STATE OF CALIFORNIA RECONCILIATION OF THE PROVIDER''''S ADJUSTMENTS TO THE AUDIT REPORT _part2 ppt

State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 25 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments SAN JOSE HEALTHCARE CENTER MARCH 6, 2007 THROUGH DECEMBER 31, 2007 ZZR06082H RECLASSIFICATIONS OF REPORTED COSTS 10 10.1(4) 100 14 8A-2 100.00 Other Ancillary Services $14,140 $2,590 $16,730 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 1,180,091 (2,590) 1,177,501 * To adjust the provider's reclassification of beauty and barber expense for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 11 Not Reported 8A-2 165.07 Administration - DHS Licensing Fees $0 $33,658 $33,658 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 1,177,501 (33,658) 1,143,843 * To reclassify DHS licensing fees for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 12 Not Reported 8A-2 165.10 Administration - Quality Assurance Fees $0 $407,033 $407,033 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 1,143,843 (407,033) 736,810 * To reclassify Quality Assurance Fees for proper cost determination. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 13 Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * $224,280 ($20,000) $204,280 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 736,810 20,000 756,810 * To reclassify medical director fees to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 *Balance carried forward from prior/to subsequent adjustments Page 4 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 25 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments SAN JOSE HEALTHCARE CENTER MARCH 6, 2007 THROUGH DECEMBER 31, 2007 ZZR06082H ADJUSTMENTS TO REPORTED COSTS 14 10.1(4) 40 14 8A-2 40.00 Property Taxes $64,284 ($5,569) $58,715 To eliminate property tax expense due to insufficient documentation. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 15 10.1(4) 45 14 8A-2 45.00 Property Insurance $8,996 ($8,996) $0 To eliminate property insurance expense due to lack of documentation. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $756,810 16 To eliminate liability insurance due to lack of documentation. ($70,121) 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 17 To eliminate advertising expenses due to lack of documentation. (2,291) 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 18 To eliminate dues and subscriptions due to lack of documentation. (2,838) 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 19 To eliminate travel expenses due to lack of documentation. (6,248) 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 20 To eliminate interest expenses due to lack of documentation. (88,985) 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 21 To eliminate bank charges due to lack of documentation. (2,630) 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 22 To adjust home office costs to agree with the filed Home Office (84,900) Cost Report. ($258,013) $498,797 42 CFR 413.17 / CMS Pub. 15-1, Sections 2150.2 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 5 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 25 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments SAN JOSE HEALTHCARE CENTER MARCH 6, 2007 THROUGH DECEMBER 31, 2007 ZZR06082H ADJUSTMENTS TO REPORTED COSTS 23 10.1(4) 5 14 8A-2 5.00 Plant Operations and Maintenance * $3,185 ($3,185) $0 10.1(4) 10 14 8A-2 10.00 Housekeeping * 17,775 (17,775) 0 10.1(4) 60 14 8A-2 60.00 Laundry and Linen * 7,952 (7,952) 0 10.1(4) 65 14 8A-2 65.00 Dietary * 24,343 (24,343) 0 10.1(4) 105 14 8A-2 105.00 Skilled Nursing Care * 173,599 (173,599) 0 10.1(4) 155 14 8A-2 155.00 Social Services * 8,039 (8,039) 0 10.1(4) 160 14 8A-2 160.00 Activities * 3,833 (3,833) 0 10.1(4) 165 14 8A-2 165.00 Administration * (15,341) 15,341 0 To adjust the reported expenses to agree with the provider's general ledger. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 6 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 25 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments SAN JOSE HEALTHCARE CENTER MARCH 6, 2007 THROUGH DECEMBER 31, 2007 ZZR06082H ADJUSTMENT TO REPORTED STATISTICS 24 Not Reported 7 5.00 Plant Operations and Maintenance (Square Feet) 0 360 360 Not Reported 7 10.00 Housekeeping 0 101 101 Not Reported 7 60.00 Laundry and Linen 0 1,524 1,524 Not Reported 7 65.00 Dietary 0 3,491 3,491 11.1(1 of 3) 75 2 7 140.00 Beauty and Barber 0 141 141 Not Reported 7 155.00 Social Services 0 200 200 Not Reported 7 160.00 Activities 0 1,661 1,661 Not Reported 7 165.00 Administration 0 600 600 Not Reported 7 165.00 Medical Records 0 251 251 11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 41,748 8,329 50,077 11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 41,748 7,969 49,717 11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 41,748 7,868 49,616 To establish the correct square footage in order to properly allocate indirect costs. 42 CFR 413.24 / CMS Pub. 15-1, Sections 2300 and 2306 Page 7 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 25 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments SAN JOSE HEALTHCARE CENTER MARCH 6, 2007 THROUGH DECEMBER 31, 2007 ZZR06082H ADJUSTMENT TO OTHER MATTERS 25 Not Reported 1 14.00 Overpayments $0 $12,332 $12,332 To recover outstanding Medi-Cal credit balances. CCR, Title 22, Sections 50761 and 51458.1 Page 8 This is trial version www.adultpdf.com . Adjusted Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments SAN JOSE HEALTHCARE CENTER MARCH 6, 2007 THROUGH DECEMBER 31, 2007 ZZR06082H ADJUSTMENTS TO REPORTED. Adjusted Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments SAN JOSE HEALTHCARE CENTER MARCH 6, 2007 THROUGH DECEMBER 31, 2007 ZZR06082H RECLASSIFICATIONS OF REPORTED. Adjusted Report References Cost Report Audit Report Explanation of Audit Adjustments Adjustments SAN JOSE HEALTHCARE CENTER MARCH 6, 2007 THROUGH DECEMBER 31, 2007 ZZR06082H ADJUSTMENT TO OTHER MATTERS 25