REPORT ON THE HOME OFFICE AUDIT MARINER HEALTH CARE, INC. ATLANTA, GEORGIA FISCAL PERIOD ENDED DECEMBER 31, 2011
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1 REPORT ON THE HOME OFFICE AUDIT ATLANTA, GEORGIA FISCAL PERIOD ENDED DECEMBER 31, 211 Audits Section - Sacramento Financial Audits Branch Audits and Investigations Department of Health Care Services Section Chief: Robert G. Kvick Audit Supervisor: Kelly Ostrom Auditor: Janice L. Varrone
2 State of California Health and Human Services Agency Department of Health Care Services TOBY DOUGLAS DIRECTOR EDMUND G. BROWN JR. GOVERNOR June 4, 213 Brian Karpodinis Director Consolidation Accounting Fundamental Administrative Services, LLC 92 Ridgebrook Road Sparks, MD FISCAL PERIOD ENDED DECEMBER 31, 211 We have examined the Medi-Cal Home Office Cost Report for the fiscal period ended December 31, 211. Our examination was made under the authority of Section 1417 of the Welfare and Institutions Code and, accordingly, included such tests of the accounting records and such other auditing procedures as we considered necessary in the circumstances. In our opinion, the data presented in the Summary of Audited Home Office Costs to Health Care Facilities represents a proper determination of home office allowable costs for the above fiscal period in accordance with Medi-Cal reimbursement principles. The audited home office cost will be incorporated, by separate adjustment, into each applicable facility audit report. This audit report includes the: 1. Summary of Audited Home Office Costs to Health Care Facilities and Supporting Schedules 2. Audit Adjustments Schedule If you disagree with the decision of the Department, the results of the home office audit may only be appealed through each individual facili ty's audit report. Please refer to the appeal instructions in each facility s audit report. Financi al Audits Branch/Audits Section Sacramento MS 216, P.O. Box , Sacramento, CA (916) / (916) fax Internet Address:
3 Brian Karpodinis Page 2 If you have questions regarding this report, you may call the Audits Section Sacramento at (916) Original Signed By Robert G. Kvick, Chief Audits Section Sacramento Financial Audits Branch Certified
4 TABLE OF CONTENTS SCHEDULES 1 - SUMMARY OF AUDITED HOME OFFICE CAPITAL AND NONCAPITAL RELATED COSTS TO CHAIN COMPONENTS 2 - COMPARISON OF REPORTED AND AUDITED HOME OFFICE COSTS 3 - SUMMARY ALLOCATION OF HOME OFFICE COSTS - CAPITAL RELATED SUMMARY ALLOCATION OF HOME OFFICE COSTS - NONCAPITAL RELATED 4 - POOLED ALLOCATION OF HOME OFFICE COSTS TO CHAIN COMPONENTS 5 - FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - CAPITAL RELATED FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - NONCAPITAL RELATED 6 - FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - CAPITAL RELATED FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - NONCAPITAL RELATED 7 - DIRECT ALLOCATION OF CAPITAL COSTS TO CHAIN COMPONENTS DIRECT ALLOCATION OF NONCAPITAL COSTS TO CHAIN COMPONENTS 8 - TRIAL BALANCE OF EXPENSES 9 - REPORTED HOME OFFICE COSTS
5 STATE OF CALIFORNIA SCHEDULE 1 SUMMARY OF AUDITED HOME OFFICE CAPITAL AND NONCAPITAL RELATED COSTS TO CHAIN COMPONENTS DECEMBER 31, 211 FISCAL PERIODS ENDING DURING HOME OFFICE FISCAL YEAR FROM TO CAPITAL RELATED (SCHEDULE 3) 1 NONCAPITAL RELATED (SCHEDULE 3-1) 2 TOTAL AUDITED H.O. COSTS (COLUMN 1 + 2) 3 1. Monterey Palms Health Care Center /1/11 12/31/11 $9,929 $27,25 $28, Autumn Hills Health Care Center /1/11 12/31/11 9, , , Fremont Health Care Center /1/11 12/31/11 12, , ,4 4. Driftwood Health Care - Hayward /1/11 12/31/11 9,31 266,82 276, Almaden Health and Rehab Center /1/11 12/31/11 8, , , Driftwood Healthcare Santa Cruz /1/11 12/31/11 8, ,82 278, Florin Healthcare Center /1/11 12/31/11 11, , , Hayward Hills Healthcare Center /1/11 12/31/11 8, ,23 236, Inglewood Healthcare Center /1/11 12/31/11 8,13 22, , Parkview Healthcare Center /1/11 12/31/11 11,45 31,92 312, Santa Monica Health Care Center /1/11 12/31/11 6, , , Skyline Healthcare - San Jose /1/11 12/31/11 22, , , Verdugo Vista Healthcare Center /1/11 12/31/11 8, , , Vale Healthcare Center /1/11 12/31/11 2,24 555,94 575, Palm Springs Health & Rehab /1/11 12/31/11 8, , , Creekside Health Care Center /1/11 12/31/11 9, ,28 275, Pine Ridge Care Center /1/11 12/31/11 9,45 256,3 265, Rehab Center of Santa Monica /1/11 12/31/11 13, , , All Other Facilities Various , ,661 SUBTOTAL (LINES 1 THROUGH 2) $197,337 $5,595,331 $5,792, $ $ $ SUBTOTAL (LINES 21 THROUGH 35) $ $ $ GRAND TOTAL $197,337 $5,595,331 $5,792,668
6 STATE OF CALIFORNIA SCHEDULE 2 COMPARISON OF REPORTED AND AUDITED HOME OFFICE COSTS DECEMBER 31, 211 FISCAL PERIODS ENDING DURING HOME OFFICE FISCAL YEAR FROM TO REPORTED HOME OFFICE COSTS (SCH. 9) 1 AUDITED H.O. COSTS (SCH. 3 & 3-1) 2 VARIANCE (COLUMN 2-1) 3 1. Monterey Palms Health Care Center /1/11 12/31/11 $428,327 $28,179 ($148,149) 2. Autumn Hills Health Care Center /1/11 12/31/11 426, ,828 (147,3) 3. Fremont Health Care Center /1/11 12/31/11 536, ,4 (185,93) 4. Driftwood Health Care - Hayward /1/11 12/31/11 415,34 276,113 (138,921) 5. Almaden Health and Rehab Center /1/11 12/31/11 397,78 265,678 (132,12) 6. Driftwood Healthcare Santa Cruz /1/11 12/31/11 412, ,758 (133,627) 7. Florin Healthcare Center /1/11 12/31/11 55, ,871 (173,68) 8. Hayward Hills Healthcare Center /1/11 12/31/11 361,53 236,547 (124,56) 9. Inglewood Healthcare Center /1/11 12/31/11 349, ,761 (12,913) 1. Parkview Healthcare Center /1/11 12/31/11 476, ,137 (164,814) 11. Santa Monica Health Care Center /1/11 12/31/11 295,57 194,923 (1,134) 12. Skyline Healthcare - San Jose /1/11 12/31/11 979, ,225 (335,598) 13. Verdugo Vista Healthcare Center /1/11 12/31/11 368, ,463 (127,228) 14. Vale Healthcare Center /1/11 12/31/11 874, ,928 (298,788) 15. Palm Springs Health & Rehab /1/11 12/31/11 354,28 231,599 (122,681) 16. Creekside Health Care Center /1/11 12/31/11 42, ,44 (145,693) 17. Pine Ridge Care Center /1/11 12/31/11 45, ,436 (14,339) 18. Rehab Center of Santa Monica /1/11 12/31/11 586, ,513 (23,15) All Other Facilities Various 139, ,661 SUBTOTAL (LINES 1 THROUGH 2) $8,595,947 $5,792,668 ($2,83,279) 21. $ $ $ SUBTOTAL (LINES 21 THROUGH 35) $ $ $ GRAND TOTAL $8,595,947 $5,792,668 ($2,83,279)
7 STATE OF CALIFORNIA SCHEDULE 3 SUMMARY ALLOCATION OF HOME OFFICE COSTS - CAPITAL RELATED DECEMBER 31, 211 FISCAL PERIODS ENDING DURING HOME OFFICE FISCAL YEAR FROM TO DIRECT FUNCTIONAL POOLED CAPITAL COSTS CAPITAL COSTSCAPITAL COSTS (SCHEDULE 7) 1 (SCHEDULE 5) 2 (SCHEDULE 4) 3 TOTAL CAPITAL COSTS (COL. 1 TO 3) 1. Monterey Palms Health Care Center /1/11 12/31/11 $ $ $9,928 $9, Autumn Hills Health Care Center /1/11 12/31/11 9,872 9, Fremont Health Care Center /1/11 12/31/11 12,461 12, Driftwood Health Care - Hayward /1/11 12/31/11 9,31 9,31 5. Almaden Health and Rehab Center /1/11 12/31/11 8,853 8, Driftwood Healthcare Santa Cruz /1/11 12/31/11 8,955 8, Florin Healthcare Center /1/11 12/31/11 11,599 11, Hayward Hills Healthcare Center /1/11 12/31/11 8,344 8, Inglewood Healthcare Center /1/11 12/31/11 8,13 8,13 1. Parkview Healthcare Center /1/11 12/31/11 11,45 11, Santa Monica Health Care Center /1/11 12/31/11 6,711 6, Skyline Healthcare - San Jose /1/11 12/31/11 22,491 22, Verdugo Vista Healthcare Center /1/11 12/31/11 8,526 8, Vale Healthcare Center /1/11 12/31/11 2,24 2, Palm Springs Health & Rehab /1/11 12/31/11 8,222 8, Creekside Health Care Center /1/11 12/31/11 9,764 9, Pine Ridge Care Center /1/11 12/31/11 9,45 9, Rehab Center of Santa Monica /1/11 12/31/11 13,615 13, All Other Facilities Various SUBTOTAL (LINES 1 THROUGH 2) $ $ $197,337 $197, $ $ $ $ SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ GRAND TOTAL $ $ $197,337 $197,337 (To Schedule 1 & 2)
8 STATE OF CALIFORNIA SCHEDULE 3-1 SUMMARY ALLOCATION OF HOME OFFICE COSTS - NONCAPITAL RELATED DECEMBER 31, 211 FISCAL PERIODS ENDING DURING HOME OFFICE FISCAL YEAR FROM TO DIRECT COSTS (SCH. 7-1) 1 FUNCTIONAL COSTS (SCH. 5-1) 2 POOLED COSTS (SCH. 4) 3 TOTAL NONCAPITAL COSTS (COL. 1 TO 3) 1. Monterey Palms Health Care Center /1/11 12/31/11 $5 $ $269,75 $27,25 2. Autumn Hills Health Care Center /1/11 12/31/ ,26 268, Fremont Health Care Center /1/11 12/31/11 338, , Driftwood Health Care - Hayward /1/11 12/31/11 13, , ,82 5. Almaden Health and Rehab Center /1/11 12/31/11 16,29 24, , Driftwood Healthcare Santa Cruz /1/11 12/31/11 26, ,31 269,82 7. Florin Healthcare Center /1/11 12/31/11 6, , , Hayward Hills Healthcare Center /1/11 12/31/11 1,5 226,73 228,23 9. Inglewood Healthcare Center /1/11 12/31/ ,158 22, Parkview Healthcare Center /1/11 12/31/ ,96 31, Santa Monica Health Care Center /1/11 12/31/11 5, , , Skyline Healthcare - San Jose /1/11 12/31/11 1, ,63 621, Verdugo Vista Healthcare Center /1/11 12/31/11 1, , , Vale Healthcare Center /1/11 12/31/11 11, ,35 555, Palm Springs Health & Rehab /1/11 12/31/11 223, , Creekside Health Care Center /1/11 12/31/11 265,28 265, Pine Ridge Care Center /1/11 12/31/ ,53 256,3 18. Rehab Center of Santa Monica /1/11 12/31/11 369, , All Other Facilities Various 136,579 2, ,552 SUBTOTAL (LINES 1 THROUGH 2) $233,815 $ $5,361,516 $5,595, $ $ $ $ SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ GRAND TOTAL $233,815 $ $5,361,516 $5,595,331 (To Schedule 1 & 2)
9 STATE OF CALIFORNIA SCHEDULE 4 POOLED ALLOCATION OF HOME OFFICE COSTS TO CHAIN COMPONENTS DECEMBER 31, 211 TOTAL COST CAPITAL NONCAPITAL TOTAL POOLED (SCH. G, COL. 1) (SCH. 8) (SCH. 8) (COL ) (Adj. 2) 1. Monterey Palms Health Care Center $8,624,578 $9,928 $269,75 $279, Autumn Hills Health Care Center ,575,217 9, ,26 278,78 3. Fremont Health Care Center ,824,72 12, , ,4 4. Driftwood Health Care - Hayward ,87,414 9,31 252, ,26 5. Almaden Health and Rehab Center ,69,472 8,853 24, , Driftwood Healthcare Santa Cruz ,779,225 8, ,31 252, Florin Healthcare Center ,75,279 11, , , Hayward Hills Healthcare Center ,248,235 8, ,73 235,47 9. Inglewood Healthcare Center ,38,997 8,13 22, , Parkview Healthcare Center ,594,81 11,45 3,96 311, Santa Monica Health Care Center ,829,365 6, , , Skyline Healthcare - San Jose ,537,17 22, ,63 633, Verdugo Vista Healthcare Center ,46,75 8, ,659 24, Vale Healthcare Center ,394,143 2,24 544,35 564, Palm Springs Health & Rehab ,141,933 8, , , Creekside Health Care Center ,481,642 9, ,28 275, Pine Ridge Care Center ,169,934 9,45 255,53 264, Rehab Center of Santa Monica ,826,55 13, , , All Other Facilities Various 95, ,973 3,82 SUBTOTAL (LINES 1 THROUGH 2) $171,42,787 $197,337 $5,361,516 $5,558, $ $ $ $ SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ GRAND TOTAL $171,42,787 $197,337 $5,361,516 $5,558,853 (To Schedule 3) (To Schedule 3-1) MULTIPLIER
10 STATE OF CALIFORNIA SCHEDULE 5 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - CAPITAL RELATED DECEMBER 31, 211 Old Cap. Related- Buildings & 1. Old Cap. Related- Movable New Cap. Related- Buildings & Monterey Palms Health Care Center $ $ $ $ $ $ 2. Autumn Hills Health Care Center Fremont Health Care Center Driftwood Health Care - Hayward Almaden Health and Rehab Center Driftwood Healthcare Santa Cruz Florin Healthcare Center Hayward Hills Healthcare Center Inglewood Healthcare Center Parkview Healthcare Center Santa Monica Health Care Center Skyline Healthcare - San Jose Verdugo Vista Healthcare Center Vale Healthcare Center Palm Springs Health & Rehab Creekside Health Care Center Pine Ridge Care Center Rehab Center of Santa Monica All Other Facilities Various SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $ $ $ 21. $ $ $ $ $ $ SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ GRAND TOTAL $ $ $ $ $ $
11 STATE OF CALIFORNIA SCHEDULE 5 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - CAPITAL RELATED DECEMBER 31, 211 New Cap. Related- Movable 5. Insurance Premiums Taxes and Licenses - Not INCM 8. Other 9. AUDITED TOTAL CAPITAL 1. Monterey Palms Health Care Center $ $ $ $ $ $ 2. Autumn Hills Health Care Center Fremont Health Care Center Driftwood Health Care - Hayward Almaden Health and Rehab Center Driftwood Healthcare Santa Cruz Florin Healthcare Center Hayward Hills Healthcare Center Inglewood Healthcare Center Parkview Healthcare Center Santa Monica Health Care Center Skyline Healthcare - San Jose Verdugo Vista Healthcare Center Vale Healthcare Center Palm Springs Health & Rehab Creekside Health Care Center Pine Ridge Care Center Rehab Center of Santa Monica All Other Facilities Various SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $ $ $ 21. $ $ $ $ $ $ SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ GRAND TOTAL $ $ $ $ $ $ (To Schedule 3)
12 STATE OF CALIFORNIA SCHEDULE 5-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - NONCAPITAL RELATED DECEMBER 31, 211 Salaries of Officers 11 Salaries and Temporary Labor 12 Payroll Taxes 13 Employee Benefits-Payroll Related 14 Employee Benefits- Nonpayroll 15 Profit Sharing/Pensio n Plans 16 Legal Fees Monterey Palms Health Care Center $ $ $ $ $ $ $ 2. Autumn Hills Health Care Center Fremont Health Care Center Driftwood Health Care - Hayward Almaden Health and Rehab Center Driftwood Healthcare Santa Cruz Florin Healthcare Center Hayward Hills Healthcare Center Inglewood Healthcare Center Parkview Healthcare Center Santa Monica Health Care Center Skyline Healthcare - San Jose Verdugo Vista Healthcare Center Vale Healthcare Center Palm Springs Health & Rehab Creekside Health Care Center Pine Ridge Care Center Rehab Center of Santa Monica All Other Facilities Various SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $ $ $ $ SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ $ GRAND TOTAL $ $ $ $ $ $ $
13 STATE OF CALIFORNIA SCHEDULE 5-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - NONCAPITAL RELATED DECEMBER 31, 211 Auditing & Accounting Fees 18 Utilities 19 Communication s 2 Travel & Entertainment 21 Automobile 22 Supplies 23 Minor Equipment Expensed Monterey Palms Health Care Center $ $ $ $ $ $ $ 2. Autumn Hills Health Care Center Fremont Health Care Center Driftwood Health Care - Hayward Almaden Health and Rehab Center Driftwood Healthcare Santa Cruz Florin Healthcare Center Hayward Hills Healthcare Center Inglewood Healthcare Center Parkview Healthcare Center Santa Monica Health Care Center Skyline Healthcare - San Jose Verdugo Vista Healthcare Center Vale Healthcare Center Palm Springs Health & Rehab Creekside Health Care Center Pine Ridge Care Center Rehab Center of Santa Monica All Other Facilities Various SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $ $ $ $ 21. $ $ $ $ $ $ $ SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ $ GRAND TOTAL $ $ $ $ $ $ $
14 STATE OF CALIFORNIA SCHEDULE 5-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - NONCAPITAL RELATED DECEMBER 31, 211 Repairs & Maintenance 25 Dues & Subscriptions 26 Contributions 27 Insurance Premium-Non Capital Related 28 Taxes & Licenses - Non Capital Related 29 Interest Expense 3 Temporary Labor Monterey Palms Health Care Center $ $ $ $ $ $ $ 2. Autumn Hills Health Care Center Fremont Health Care Center Driftwood Health Care - Hayward Almaden Health and Rehab Center Driftwood Healthcare Santa Cruz Florin Healthcare Center Hayward Hills Healthcare Center Inglewood Healthcare Center Parkview Healthcare Center Santa Monica Health Care Center Skyline Healthcare - San Jose Verdugo Vista Healthcare Center Vale Healthcare Center Palm Springs Health & Rehab Creekside Health Care Center Pine Ridge Care Center Rehab Center of Santa Monica All Other Facilities Various SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $ $ $ $ 21. $ $ $ $ $ $ $ SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ $ GRAND TOTAL $ $ $ $ $ $ $
15 STATE OF CALIFORNIA SCHEDULE 5-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - NONCAPITAL RELATED DECEMBER 31, 211 Forms & Printing 32 Meetings & Conferences 33 Contracted Professional Services 34 Bank Charges 35 Clinical Monterey Palms Health Care Center $ $ $ $ $ $ $ 2. Autumn Hills Health Care Center Fremont Health Care Center Driftwood Health Care - Hayward Almaden Health and Rehab Center Driftwood Healthcare Santa Cruz Florin Healthcare Center Hayward Hills Healthcare Center Inglewood Healthcare Center Parkview Healthcare Center Santa Monica Health Care Center Skyline Healthcare - San Jose Verdugo Vista Healthcare Center Vale Healthcare Center Palm Springs Health & Rehab Creekside Health Care Center Pine Ridge Care Center Rehab Center of Santa Monica All Other Facilities Various SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $ $ $ $ 21. $ $ $ $ $ $ $ SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ $ GRAND TOTAL $ $ $ $ $ $ $
16 STATE OF CALIFORNIA SCHEDULE 5-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS - NONCAPITAL RELATED DECEMBER 31, AUDITED TOTAL NONCAPITAL 1. Monterey Palms Health Care Center $ $ $ $ $ $ 2. Autumn Hills Health Care Center Fremont Health Care Center Driftwood Health Care - Hayward Almaden Health and Rehab Center Driftwood Healthcare Santa Cruz Florin Healthcare Center Hayward Hills Healthcare Center Inglewood Healthcare Center Parkview Healthcare Center Santa Monica Health Care Center Skyline Healthcare - San Jose Verdugo Vista Healthcare Center Vale Healthcare Center Palm Springs Health & Rehab Creekside Health Care Center Pine Ridge Care Center Rehab Center of Santa Monica All Other Facilities Various SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $ $ $ 21. $ $ $ $ $ $ SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ GRAND TOTAL $ $ $ $ $ $
17 STATE OF CALIFORNIA SCHEDULE 6 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - CAPITAL RELATED DECEMBER 31, 211 Old Cap. Related Old Cap. Related New Cap. Related (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) 1. Monterey Palms Health Care Center Autumn Hills Health Care Center Fremont Health Care Center Driftwood Health Care - Hayward Almaden Health and Rehab Center Driftwood Healthcare Santa Cruz Florin Healthcare Center Hayward Hills Healthcare Center Inglewood Healthcare Center Parkview Healthcare Center Santa Monica Health Care Center Skyline Healthcare - San Jose Verdugo Vista Healthcare Center Vale Healthcare Center Palm Springs Health & Rehab Creekside Health Care Center Pine Ridge Care Center Rehab Center of Santa Monica All Other Facilities Various SUBTOTAL (LINES 1 THROUGH 2) SUBTOTAL (LINES 21 THROUGH 35) GRAND TOTAL TOTAL STATISTICS COST TO BE ALLOCATED (FROM SCHEDULE 8) $ $ $ $ $ $ UNIT COST MULTIPLIER......
18 STATE OF CALIFORNIA SCHEDULE 6 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - CAPITAL RELATED DECEMBER 31, 211 New Cap. Insurance Taxes and Other Related- Premiums Licenses - Not (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) 1. Monterey Palms Health Care Center Autumn Hills Health Care Center Fremont Health Care Center Driftwood Health Care - Hayward Almaden Health and Rehab Center Driftwood Healthcare Santa Cruz Florin Healthcare Center Hayward Hills Healthcare Center Inglewood Healthcare Center Parkview Healthcare Center Santa Monica Health Care Center Skyline Healthcare - San Jose Verdugo Vista Healthcare Center Vale Healthcare Center Palm Springs Health & Rehab Creekside Health Care Center Pine Ridge Care Center Rehab Center of Santa Monica All Other Facilities Various SUBTOTAL (LINES 1 THROUGH 2) SUBTOTAL (LINES 21 THROUGH 35) GRAND TOTAL TOTAL STATISTICS COST TO BE ALLOCATED (FROM SCHEDULE 8) $ $ $ $ $ UNIT COST MULTIPLIER.....
19 STATE OF CALIFORNIA SCHEDULE 6-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - NONCAPITAL RELATED DECEMBER 31, 211 Salaries of Officers Salaries and Temporary Payroll Taxes Employee Benefits-Payroll Employee Benefits- Profit Sharing/Pensio (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) 1. Monterey Palms Health Care Center Autumn Hills Health Care Center Fremont Health Care Center Driftwood Health Care - Hayward Almaden Health and Rehab Center Driftwood Healthcare Santa Cruz Florin Healthcare Center Hayward Hills Healthcare Center Inglewood Healthcare Center Parkview Healthcare Center Santa Monica Health Care Center Skyline Healthcare - San Jose Verdugo Vista Healthcare Center Vale Healthcare Center Palm Springs Health & Rehab Creekside Health Care Center Pine Ridge Care Center Rehab Center of Santa Monica All Other Facilities Various SUBTOTAL (LINES 1 THROUGH 2) SUBTOTAL (LINES 21 THROUGH 35) GRAND TOTAL TOTAL STATISTICS COST TO BE ALLOCATED (FROM SCHEDULE 8) $ $ $ $ $ $ UNIT COST MULTIPLIER......
20 STATE OF CALIFORNIA SCHEDULE 6-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - NONCAPITAL RELATED DECEMBER 31, 211 Legal Fees Auditing & Utilities Communication Travel & Automobile 17. Accounting s 2. Entertainment (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) 1. Monterey Palms Health Care Center Autumn Hills Health Care Center Fremont Health Care Center Driftwood Health Care - Hayward Almaden Health and Rehab Center Driftwood Healthcare Santa Cruz Florin Healthcare Center Hayward Hills Healthcare Center Inglewood Healthcare Center Parkview Healthcare Center Santa Monica Health Care Center Skyline Healthcare - San Jose Verdugo Vista Healthcare Center Vale Healthcare Center Palm Springs Health & Rehab Creekside Health Care Center Pine Ridge Care Center Rehab Center of Santa Monica All Other Facilities Various SUBTOTAL (LINES 1 THROUGH 2) SUBTOTAL (LINES 21 THROUGH 35) GRAND TOTAL TOTAL STATISTICS COST TO BE ALLOCATED (FROM SCHEDULE 8) $ $ $ $ $ $ UNIT COST MULTIPLIER......
21 STATE OF CALIFORNIA SCHEDULE 6-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - NONCAPITAL RELATED DECEMBER 31, 211 Supplies Minor Equipment Repairs & Maintenance Dues & Subscriptions Contributions Insurance Premium-Non (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) 1. Monterey Palms Health Care Center Autumn Hills Health Care Center Fremont Health Care Center Driftwood Health Care - Hayward Almaden Health and Rehab Center Driftwood Healthcare Santa Cruz Florin Healthcare Center Hayward Hills Healthcare Center Inglewood Healthcare Center Parkview Healthcare Center Santa Monica Health Care Center Skyline Healthcare - San Jose Verdugo Vista Healthcare Center Vale Healthcare Center Palm Springs Health & Rehab Creekside Health Care Center Pine Ridge Care Center Rehab Center of Santa Monica All Other Facilities Various SUBTOTAL (LINES 1 THROUGH 2) SUBTOTAL (LINES 21 THROUGH 35) GRAND TOTAL TOTAL STATISTICS COST TO BE ALLOCATED (FROM SCHEDULE 8) $ $ $ $ $ $ UNIT COST MULTIPLIER......
22 STATE OF CALIFORNIA SCHEDULE 6-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - NONCAPITAL RELATED DECEMBER 31, 211 Taxes & Licenses - Non Interest Expense Temporary Labor Forms & Printing Meetings & Conferences Contracted Professional (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) 1. Monterey Palms Health Care Center Autumn Hills Health Care Center Fremont Health Care Center Driftwood Health Care - Hayward Almaden Health and Rehab Center Driftwood Healthcare Santa Cruz Florin Healthcare Center Hayward Hills Healthcare Center Inglewood Healthcare Center Parkview Healthcare Center Santa Monica Health Care Center Skyline Healthcare - San Jose Verdugo Vista Healthcare Center Vale Healthcare Center Palm Springs Health & Rehab Creekside Health Care Center Pine Ridge Care Center Rehab Center of Santa Monica All Other Facilities Various SUBTOTAL (LINES 1 THROUGH 2) SUBTOTAL (LINES 21 THROUGH 35) GRAND TOTAL TOTAL STATISTICS COST TO BE ALLOCATED (FROM SCHEDULE 8) $ $ $ $ $ $ UNIT COST MULTIPLIER......
23 STATE OF CALIFORNIA SCHEDULE 6-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - NONCAPITAL RELATED DECEMBER 31, 211 Bank Charges Clinical (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) 1. Monterey Palms Health Care Center Autumn Hills Health Care Center Fremont Health Care Center Driftwood Health Care - Hayward Almaden Health and Rehab Center Driftwood Healthcare Santa Cruz Florin Healthcare Center Hayward Hills Healthcare Center Inglewood Healthcare Center Parkview Healthcare Center Santa Monica Health Care Center Skyline Healthcare - San Jose Verdugo Vista Healthcare Center Vale Healthcare Center Palm Springs Health & Rehab Creekside Health Care Center Pine Ridge Care Center Rehab Center of Santa Monica All Other Facilities Various SUBTOTAL (LINES 1 THROUGH 2) SUBTOTAL (LINES 21 THROUGH 35) GRAND TOTAL TOTAL STATISTICS COST TO BE ALLOCATED (FROM SCHEDULE 8) $ $ $ $ $ $ UNIT COST MULTIPLIER......
24 STATE OF CALIFORNIA SCHEDULE 6-1 FUNCTIONAL ALLOCATION OF EXPENSES TO CHAIN COMPONENTS STATISTICS - NONCAPITAL RELATED DECEMBER 31, (Adj. ) (Adj. ) (Adj. ) 1. Monterey Palms Health Care Center Autumn Hills Health Care Center Fremont Health Care Center Driftwood Health Care - Hayward Almaden Health and Rehab Center Driftwood Healthcare Santa Cruz Florin Healthcare Center Hayward Hills Healthcare Center Inglewood Healthcare Center Parkview Healthcare Center Santa Monica Health Care Center Skyline Healthcare - San Jose Verdugo Vista Healthcare Center Vale Healthcare Center Palm Springs Health & Rehab Creekside Health Care Center Pine Ridge Care Center Rehab Center of Santa Monica All Other Facilities Various SUBTOTAL (LINES 1 THROUGH 2) SUBTOTAL (LINES 21 THROUGH 35) GRAND TOTAL TOTAL STATISTICS COST TO BE ALLOCATED (FROM SCHEDULE 8) $ $ $ UNIT COST MULTIPLIER...
25 STATE OF CALIFORNIA SCHEDULE 7 DIRECT ALLOCATION OF CAPITAL COSTS TO CHAIN COMPONENTS DECEMBER 31, 211 REPORTED AUDITED TOTAL TOTAL (SCH. E) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) 1. Monterey Palms Health Care Center $ $ $ $ $ $ $ 2. Autumn Hills Health Care Center Fremont Health Care Center Driftwood Health Care - Hayward Almaden Health and Rehab Center Driftwood Healthcare Santa Cruz Florin Healthcare Center Hayward Hills Healthcare Center Inglewood Healthcare Center Parkview Healthcare Center Santa Monica Health Care Center Skyline Healthcare - San Jose Verdugo Vista Healthcare Center Vale Healthcare Center Palm Springs Health & Rehab Creekside Health Care Center Pine Ridge Care Center Rehab Center of Santa Monica All Other Facilities Various SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $ $ $ $ 21. $ $ $ $ $ $ $ SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ $ GRAND TOTAL $ $ $ $ $ $ $ (To Schedule 3)
26 STATE OF CALIFORNIA SCHEDULE 7-1 DIRECT ALLOCATION OF NONCAPITAL COSTS TO CHAIN COMPONENTS DECEMBER 31, 211 REPORTED TOTAL (SCH. E-1) Legal Fees Legal Fees Legal Fees Contracted Professional Services Contracted Professional Services (Adj. 2 ) (Adj. 3 ) (Adj. 4 ) (Adj. 5 ) (Adj. 6 ) (Adj. ) (Adj. ) 1. Monterey Palms Health Care Center $5 $ $ $ $ $ $ $ 2. Autumn Hills Health Care Center Fremont Health Care Center Driftwood Health Care - Hayward , Almaden Health and Rehab Center ,29 6. Driftwood Healthcare Santa Cruz , Florin Healthcare Center , Hayward Hills Healthcare Center ,5 9. Inglewood Healthcare Center Parkview Healthcare Center Santa Monica Health Care Center , Skyline Healthcare - San Jose , Verdugo Vista Healthcare Center , Vale Healthcare Center , Palm Springs Health & Rehab Creekside Health Care Center Pine Ridge Care Center Rehab Center of Santa Monica All Other Facilities Various 68,352 1,215 1,336 46,736 9,94 SUBTOTAL (LINES 1 THROUGH 2) $97,236 $68,352 $1,215 $1,336 $46,736 $9,94 $ $ SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ $ $ GRAND TOTAL $97,236 $68,352 $1,215 $1,336 $46,736 $9,94 $ $
27 STATE OF CALIFORNIA SCHEDULE 7-1 DIRECT ALLOCATION OF NONCAPITAL COSTS TO CHAIN COMPONENTS DECEMBER 31, 211 (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) (Adj. ) AUDITED TOTAL 1. Monterey Palms Health Care Center $ $ $ $ $ $ $5 2. Autumn Hills Health Care Center Fremont Health Care Center Driftwood Health Care - Hayward , Almaden Health and Rehab Center ,29 6. Driftwood Healthcare Santa Cruz , Florin Healthcare Center , Hayward Hills Healthcare Center ,5 9. Inglewood Healthcare Center Parkview Healthcare Center Santa Monica Health Care Center , Skyline Healthcare - San Jose , Verdugo Vista Healthcare Center , Vale Healthcare Center , Palm Springs Health & Rehab Creekside Health Care Center Pine Ridge Care Center Rehab Center of Santa Monica All Other Facilities Various 136,579 SUBTOTAL (LINES 1 THROUGH 2) $ $ $ $ $ $ $233, SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ $ GRAND TOTAL $ $ $ $ $ $ $233,815 (To Schedule 3-1)
28 STATE OF CALIFORNIA SCHEDULE 8 TRIAL BALANCE OF EXPENSES DECEMBER 31, 211 LINE NO. COST CENTER DESCRIPTION REPORTED ADJ. ADJUSTMENT AUDITED POOLED ALLOC. NO. AMOUNT(S) POOLED (SCH. B, COL 8) COSTS CAPITAL-RELATED COSTS - OLD 1. Old Cap. Related-Buildings & Fixtures $ Old Cap. Related-Movable Equipment SUBTOTAL (sum of lines 1 through 2.1) $ $ $ CAPITAL-RELATED COSTS - NEW 4. New Cap. Related-Buildings & Fixtures $ $ $ New Cap. Related-Movable Equipment 29,59 1 (12,172) 197, SUBTOTAL (sum of lines 4 through 5.1) $29,59 ($12,172) $197,337 OTHER CAPITAL-RELATED COSTS 7. Insurance Premiums $ $ $ 8. Taxes and Licenses - Not INCM 9. Other 1. SUBTOTAL (sum of lines 7 through 9) $ $ $ NON CAPITAL-RELATED COSTS 11. Salaries of Officers $ $ $ 12. Salaries and Temporary Labor 3,333,38 7 (1,462,35) 1,871,3 13. Payroll Taxes 24,993 24, Employee Benefits-Payroll Related 185,3 185,3 15. Employee Benefits-Nonpayroll Related 16. Profit Sharing/Pension Plans 17. Legal Fees 222,812 2,3,4,8 (83,224) 139, Auditing & Accounting Fees 19. Utilities (13,66) (13,66) 2. Communications 19,563 19, Travel & Entertainment 293, , Automobile 14,924 14, Supplies 31,946 31, Minor Equipment Expensed 25. Repairs & Maintenance 1,147 1, Dues & Subscriptions 16,132 16, Contributions 28. Insurance Premium-Non Capital Related 29. Taxes & Licenses - Non Capital Related 13,915 13, Interest Expense 318,99 1,19 (318,99) 31. Temporary Labor 32. Forms & Printing 3,26 3, Meetings & Conferences 2,519 2, Contracted Professional Services 1,562,875 5,6,9-18 (1,63,251) 499, Bank Charges 288, , Clinical 1,438,35 1,438, SUBTOTAL (sum of lines 11 through 35.8) $8,289,25 ($2,927,689) $5,361, TOTAL ALLOWABLE EXPENSES $8,498,714 ($2,939,861) $5,558,853 (To Sch. 4) 38. NONREIMBURSABLE EXPENSES $ $ $ TOTAL EXPENSES $8,498,714 ($2,939,861) $5,558,853
29 STATE OF CALIFORNIA SCHEDULE 8 TRIAL BALANCE OF EXPENSES DECEMBER 31, 211 LINE NO. COST CENTER DESCRIPTION REPORTED ADJ. ADJUSTMENT AUDITED DIRECT ALLOC. NO. AMOUNT(S) DIRECT (SCH. B, COL 6) COSTS CAPITAL-RELATED COSTS - OLD 1. Old Cap. Related-Buildings & Fixtures Old Cap. Related-Movable Equipment SUBTOTAL (sum of lines 1 through 2.1) CAPITAL-RELATED COSTS - NEW 4. New Cap. Related-Buildings & Fixtures New Cap. Related-Movable Equipment SUBTOTAL (sum of lines 4 through 5.1) OTHER CAPITAL-RELATED COSTS 7. Insurance Premiums 8. Taxes and Licenses - Not INCM 9. Other 1. SUBTOTAL (sum of lines 7 through 9) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ NON CAPITAL-RELATED COSTS 11. Salaries of Officers 12. Salaries and Temporary Labor 13. Payroll Taxes 14. Employee Benefits-Payroll Related 15. Employee Benefits-Nonpayroll Related 16. Profit Sharing/Pension Plans 17. Legal Fees 18. Auditing & Accounting Fees 19. Utilities 2. Communications 21. Travel & Entertainment 22. Automobile 23. Supplies 24. Minor Equipment Expensed 25. Repairs & Maintenance 26. Dues & Subscriptions 27. Contributions 28. Insurance Premium-Non Capital Related 29. Taxes & Licenses - Non Capital Related 3. Interest Expense 31. Temporary Labor 32. Forms & Printing 33. Meetings & Conferences 34. Contracted Professional Services 35. Bank Charges Clinical SUBTOTAL (sum of lines 11 through 35.8) $ 97,236 $97,236 2,3,4 5,6 $ $ 79,93 177,139 56,676 56,676 $136,579 $233, TOTAL ALLOWABLE EXPENSES $97,236 $136,579 $233,815 (To Sch. 7, 7-1) 38. NONREIMBURSABLE EXPENSES $ $ $ TOTAL EXPENSES $97,236 $136,579 $233,815
30 STATE OF CALIFORNIA SCHEDULE 8 TRIAL BALANCE OF EXPENSES DECEMBER 31, 211 LINE NO. COST CENTER DESCRIPTION REPORTED ADJ. ADJUSTMENT AUDITED FUNCTIONAL COSTS NO. AMOUNT(S) FUNCTIONAL (SCH. B, COL 7) COSTS CAPITAL-RELATED COSTS - OLD 1. Old Cap. Related-Buildings & Fixtures Old Cap. Related-Movable Equipment SUBTOTAL (sum of lines 1 through 2.1) CAPITAL-RELATED COSTS - NEW 4. New Cap. Related-Buildings & Fixtures New Cap. Related-Movable Equipment SUBTOTAL (sum of lines 4 through 5.1) OTHER CAPITAL-RELATED COSTS 7. Insurance Premiums 8. Taxes and Licenses - Not INCM 9. Other 1. SUBTOTAL (sum of lines 7 through 9) NON CAPITAL-RELATED COSTS 11. Salaries of Officers 12. Salaries and Temporary Labor 13. Payroll Taxes 14. Employee Benefits-Payroll Related 15. Employee Benefits-Nonpayroll Related 16. Profit Sharing/Pension Plans 17. Legal Fees 18. Auditing & Accounting Fees 19. Utilities 2. Communications 21. Travel & Entertainment 22. Automobile 23. Supplies 24. Minor Equipment Expensed 25. Repairs & Maintenance 26. Dues & Subscriptions 27. Contributions 28. Insurance Premium-Non Capital Related 29. Taxes & Licenses - Non Capital Related 3. Interest Expense 31. Temporary Labor 32. Forms & Printing 33. Meetings & Conferences 34. Contracted Professional Services 35. Bank Charges Clinical SUBTOTAL (sum of lines 11 through 35.8) 37. TOTAL ALLOWABLE EXPENSES 38. NONREIMBURSABLE EXPENSES TOTAL EXPENSES $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ (To Sch. 6, 6-1) $ $ $ $ $ $
31 STATE OF CALIFORNIA SCHEDULE 9 REPORTED HOME OFFICE COSTS MARINER HEALTH CARE, INC DECEMBER 31, 211 FISCAL PERIODS ENDING DURING HOME OFFICE FISCAL YEAR FROM TO DIRECT ALLOCATION FUNCTIONAL ALLOCATION POOLED ALLOCATION TOTAL NON-CAPITAL CAPITAL NON-CAPITAL CAPITAL NON-CAPITAL RELATED RELATED RELATED RELATED RELATED COSTS COSTS COSTS COSTS COSTS (SCH. E-1) (SCH. F) (SCH. F-1) (SCH. G) (SCH. G) CAPITAL RELATED COSTS (SCH. E) ALLOCATION HOME OFFICE COSTS 1. Monterey Palms Health Care Center /1/11 12/31/11 $5 $1,547 $417,28 $428, Autumn Hills Health Care Center /1/11 12/31/ , , , Fremont Health Care Center /1/11 12/31/11 13, , , Driftwood Health Care - Hayward /1/11 12/31/11 13,853 9,89 391, ,34 5. Almaden Health and Rehab Center /1/11 12/31/11 16,29 9,44 372,86 397,78 6. Driftwood Healthcare Santa Cruz /1/11 12/31/11 26,492 9, ,38 412, Florin Healthcare Center /1/11 12/31/11 6,149 12, ,469 55, Hayward Hills Healthcare Center /1/11 12/31/11 1,5 8,864 35, ,53 9. Inglewood Healthcare Center /1/11 12/31/11 5 8,68 34, , Parkview Healthcare Center /1/11 12/31/ , , , Santa Monica Health Care Center /1/11 12/31/11 5,888 7, ,4 295, Skyline Healthcare - San Jose /1/11 12/31/11 1,671 23, , , Verdugo Vista Healthcare Center /1/11 12/31/11 1,278 9,57 358, , Vale Healthcare Center /1/11 12/31/11 11,869 21, , , Palm Springs Health & Rehab /1/11 12/31/11 8, , , Creekside Health Care Center /1/11 12/31/11 1,372 41,365 42, Pine Ridge Care Center /1/11 12/31/11 5 9, ,284 45, Rehab Center of Santa Monica /1/11 12/31/11 14, ,21 586, All Other Facilities Various SUBTOTAL (LINES 1 THROUGH 2) $ $97,236 $ $ $29,59 $8,289,22 $8,595, $ SUBTOTAL (LINES 21 THROUGH 35) $ $ $ $ $ $ $ GRAND TOTAL $ $97,236 $ $ $29,59 $8,289,22 $8,595,947 (To Sch. 2, Col. 1)
32 State of California Department of Health Care Services Provider Name Report References Fiscal Period JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider Number Adjustments N/A 2 Adj. No. Audit Report Cost Report Work Sheet Part Title Line Col. Explanation of Audit Adjustments RECLASSIFICATIONS OF REPORTED COSTS As Reported Increase (Decrease) As Adjusted 1 8 B 5. 8 Capital Related Costs $29,59 ($12,172) $197,337 8 B 3. 8 Interest Expense 318,99 12, ,81 * To reverse provider's reclassification of interest expense to capital related costs due to insufficient supporting documentation that the borrowing was necessary, proper, reasonable, and related to patient care in conjunction with adjustment CFR 413.9, 413.2, , and CMS Pub. 15-1, Sections 22, 22.1, 22.2, 23, and E 2. 6 All Other Facilities $ $68,352 $68,352 * 8 B Legal Fees 222,812 (68,352) 154,46 * 8 B Legal Fees 97,236 68, ,588 * To directly allocate the Abelson Herron LLP legal expense for landlord dispute during divestiture of facilities not related to patient care. 42 CFR 413.9(c)(3), 413.2, and CMS Pub. 15-1, Sections 212.3, 2183, 23, 234, and E 2. 6 All Other Facilities * $68,352 $1,215 $78,567 * 8 B Legal Fees * 154,46 (1,215) 144,245 * 8 B Legal Fees * 165,588 1, ,83 * To directly allocate the Beach Whitman Cowdrey LLP legal expense for landlord dispute during divestiture of facilities not related to patient care. 42 CFR 413.9(c)(3), 413.2, and CMS Pub. 15-1, Sections 212.3, 2183, 23, 234, and *Balance carried forward from prior/to subsequent adjustments Page 1
33 State of California Department of Health Care Services Provider Name Report References Fiscal Period JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider Number Adjustments N/A 2 Adj. No. Audit Report Cost Report Work Sheet Part Title Line Col. Explanation of Audit Adjustments RECLASSIFICATIONS OF REPORTED COSTS As Reported Increase (Decrease) As Adjusted E 2. 6 All Other Facilities * $78,567 $1,336 $79,93 * 8 B Legal Fees * 144,245 (1,336) 142,99 * 8 B Legal Fees * 175,83 1, ,139 To directly allocate the Driftwood Torrance legal expense after divestiture of the facility not related to patient care. 42 CFR 413.9(c)(3), 413.2, and CMS Pub. 15-1, Sections 212.3, 2183, 23, 234, and E 2. 6 All Other Facilities * $79,93 $46,736 $126,639 * 8 B Contracted Professional Services 1,562,875 (46,736) 1,516,139 * 8 B Contracted Professional Services 46,736 46,736 * To directly allocate the IKON copy expense for the Heavy litigation in La Salle facility not related to patient care. 42 CFR 413.9(c)(3), 413.2, and CMS Pub. 15-1, Sections 212.3, 2183, 23, 234, and E 2. 6 All Other Facilities * $126,639 $9,94 $136,579 8 B Contracted Professional Services * 1,516,139 (9,94) 1,56,199 * 8 B Contracted Professional Services * 46,736 9,94 56,676 To directly allocate the DataLok box destruction expense after the divestiture of Driftwood Torrance not related to patient care 42 CFR 413.9(c)(3) Sections CMS Pub. 15-1, Sections 12.1, 212.3, and *Balance carried forward from prior/to subsequent adjustments Page 2
34 State of California Department of Health Care Services Provider Name Report References Fiscal Period JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider Number Adjustments N/A 2 Adj. No. Audit Report Cost Report Work Sheet Part Title Line Col. Explanation of Audit Adjustments ADJUSTMENTS TO REPORTED POOLED COSTS As Reported Increase (Decrease) As Adjusted 7 8 B Salaries and Temporary Labor $3,333,38 ($1,462,35) $1,871,3 To eliminate bonus expense due to insufficient documentation of the criteria for granting the bonus and the relationship to patient care. 42 CFR and CMS Pub. 15-1, Sections 94, 212.1, 213, , 23, 234, and B Legal Fees * $142,99 ($3,321) $139,588 To eliminate the FMSC name change legal expenses not related to patient care. 42 CFR 413.9(c)(3) Sections CMS Pub. 15-1, Sections 12.1, 212.3, and B Contracted Professional Services * $1,56,199 To eliminate the income tax services for National Senior Care ($25,64) not related to patient care. 42 CFR 413.9(c)(3) Sections CMS Pub. 15-1, Sections 12.1, 212.3, and To eliminate related party restructuring cost expenses not (233,732) related to patient care. 42 CFR 413.9(c)(3) Sections CMS Pub. 15-1, Sections 12.1, 212.3, and To eliminate consultant expense due to insufficient documentation (21,154) that shows the expenses are related to patient care. ($685,526) $82,673 * 42 CFR and CMS Pub. 15-1, Sections 2183, 23, and 234 *Balance carried forward from prior/to subsequent adjustments Page 3
35 State of California Department of Health Care Services Provider Name Report References Fiscal Period JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider Number Adjustments N/A 2 Adj. No. Audit Report Cost Report Work Sheet Part Title Line Col. Explanation of Audit Adjustments ADJUSTMENTS TO REPORTED POOLED COSTS As Reported Increase (Decrease) As Adjusted 12 8 B Contracted Professional Services * $82,673 To eliminate consulting expense due to lack of documentation ($165,) the expenses are related to patient care. 42 CFR 413.2, , and CMS Pub. 15-1, Sections 23 and 234 / W&I Code (b) 13 To eliminate reorganization accounting expense performed (89,483) by Sava Healthcare not related to patient care. 42 CFR 413.9(c)(3) / CMS Pub. 15-1, Sections and To eliminate reorganization accounting expense performed (44,282) by Sava Healthcare not related to patient care. 42 CFR 413.9(c)(3) / CMS Pub. 15-1, Sections and To eliminate related party restructuring costs expense not (11,859) related to patient care. 42 CFR 413.9(c)(3) CMS Pub. 15-1, Sections 12.1, 212.3, and To eliminate data entry expense due to insufficient (5,) documentation that shows the expenses are related to patient care. 42 CFR 413.2, , and CMS Pub. 15-1, Sections 23 and 234, W&I Code (b) 17 To eliminate PineBridge Investments management fee expense (3,795) due to insufficient documentation that shows the expenses are ($319,419) $51,254 * related to patient care. 42 CFR 413.2, , and CMS Pub. 15-1, Sections 23 and 234, W&I Code (b) *Balance carried forward from prior/to subsequent adjustments Page 4
36 State of California Department of Health Care Services Provider Name Report References Fiscal Period JANUARY 1, 211 THROUGH DECEMBER 31, 211 Provider Number Adjustments N/A 2 Adj. No. Audit Report Cost Report Work Sheet Part Title Line Col. Explanation of Audit Adjustments ADJUSTMENTS TO REPORTED POOLED COSTS As Reported Increase (Decrease) As Adjusted 18 8 B Contracted Professional Services * $51,254 ($1,63) $499,624 To eliminate the geoscientist travel expense due to insufficient documentation that shows the expenses are related to patient care. 42 CFR 413.2, , and CMS Pub. 15-1, Sections 23 and 234 / W&I Code (b) 19 8 B 3. 8 Interest Expense * $331,81 ($331,81) $ To eliminate interest expense at the Home Office due to insufficient supporting documentation that the borrowing was necessary, proper, reasonable, and that shows the expenses are related to patient care in conjunction with adjustment CFR 413.9, 413.2, , and CMS Pub. 15-1, Sections 22, 22.1, 22.2, 23 and 234 *Balance carried forward from prior/to subsequent adjustments Page 5
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