Assisted Living Financial and Statistical Report Instructions

Transcription

1 Assisted Living Financial and Statistical Reprt Instructins Schedule A, B, C, D, and E are t be prepared by each prvider frm the prvider s histrical recrds, using the accrual system f accunting. Please use yur agency s mst recent fiscal year as yur reprting perid. The Attestatins page must be cmpleted and signed by the agency directr. Please return riginals nly. All expenses and revenue reflected n these frms must be supprted by the prvider s prfit / lss statement r trial balance. Adjusting jurnal entries must be supprted by wrksheets r an explanatin, which reasnably justifies the entry. The prfit/lss statements, trial balance all recrds and wrksheets used in preparing the reprts must be submitted with the cst reprt. A new agency r an existing agency that has been in peratin fr six mnths r less shuld submit a prjected annual budget. An agency that has been in peratin fr mre than six mnths but less than ne year, shuld reprt histrical data in the lngest timeframe feasible, alng with a prjected annual budget. The Financial and Statistical reprt is nt cmplete until all required schedules are cmplete and crrect and all inquiries t the prvider are satisfactrily reslved. All incmplete r incrrect reprts will be returned t the prvider fr crrectin. SCHEDULE A CHART OF ACCOUNTS FOR EXPENDITURE ITEMS All csts reprted n Schedule A are t be grss csts and runded t the nearest dllar. Example: if a facility s telephne bills ttaled $3,500 fr the year, and they were reimbursed by residents, emplyees, guests, and thers fr lng distance calls fr $220, $3,500 shuld be shwn in the Ttal Cst Clumn Acct. The $220 received as telephne reimbursement wuld be adjusted ut n Schedule A f the Cst Reprt as a nn-allwable cst. If yur accunting recrds reflect net csts in the expense accunts, nly the net cst wuld be entered n Schedule A and the amunt reimbursed wuld nt be shwn. Ttal depreciatin csts shuld be shwn in the Ttal Csts Clumn, and the unallwable prtins shuld be shwn in the Prgram Related Adjustments. Prviders wh are multiple prgram agencies shuld submit the cst apprtinment Schedule A prepared in accrdance with apprved methds and prcedures fr a fair presentatin f expenses attributable t assisted living services prvided. If yu have csts assciated with prgrams ther than assisted living that can be charged directly t thse prgrams thse csts shuld be shwn in bth the Ttal Cst clumn and the Other Prgrams Csts clumn, n Schedule A. Csts that can be fairly allcated t different prgrams, by use f square ftage, time studies, r ther apprved methds shuld be allcated n the cst reprt. A narrative must be attached shwing the allcatin methds used fr allcating csts t excluded prgrams. The accunt numbers fr expenditures are nt intended t be all-inclusive in detailing expenses f an agency. Hwever, there is flexibility available t prvide all required detailed infrmatin. The numbering system used in the chart f accunts is nt imprtant ther than t have a basis f identifying bject expenses in a manner that is unifrm fr reprting purpses. All expense infrmatin reprted in the ttal csts clumn shuld cme frm the facilities prfit and lss statement r trial balance and be classified int the expense accunts listed belw. Please attach a cpy f yur prfit and lss statement r trial balance and any supprt fr Nnallwable, Other Prgrams adjustments and administrative expense. July 23,

2 Ttal Cst Clumn: Cst reprted in this clumn are the agencies ttal csts and shuld be supprted by the agencies prfit and lss statement r trial balance. Nn-Allwable adjustment Clumn: Csts that are nn-allwable fr reimbursement shuld be reprted in the nn-allwable cst clumn. Examples f Nn-Allwable Cst fr Reimbursement include: Incme Tax Prmtinal and advertising expenses are nt allwed except fr recruiting f emplyees Travel and entertainment ther then fr prfessinal meetings and direct peratin and maintenance Dnatins Bad debts, charity, and curtesy allwances Prir year csts Csts f legal fees, accunting and cnsultant services r ther related csts incurred in cnnectin with hearings, arbitratin, r judicial prceedings pertaining t reimbursement rates. Hwever, such csts are allwable when an agency s request fr reimbursement rate adjustment cnstitutes a valid claim. Acquisitin cst, including legal fees, brkerage fees r cmmissins, accunting, administratin, travel, and feasibility studies. This applies whether the csts are incurred as the result f the purchase r lease f an agency. Any cst f a sublease that exceeds the csts f the lease between the wner and the first lessee f the current lease. Any penalty f fee assessed by a gvernment agency fr tardy reprting, nnpayment f any ther fee, r any ther fee which culd have been avided. Other Prgram Csts: Csts that can be fairly allcated t different prgrams, by using square ftage, time studies, r ther apprved methds shuld be allcated. If yu have csts assciated with prgrams ther than assisted living that can be charged directly t thse prgrams, then thse csts shuld be reprted in bth the Ttal Cst clumn, and Other Prgram clumn. A narrative must be attached shwing the allcatin methds used fr allcating indirect csts nt assciated with Assisted Living Care. Ttal Allcated Administrative Csts: This clumn is used identify Central Office and r Crprate administrative csts which are allcated t the Assisted Living facility. The csts shuld be allcated based n a sund statistical methd, which can be auditable. Sme allcatin methds include a basis f ttal number f bed days, ttal accumulated csts, and square ftages. Ttal Assisted Living Prgram Csts: This clumn is used t reprt ttal assisted living csts minus Nn-allwable and Other Prgram adjustments, plus Allcated Assisted Living Administrative cts. July 23,

3 2100 PERSONNEL SALARIES The 2100 series f accunts is fr recrding all salaries and wages earned by an agency s regular emplyees (full r part time) and temprary emplyees. Payments t persns emplyed n a fee fr services, such as lawyers and auditrs shuld nt be reprted here but under accunt Administrative, Clerical & Maintenance Staff Reprt the salaries f: Executive Directr Finance Directr Prgram Crdinatr Prgram Manager Branch Directr Office Manager Clerical Staff Maintenance Staff *Nte: Prgram Crdinatr/Branch Directr wuld be included in the administrative staff if that individual were ver several supervisrs/managers f different prgrams in a multi-purpse agency. Clerical Staff includes salaries f Secretary / Office Assistant / Bkkeeper / Billing Clerk. Maintenance Staff includes salaries f the Custdian / Maintenance Persn Direct Staff Reprt the salaries f: RN / LPN Direct Care Aides / Medicatin Aides Ck / Dietitian / Dietary Aide Activities Directr / Activities Assistant Husekeeping Supervisr / Janitr / Husekeeper Any ther prgram staff that may nt be listed abve and 2300 PERSONNEL BENEFITS AND TAXES The 2200 & 2300 series f accunts is fr the accumulatin paid and accrued by an agency under its wn r ther emplyee health and retirement benefits plans, including vluntary emplyee terminatin r retirement payments utside a frmal plan. This is nt t include emplyee cntributins r payments Health Benefit Plans Includes the cst f hspitalizatins and ther health insurance cverage fr agency staff Retirement Plans Includes the csts f the Retirement Annuity Plan r ther apprved private retirement plan is t be reprted under this accunt number Vacatin/Paid Persnal Leave July 23,

4 The cst f vacatin and paid persnal leave the agency prvides the emplyees Other Benefits The cst f any ther agency emplyee benefits, which cannt be reprted under accunts 2210 and 2220, are t be reprted here such as grup life insurance premiums, Lng Term Care Insurance, disability, AFLAC, etc FICA Recrd FICA tax expense f the agency in this accunt Unemplyment Insurance Recrd the State and Federal Unemplyment Insurance payable by emplyers under State and Federal law Wrker s Cmpensatin Insurance Wrkmen s Cmpensatin Insurance premiums payable by the emplyers PROFESSIONAL FEES AND CONTRACT SERVICES This accunt includes the accumulatin f fees and expenses f prfessinal practitiners and cnsultants wh are nt emplyees f the agency and are engaged as independent cntractrs fr specified services n a fee r ther individual cntract basis. Items included are: Auditing and Accunting Fees Fees paid fr auditing the agencies bks and fees paid fr bkkeeping r accunting services. Salaries fr regular bkkeeping services shuld be reprted in accunt 2120 if the bkkeeper is n the agency staff. Legal Services Fees paid t attrneys by the agency fr legal services fr the agency itself. Csts f ntices in legal publicatins. Maintenance/Prfessinal Services Fees paid by the agency t cntractrs fr services rendered t maintain the agency r ther csts f ther services purchased n a fee-fr-service basis. Other Prfessinal Fees and Cntract Fees Any ther fees paid by yur rganizatin that may nt have been listed abve. *Nte: Allwable Cst Allcatin Methds fr Prfessinal Fees and Cntract Services wuld include Time Studies, Accumulated Csts, Analysis f expenditures and Cntracts. July 23,

5 2600 SUPPLIES The cst f supplies culd include the fllwing items. Office Supplies Cnsumable ffice supplies used in carrying ut individual client prgrams. Medical Supplies Agency stck items used fr residents such as band-aids r ther dressing changes items, alchl swabs, etc. Dietary Supplies Fd Husekeeping Supplies Laundry Supplies. Maintenance Supplies Activities Supplies Other Supplies/Minr Equipment Purchases OCCUPANCY (BUILDINGS) The 3100 series f accunts shuld be allcated by a space utilizatin frmula if the prvider is a multiple prgram agency. Square ftage by prgram shuld be develped s a fair distributin f all ccupancy expense can be distributed Rent r Lease Space Enter all rent paid fr land, buildings, and ffice space used in the peratin f the agency. This wuld als include any allcated csts f space fr the agency Building Repairs/Maintenance Reprt the csts assciated with building repairs and maintenance fr yur agency. Any building repairs and/r maintenance that exceed $5,000 must be depreciated Utilities This includes the cst f any f the fllwing, unless the cst f ne r mre f them is included in the rent: Heating fuel Water Gas Electricity Waste remval Telephne including cell phne services FAX 3140 Building Depreciatin and Leasehld Imprvements Leasehld imprvements are t be depreciated fr the life f the lease. Buildings are t be depreciated at 3% fr masnry and 4% fr frame. N depreciatin is t be taken fr rental July 23,

6 prperty r land. The depreciatin n buildings shuld be prrated amng all applicable prgrams. *Nte: Allwable Cst Allcatin Methds fr Depreciatin f Fixed Assets wuld include Actual Square Ftage, Analysis f expenditures and Cntracts 3160 Prperty Insurance and Taxes Reprt the cst f prperty insurance, taxes, and fire insurance. D NOT include autmbile insurance Other Occupancy Expense (Buildings) Any ther ccupancy expense that cannt be reprted under the ther headings in the 3100 accunt classificatins. *Nte: Allwable Cst Allcatin Methds fr ccupancy expense (Building) wuld include Actual Square Ftage, Analysis f Expenditures and Cntracts, and r the Medicare Cst Reprt Step Dwn OTHER AGENCY EXPENSES 3240 Advertising Intended and limited t the cst f advertising fr staff recruitment. Any cst assciated with marketing and public relatins shuld be reprted in this clumn and then adjusted ut in the nnallwable, adjustment clumn n Schedule A f the cst reprt Dues, Membership, Subscriptins, and Educatinal Expenses. Intended fr the amunt paid fr bna-fide membership in ther rganizatins, subscriptins, reference, and resurce publicatins purchased fr use by the staff f the agency fr training and educatinal purpses Bad Debt Bad Debt shuld be reprted in the ttal cst clumn and adjusted ff in the Nn-Allwable adjustment clumn Prfessinal/General Liability Insurance Reprt the cst f prtectin against fraudulent, negligent, r dishnest acts by fficers r emplyees f yur rganizatin TRAVEL and TRANSPORTATION EXPENSES Include mileage payments t staff. Attach dcumentatin f mileage reimbursement rates yur agency has used t justify the expense. Rentals fr auts shuld be included here. Principal payments in the purchase f vehicles cannt be charged t this accunt r any ther accunt. Vehicles shuld be depreciated in accunt Other direct csts f repairing and maintaining agency cars, including gas, il, lubricatin, tires, license and insurance which are directly related t rendering services t the residents being served by the agency Other Miscellaneus Expense July 23,

7 If the ttal miscellaneus expense exceeds $1000, the agency must attach a breakdwn f expenses DEPRECIATION OF FIXED ASSETS The acceptable methd f recrding depreciatin is the use f the straight-line methd fllwing the American Hspitalizatin Assciatin (AHA) guidelines. This accunt may by utilize t writeff fixed assets ver respective useful lives. The amunt entered fr depreciatin n equipment and furniture must be identifiable in the accunting recrds f the facility and acceptable fr certificatin Depreciatin f Agency Vehicles Any vehicle purchases that exceed $5,000 must be reprted here Depreciatin f Office Equipment Any ffice equipment purchases that exceed $5,000 must be depreciated and reprted here. SCHEDULE B On schedule B f the financial and statistical reprt, assisted living prviders are expected t list all revenue by type and amunt. This includes, but nt limited t, Department f Scial Services, State Disregard, waiver, and State pay, private pay, lng-term care insurance, and ther payer resurces. The ttal revenue fr each categry is bases n the trial balance r prfit/lss statement. SCHEDULE C Schedule C is used t reprt infrmatin regarding salary and turnver infrmatin. A breakdwn f psitin r jb title, the emplyee name, start date, end date, hurly / salary (at the end f the cst reprting year, the amunt f bnus, the ttal wages paid, and the number f hurs wrked. Ttal wages and bnuses must tie t the payrll recrds, the Prfit/Lss Statement r Trial Balance, and Schedule A f the cst reprt. SCHEDULE D Schedule D f the cst reprt captures infrmatin abut the number f residents served in the agency and the payer surce. Fr the Private Pay Resident reprt the ttal number f private pay days in the Ttal Paid Days clumn.. Fr the Waiver Assisted Living reprt ttal days in agency in the Ttal Days in Agency clumn fr each mnth. Reprt ttal hspital days in the Days in Hspital clumn fr each mnth. Reprt the days the resident is in the hspital fr mre than (5) cnsecutive days in the Days in Excess f 5 Hspital Days clumn fr each mnth. Reprt the ttal number f days the resident is ut n leave in the Leave clumn. Reprt the ttal number f days the resident is ut n leave fr mre than (5) cnsecutive days in the Leave in Excess f 5 Days clumn fr each mnth. An example: A resident is in the Agency fr the first twenty days f the mnth and then ges t the hspital fr seven cnsecutive days, and then returns t the facility fr the rest f the mnth. If the mnth had thirty-ne days then the agency wuld reprt twenty-fur days physically present, seven Hspital Days, and tw excess days. July 23,

8 Fr State Pay Assisted Living the Agency reprt the ttal days in the agency in the Days in Agency clumn fr each mnth. Reprt the ttal days the resident is in the hspital in the Days in Hspital clumn fr each mnth. Reprt the ttal days the resident is ut n leave in the Days ut n Leave clumn. SCHEDULE E Schedule E f the cst reprt requires assisted living prviders t reprt infrmatin abut the types and number f days the Agency prvided special services in key areas. The areas f special services include Medicatin Administratin, Supplemental Oxygen, Self Preservatin, and Therapeutic Diet. Fr Medicatin Administratin days, the assisted living center must emply r cntract with a licensed nurse wh reviews and dcuments residents cnditins at lest weekly. A registered nurse r registered pharmacist shall prvide medicatin administratin training pursuant t 20:48:04:01 t unlicensed assistive persnnel emplyed by a facility wh will be administering medicatins. Licensed practical nurses wh review resident care and cnditin must be in cmpliance with requirements fr supervisin pursuant t SDCL Fr Supplemental Oxygen days, the assisted living center must have their staff trained regarding xygen safety, prper administratin f xygen, and must practice safe xygen handling prcedures. Fr Self Preservatin days, the assisted living center must meet MFPA 101 Life Safety Cde, 2000 editin, health care ccupancy standards in Chapter 18 and 19 r equip the facility with autmatic sprinkler prtectin. Fr Therapeutic Diet days, the resident must have a physician s rder fr it. The assisted living center must emply r cntract with a dietitian. The dietitian shall apprve written menus and diet extensins, assess the resident s nutritinal status and dietary needs, plan individual diets, and prvide guidance t dietary staff in areas f preparatin, service, and mnitring the resident s acceptance f the diet. The frequency f dietitian visits shall be at least quarterly r sner as determined by the resident s dietary need and the facility s ability t implement the diet crrectly. ATTESTATION PAGE The Attestatins page must be cmpleted and signed by the agency directr. Please return riginals nly. July 23,