS 37.00 Operating Room 37.01 Gastro Intestinal Service 37.20 Cardicac Cath Lab 38.00 Recovery Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 41.01 CT Scan and MRI 43.00 Radioisotope 44.00 Laboratory 44.01 Pathological Lab 46.00 Whole Blood & Packed Red Blood 47.00 Blood Storing and Processing 48.00 Intravenous Therapy 49.00 Respiratory Therapy 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 Medical Supplies Chrg. Pat. - IMP 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 58.00 ASC (Non-Distinct Part) 59.00 Ultrasound 59.02 59.03 60.00 Clinic 60.01 Other Clinic Services 61.00 Emergency 62.00 Observation Beds 71.00 Home Health Agency 89.00 Utilization Review 93.00 Hospice 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 99.05 100.00 100.01 Foundation 100.02 100.03 Community Relations 100.04 101.00 TOTAL SCHEDULE 10A Page 2 Fiscal Period Ended: 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 14 ADJUSTMENTS TO REPORTED COSTS (200,239) 0 0 0000000000 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 29 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted MEMORANDUM ADJUSTMENT 1 1 E-3 III XIX 50.00 1 AB5 Settlement Reductions $926,000 ($27,028) $898,972 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5. W&I Code, Section 14105.245 Page 1 Report References MARIAN MEDICAL CENTER Adjustments Explanation of Audit Adjustments JULY 1, 2008 THROUGH JUNE 30, 2009 ZZT30107H Cost Report This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 29 Adj. Audit Work As Increase As No. Report Sheet Part Title Line Col. Reported (Decrease) Adjusted Report References MARIAN MEDICAL CENTER Adjustments Explanation of Audit Adjustments JULY 1, 2008 THROUGH JUNE 30, 2009 ZZT30107H Cost Report RECLASSIFICATIONS OF REPORTED COSTS 2 10A A 6.00 7 Administrative and General $28,987,953 ($290,976) $28,696,977 * 10A A 100.03 7 Community Relations 1,133,607 290,976 1,424,583 * To reclassify public relation expenses for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2304 and 2328 3 10A A 6.00 7 Administrative and General * 28,696,977 (47,737) 28,649,240 * 10A A 100.03 7 Community Relations * 1,424,583 47,737 1,472,320 * To reclassify mission service expenses for proper cost determination. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2304 and 2328 4 10A A 25.00 7 Adults and Pediatrics 13,791,449 (49,539) 13,741,910 * 10A A 33.00 7 Nursery 1,433,129 49,539 1,482,668 * To reclassify Adults and Pediatrics other costs to agree with provider's supporting documents. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 5 10A A 16.00 7 Pharmacy 2,576,016 (175,138) 2,400,878 * 10A A 33.00 7 Nursery * 1,482,668 (16) 1,482,652 * 10A A 56.00 7 Drugs Charged to Patients 3,527,163 175,154 3,702,317 To reclassify IV solutions and pharmaceuticals for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 2 This is trial version www.adultpdf.com . Business Office 0 6.06 0 6. 07 0 6.08 0 6.00 Administrative and General (5,894 ,76 4) (434) (290, 976 ) ( 47, 7 37) (80 ,76 0) (5, 474 ,8 57) 7. 00 Maintenance and Repairs (25) (25) 8.00 Operation of Plant (1 97, 296) (1 97, 296) 9.00 Laundry. 2300, 2304 and 2328 3 10A A 6.00 7 Administrative and General * 28,696, 977 ( 47, 7 37) 28,649,240 * 10A A 100.03 7 Community Relations * 1,424,583 47, 7 37 1, 472 ,320 * To reclassify mission service. 5 10A A 16.00 7 Pharmacy 2, 576 ,016 ( 175 ,138) 2,400, 878 * 10A A 33.00 7 Nursery * 1,482,668 (16) 1,482,652 * 10A A 56.00 7 Drugs Charged to Patients 3,5 27, 163 175 ,154 3 ,70 2,3 17 To reclassify