STATE OF CALIFORNIA Provider Name: SEAPORT 17TH CARE CENTER Line Sub No. No. 167 4 DPH Licensing Fees 168 4 Liability Insurance 169 4 Quality Assurance Fees 170 1 Inservice Education - Nursing - Salaries and Wages 170 2 Inservice Education - Nursing - Fringe Benefits 170 3 Inservice Education - Nursing - Agency Staff 170 4 Inservice Education - Nursing - Other - Nonlabor 174 1 Caregiver Training - Salaries and Wages 174 2 Caregiver Training - Fringe Benefits 174 3 Caregiver Training - Agency Staff 174 4 Caregiver Training - Other - Nonlabor 200 Total Schedule 8A-2 Page 3 Provider Number: NPI: OSHPD Facility Number: Fiscal Period: ZZT05155I 1164403739 206190037 JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ 20 RECLASSIFICATIONS AND/OR ADJUSTMENTS TO REPORTED COSTS (3,425) (85,627) 00000000 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 23 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted MEMORANDUM ADJUSTMENTS 1 10.7 105 2,3 7 105 N/A Skilled Nursing Care (Square Feet) 0 22,277 22,277 * 2 10.7 105 4 7 105 N/A Skilled Nursing Care (Pounds of Laundry) 0 112,955 112,955 3 10.7 105 5 7 105 N/A Skilled Nursing Care (Meals Served) 0 67,773 67,773 To reconcile the provider's reported statistics on Page 10.7 to the provider's reported statistics on page 11(1). 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 1 Adjustments SEAPORT 17TH CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZT05155I Cost Report Explanation of Audit Adjustments Report References Audit Report This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 23 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustments SEAPORT 17TH CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZT05155I Cost Report Explanation of Audit Adjustments Report References Audit Report RECLASSIFICATIONS OF REPORTED COSTS 4 10.5 005 2 8A-2 005 2 Plant Operations and Maintenance - Fringe Benefits $20,413 ($3,394) $17,019 * 10.5 010 2 8A-2 010 2 Housekeeping - Fringe Benefits 27,904 (15,088) 12,816 * 10.5 060 2 8A-2 060 2 Laundry and Linen - Fringe Benefits 25,737 (14,697) 11,040 * 10.5 065 2 8A-2 065 2 Dietary - Fringe Benefits 57,398 (26,729) 30,669 * 10.5 105 2 8A-2 105 2 Skilled Nursing Care - Fringe Benefits 408,503 22,626 431,129 * 10.5 155 2 8A-2 155 2 Social Services - Fringe Benefits 19,714 (2,863) 16,851 * 10.5 160 2 8A-2 160 2 Activities - Fringe Benefits 16,602 (6,727) 9,875 * 10.5 165 2 8A-2 165 2 Administration - Fringe Benefits 87,966 41,700 129,666 * 10.5 166 2 8A-2 166 2 Medical Records - Fringe Benefits 11,778 2,693 14,471 * 10.5 170 2 8A-2 170 2 Inservice Education - Nursing - Fringe Benefits 21,094 2,479 23,573 * To allocate the fringe benefits based on gross salaries for proper cost determination. 42 CFR 413.20 and 413.24, Sections 2300 and 2304 5 10.5 080 4 8A-2 080 4 Physical Therapy - Other - Nonlabor $511,439 $1,651 $513,090 10.5 100 4 8A-2 100 4 Other Ancillary Services - Other - Nonlabor 3,221 12,608 15,829 10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor 153,100 (14,259) 138,841 * To reclassify parallel bars and concentrator expenses to the appropriate cost center. CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 CCR, Title 22, Section 51511.5 *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 23 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustments SEAPORT 17TH CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZT05155I Cost Report Explanation of Audit Adjustments Report References Audit Report RECLASSIFICATIONS OF REPORTED COSTS 6 10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor * $138,841 $3,638 $142,479 * 10.5 105 3 8A-2 105 3 Skilled Nursing Care - Agency Staff 115,017 (3,638) 111,379 To reclassify consulting expense to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 Medi-Cal Bulletin #375 7 10.5 045 4 8A-2 045 4 Property Insurance $39,886 $1,822 $41,708 * 10.5 168 4 8A-2 168 4 Administration - Liability Insurance 123,551 (1,822) 121,729 * To reclassify property insurance expense to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 8 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor $232,857 $3,272 $236,129 * 10.5 168 4 8A-2 168 4 Administration - Liability Insurance * 121,729 (3,272) 118,457 * To reclassify finance charges to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 9 10.5 082 4 8A-2 082 4 Occupational Therapy - Other - Nonlabor $393,641 $2,989 $396,630 10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor * 142,479 (2,989) 139,490 * To reclassify occupational therapy cost 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 3 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 23 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustments SEAPORT 17TH CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZT05155I Cost Report Explanation of Audit Adjustments Report References Audit Report ADJUSTMENTS TO REPORTED COSTS 10.5 040 4 8A-2 040 4 Property Taxes $46,872 10 To adjust property taxes expenses to agree with the property tax bills. ($4,508) 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 11 To eliminate tax penalties not related to patient care. (1,910) 42 CFR 413.9(c)(3) / CMS Pub. 15-1, Sections 2102.3 and 2122.1 ($6,418) $40,454 12 10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor * $139,490 ($5,000) $134,490 To eliminate nursing therapy consultant fees due to the lack of sufficient documentation. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 13 10.5 168 4 8A-2 168 4 Administration - Liability Insurance * $118,457 ($14,335) $104,122 To adjust liability insurance expense to agree with the supporting invoices. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 14 10.5 045 4 8A-2 045 4 Property Insurance * $41,708 ($35,567) $6,141 To adjust property insurance expense to agree with the supporting documentation. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 *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 23 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustments SEAPORT 17TH CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZT05155I Cost Report Explanation of Audit Adjustments Report References Audit Report ADJUSTMENTS TO REPORTED COSTS 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * $236,129 15 To eliminate pharmacy consultant fees due to insufficient ($2,365) documentation. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 16 To eliminate license fees due to the lack of documentation. (8,469) 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 17 To eliminate patient telephone costs. (4,170) 42 CFR 413.9(c)(3) / CMS Pub 15-1, Section 2106.1 18 To eliminate legal expenses due to the lack of sufficient documentation. (24,313) 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 ($39,317) $196,812 19 10.5 165 2 8A-2 165 2 Administration - Fringe Benefits * $129,666 ($89,119) $40,547 * To eliminate life insurance expense due to the lack of sufficient documentation. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 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 23 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustments SEAPORT 17TH CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZT05155I Cost Report Explanation of Audit Adjustments Report References Audit Report ADJUSTMENTS TO REPORTED COSTS 20 10.5 005 2 8A-2 005 2 Plant Operations and Maintenance - Fringe Benefits * $17,019 ($2,473) $14,546 10.5 010 2 8A-2 010 2 Housekeeping - Fringe Benefits * 12,816 (1,862) 10,954 10.5 060 2 8A-2 060 2 Laundry and Linen - Fringe Benefits * 11,040 (1,604) 9,436 10.5 065 2 8A-2 065 2 Dietary - Fringe Benefits * 30,669 (4,456) 26,213 10.5 105 2 8A-2 105 2 Skilled Nursing Care - Fringe Benefits * 431,129 (59,059) 372,070 10.5 155 2 8A-2 155 2 Social Services - Fringe Benefits * 16,851 (2,448) 14,403 10.5 160 2 8A-2 160 2 Activities - Fringe Benefits * 9,875 (1,435) 8,440 10.5 165 2 8A-2 165 2 Administration - Fringe Benefits * 40,547 (7,201) 33,346 10.5 166 2 8A-2 166 2 Medical Records - Fringe Benefits * 14,471 (1,664) 12,807 10.5 170 2 8A-2 170 2 Inservice Education - Nursing - Fringe Benefits * 23,573 (3,425) 20,148 To eliminate other employee benefits due to the lack of documentation. 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 23 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustments SEAPORT 17TH CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZT05155I Cost Report Explanation of Audit Adjustments Report References Audit Report ADJUSTMENTS TO REPORTED STATISTICS 21 10.7 080 1 7 080 N/A Physical Therapy (Square Feet) 0 169 169 10.7 082 1 7 082 N/A Occupational Therapy 0 169 169 10.7 140 1 7 140 N/A Beauty and Barber 07272 10.7 175 1 7 N/A N/A Total - Square Feet Column 1 * 22,277 410 22,687 22 10.7 010 2 7 010 N/A Housekeeping (Square Feet) 0 39 39 10.7 060 2,3 7 060 N/A Laundry and Linen 0 416 416 10.7 065 2,3 7 065 N/A Dietary 0 696 696 10.7 080 2,3 7 080 N/A Physical Therapy 0 169 169 10.7 082 2,3 7 082 N/A Occupational Therapy 0 169 169 10.7 105 2,3 7 105 N/A Skilled Nursing Care * 22,277 (2,104) 20,173 10.7 140 2,3 7 140 N/A Beauty and Barber 07272 10.7 155 2,3 7 155 N/A Social Services 09191 10.7 160 2,3 7 160 N/A Activities 06262 10.7 165 2,3 7 165 N/A Administration 0 104 104 10.7 166 2,3 7 166 N/A Medical Records 0 285 285 10.7 170 2,3 7 170 N/A Inservice Education - Nursing 0 221 221 10.7 175 2 7 N/A N/A Total - Square feet Column 2 22,277 220 22,497 10.7 175 3 7 N/A N/A Total - Square feet Column 3 22,277 181 22,458 To adjust square footage for proper allocation. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 7 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 23 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustments SEAPORT 17TH CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZT05155I Cost Report Explanation of Audit Adjustments Report References Audit Report ADJUSTMENT TO OTHER MATTERS 23 Not Reported 1 14 Overpayments $0 $509 $509 To recover overpayments for overstated Medi-Cal patient days. CCR, Title 22, Section 51458.1 Page 8 This is trial version www.adultpdf.com . AUDIT ADJ AUDIT ADJ 20 RECLASSIFICATIONS AND/OR ADJUSTMENTS TO REPORTED COSTS (3,425) (85,627) 00000000 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider. Adjusted Adjustments SEAPORT 17TH CARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZT05155I Cost Report Explanation of Audit Adjustments Report References Audit Report RECLASSIFICATIONS OF REPORTED. 51511.5 *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