REPORT ON THE RATE SETTING AUDIT SANTA MONICA … filench/Audits Sec Suite 280, MS 6-4757 FAX: ess:...
26
REPORT ON THE RATE SETTING AUDIT SANTA MONICA CONVALESCENT CENTER (UNIT II) SANTA MONICA, CALIFORNIA NATIONAL PROVIDER IDENTIFIER: 1578649810 FISCAL PERIOD ENDED DECEMBER 31, 2011 Audits Section—Gardena Financial Audits Branch Audits and Investigations Department of Health Care Services Section Chief: Maria Delgado Audit Supervisor: Deborah Lee Auditor: Gary Chan
Transcript of REPORT ON THE RATE SETTING AUDIT SANTA MONICA … filench/Audits Sec Suite 280, MS 6-4757 FAX: ess:...
REPORT ON THE
RATE SETTING AUDIT
SANTA MONICA CONVALESCENT CENTER (UNIT II) SANTA MONICA, CALIFORNIA
NATIONAL PROVIDER IDENTIFIER: 1578649810
FISCAL PERIOD ENDED DECEMBER 31, 2011
Audits Section—Gardena Financial Audits Branch
Audits and Investigations Department of Health Care Services
Section Chief: Maria Delgado Audit Supervisor: Deborah Lee Auditor: Gary Chan
TO
OBY DOUGLAS DIRECTOR
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If you disagree with the decision of the Department, you may appeal by writing to: Chief Department of Health Care Services Office of Administrative Hearings and Appeals 1029 J Street, Suite 200 Sacramento, CA 95814 (916) 322-5603 The written notice of disagreement must be received by the Department within 60 calendar days from the day you receive this letter. A copy of this notice should be sent to: United States Postal Service (USPS) Courier (UPS, FedEx, etc.) Assistant Chief Counsel Assistant Chief Counsel Department of Health Care Services Department of Health Care Services Office of Legal Services Office of Legal Services MS 0010 MS 0010 PO Box 997413 1501 Capitol Avenue, Suite 71.5001 Sacramento, CA 95899 Sacramento, CA 95814 (916) 440-7700 The procedures that govern an appeal are contained in Welfare and Institutions Code, Section 14171, and California Code of Regulations, Title 22, Section 51016, et seq. If you have questions regarding this report, you may call the Audits Section—Gardena at (310) 516-4757. Original Signed By: Maria Delgado, Chief Audits Section—Gardena Financial Audits Branch Certified Enclosures
STATE OF CALIFORNIA SCHEDULE 1
Provider Name: Fiscal Period:SANTA MONICA CONVALESCENT CENTER (UNIT II) JANUARY 1, 2011 THROUGH DECEMBER 31, 2011
Provider NPI: OSHPD Facility No.:1578649810 206190689
LineNo.
SKILLED NURSING CARE1 Cost of Direct Care - Labor (Sch. 2, Ln. 105) $ N/A $ 996,959 $ 69.632 Cost of Indirect Care - Labor (Sch. 3, Ln. 105) $ N/A $ 243,670 $ 17.023 Cost of Direct and Indirect Nonlabor - Other (Sch. 4, Ln. 105) $ N/A $ 273,592 $ 19.114 Cost of Capital Related (Sch. 5, Ln. 105) $ N/A $ 223,741 $ 15.635 Property Taxes (Sch. 5, Ln. 105) $ N/A $ 5,507 $ 0.386 CDPH Licensing Fees (Sch. 6, Ln. 105) $ N/A $ 9,865 $ 0.697 Professional Liability Insurance (Sch. 6, Ln. 105) $ N/A $ 28,358 $ 1.988 Caregiver Training (Sch. 6, Ln. 105) $ N/A $ 0 $ 0.009 Quality Assurance Fees (Sch. 6, Ln. 105) $ N/A $ 171,134 $ 11.9510 Cost of Administration (Sch. 6, Ln. 105) $ N/A $ 195,142 $ 13.6311 Cost of Routine Service/Audited Total Costs $ 2,105,797.00 $ 2,147,969 $ 150.0312 Total Patient Days (Adj ) 14,317 14,31713 Cost Per Patient Day (Cost Divided by Days) $ 147.08 $ 150.03 14 Overpayments (Adj ) $ $ 015 Medi-Cal Days (Adj 7) 10,590 10,73116 Medi-Cal Managed Care Days (Adj ) 0
INTERMEDIATE CARE17 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 018 Total Patient Days (Adj ) 019 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0020 Overpayments (Adj ) $ $ 0
MENTALLY DISORDERED CARE21 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 022 Total Patient Days (Adj ) 023 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0024 Overpayments (Adj ) $ $ 0
DEVELOPMENTALLY DISABLED CARE25 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 026 Total Patient Days (Adj ) 027 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0028 Overpayments (Adj ) $ $ 0
SUBACUTE CARE29 Cost of Direct Care - Labor (Subacute Care Sch. 1, Ln. 25) $ N/A $ 0 $ 0.0030 Cost of Indirect Care - Labor (Subacute Care Sch. 1, Ln. 26) $ N/A $ 0 $ 0.0031 Cost of Direct and Indirect Nonlabor - Other (Subacute Care Sch. 1, Ln. 27) $ N/A $ 0 $ 0.0032 Cost of Capital Related (Subacute Care Sch. 1, Ln. 28) $ N/A $ 0 $ 0.0033 Property Taxes (Subacute Care Sch. 1, Ln. 29) $ N/A $ 0 $ 0.0034 CDPH Licensing Fees (Subacute Care Sch. 1, Ln. 30) $ N/A $ 0 $ 0.0035 Professional Liability Insurance (Subacute Care Sch. 1, Ln. 31) $ N/A $ 0 $ 0.0036 Quality Assurance Fees (Subacute Care Sch. 1, Ln. 32) $ N/A $ 0 $ 0.0037 Caregiver Training (Subacute Care Sch. 1, Ln. 33) $ N/A $ 0 $ 0.0038 Cost of Administration (Subacute Care Sch.1, Ln. 34) $ N/A $ 0 $ 0.0039 Total Cost of Subacute Service (Subacute Care Sch. 1, Ln. 35) $ 0 $ 0 $ 0.0040 Total Patient Days (Subacute Care Sch. 1, Ln. 36) 0 041 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0042 Amount Due Provider (State) (Subacute Care Sch. 1, Ln. 40) $ 0 $ 0
AS REPORTED AS AUDITED PATIENT DAY
SUMMARY OF AUDITED FACILITY COSTS / COST PER PATIENT DAY
COST PERAUDITED
PROGRAM DESCRIPTION
STATE OF CALIFORNIA SCHEDULE 1
Provider Name: Fiscal Period:SANTA MONICA CONVALESCENT CENTER (UNIT II) JANUARY 1, 2011 THROUGH DECEMBER 31, 2011
Provider NPI: OSHPD Facility No.:1578649810 206190689
LineNo. AS REPORTED AS AUDITED PATIENT DAY
SUMMARY OF AUDITED FACILITY COSTS / COST PER PATIENT DAY
COST PERAUDITED
PROGRAM DESCRIPTION
SUBACUTE CARE - PEDIATRIC43 Cost of Routine Service (Subacute Care - Pediatric, Sch. 1, Ln 3) $ 0 $ 044 Cost of Ancillary Service (Subacute Care - Pediatric, Sch. 1, Ln. 1 + Ln. 2) $ 0 $ 045 Total Cost of Subacute Care - Pediatric Service (Ln. 43 + Ln. 44) $ 0 $ 046 Total Patient Days (Subacute Care - Pediatric, Sch. 1, Ln. 5) 0 047 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0048 Amount Due Provider (State) (Subacute Care - Pediatric, Sch. 1, Ln. 9) $ 0 $ 0
TRANSITIONAL INPATIENT CARE49 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 050 Total Patient Days (Adj ) 051 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0052 Overpayments (Adj ) $ $ 0
HOSPICE INPATIENT CARE53 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 054 Total Patient Days (Adj ) 055 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0056 Overpayments (Adj ) $ $ 0
OTHER ROUTINE SERVICES57 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 058 Total Patient Days (Adj ) 059 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.0060 Overpayments (Adj ) $ $ 0
STATE OF CALIFORNIA SCHEDULE 2
Provider Name: Fiscal Period:SANTA MONICA CONVALESCENT CENTER (UNIT II) JANUARY 1, 2011 THROUGH DECEMBER 31, 2011
Provider NPI: OSHPD Facility No.:1578649810 206190689
Soc Srvs ActivitiesNet Exp For
Line DESCRIPTION Cost AllocNo. (From Sch 8) 155 160 Total
GENERAL SERVICES005 Plant Operations and Maintenance010 Housekeeping060 Laundry and Linen065 Dietary155 Social Services 14,174$ 14,174$ 160 Activities 49,671 49,671$ 165 Administration166 Medical Records170 Inservice Education - Nursing
ANCILLARY SERVICES075 Patient Supplies 0 0 0 0077 Specialized Support Surfaces N/A 0 0 0080 Physical Therapy 0 0 0 0081 Respiratory Therapy 0 0 0 0082 Occupational Therapy 0 0 0 0083 Speech Pathology 0 0 0 0085 Pharmacy 0 0 0 0090 Laboratory 0 0 0 0095 Home Health Services 0 0 0 0100 Other Ancillary Services 0 0 0 0101 Subacute Care Ancillary Services 0 0 0 0102 Subacute Care - Pediatric Ancillary Services 0 0 0 0
ROUTINE SERVICES105 Skilled Nursing Care 933,114 14,174 49,671 996,959 *110 Intermediate Care 0 0 0 0 *115 Mentally Disordered Care 0 0 0 0 *120 Developmentally Disabled Care 0 0 0 0 *125 Subacute Care 0 0 0 0 *126 Subacute Care - Pediatric 0 0 0 0 *128 Transitional Inpatient Care 0 0 0 0 *130 Hospice Inpatient Care 0 0 0 0 *135 Other Routine Services 0 0 0 0 *
NONREIMBURSABLE 139 Residential Care 0 0 0 0140 Beauty and Barber 0 0 0 0145 Other Nonreimbursable 0 0 0 0
TOTAL 996,959$ 14,174$ 49,671$ 996,959$ * (To Schedule 1)
ALLOCATION OF GENERAL SERVICES DIRECT CARE LABOR
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STATE OF CALIFORNIA SCHEDULE 5
ALLOCATION OF CAPITAL COSTS
Provider Name: Fiscal Period:SANTA MONICA CONVALESCENT CENTER (UNIT II) JANUARY 1, 2011 THROUGH DECEMBER 31, 2011
Provider NPI: OSHPD Facility Number:1578649810 206190689
Capital Plant Ops Hskpng Laundry Dietary Soc Srvs ActivitiesNet Exp For
Line DESCRIPTION Cost AllocNo. (From Sch 8) Ratio Various 5 10 60 65 155 160
GENERAL SERVICESCapital Related (excluding lines 40 & 45) 234,088$ 98%Property Tax (line 40) 5,762 2% 239,850$
005 Plant Operations and Maintenance 8,078 8,078$ 010 Housekeeping 1,977 69 2,046$ 060 Laundry and Linen 3,276 114 29 3,420$ 065 Dietary 46,829 1,632 417 0 48,878$ 155 Social Services 0 0 0 0 0 -$ 160 Activities 1,440 50 13 0 0 0 1,503$ 165 Administration 28,216 983 251 0 0 0 0166 Medical Records 1,610 56 14 0 0 0 0170 Inservice Education - Nursing 0 0 0 0 0 0 0
ANCILLARY SERVICES075 Patient Supplies 3,050 106 27 0 0 0 0077 Specialized Support Surfaces 0 0 0 0 0 0 0080 Physical Therapy 0 0 0 0 0 0 0081 Respiratory Therapy 0 0 0 0 0 0 0082 Occupational Therapy 0 0 0 0 0 0 0083 Speech Pathology 0 0 0 0 0 0 0085 Pharmacy 0 0 0 0 0 0 0090 Laboratory 0 0 0 0 0 0 0095 Home Health Services 0 0 0 0 0 0 0100 Other Ancillary Services 0 0 0 0 0 0 0101 Subacute Care Ancillary Services 0 0 0 0 0 0 0102 Subacute Care - Pediatric Ancillary Services 0 0 0 0 0 0 0
ROUTINE SERVICES105 Skilled Nursing Care 141,617 4,936 1,261 3,420 48,878 0 1,503110 Intermediate Care 0 0 0 0 0 0 0115 Mentally Disordered Care 0 0 0 0 0 0 0120 Developmentally Disabled Care 0 0 0 0 0 0 0125 Subacute Care 0 0 0 0 0 0 0126 Subacute Care - Pediatric 0 0 0 0 0 0 0128 Transitional Inpatient Care 0 0 0 0 0 0 0130 Hospice Inpatient Care 0 0 0 0 0 0 0135 Other Routine Services 0 0 0 0 0 0 0
NONREIMBURSABLE 139 Residential Care 0 0 0 0 0 0 0140 Beauty and Barber 3,756 131 33 0 0 0 0145 Other Nonreimbursable 0 0 0 0 0 0 0
TOTAL 239,850$ 100% 239,850$ 8,078$ 2,046$ 3,420$ 48,878$ -$ 1,503$ * (To Schedule 1)
STATE OF CALIFORNIA
Provider Name:SANTA MONICA CONVALESCENT CENTER (UNIT II)
Provider NPI:1578649810
Net Exp ForLine DESCRIPTION Cost AllocNo. (From Sch 8) Ratio
GENERAL SERVICESCapital Related (excluding lines 40 & 45) 234,088$ 98%Property Tax (line 40) 5,762 2%
005 Plant Operations and Maintenance010 Housekeeping060 Laundry and Linen065 Dietary155 Social Services160 Activities165 Administration166 Medical Records170 Inservice Education - Nursing
ANCILLARY SERVICES075 Patient Supplies077 Specialized Support Surfaces080 Physical Therapy081 Respiratory Therapy082 Occupational Therapy083 Speech Pathology085 Pharmacy090 Laboratory095 Home Health Services100 Other Ancillary Services101 Subacute Care Ancillary Services102 Subacute Care - Pediatric Ancillary Services
ROUTINE SERVICES105 Skilled Nursing Care110 Intermediate Care115 Mentally Disordered Care120 Developmentally Disabled Care125 Subacute Care126 Subacute Care - Pediatric128 Transitional Inpatient Care130 Hospice Inpatient Care135 Other Routine Services
NONREIMBURSABLE 139 Residential Care140 Beauty and Barber145 Other Nonreimbursable
TOTAL 239,850$ 100%* (To Schedule 1)
SCHEDULE 5
ALLOCATION OF CAPITAL COSTS
Fiscal Period:JANUARY 1, 2011 THROUGH DECEMBER 31, 2011
OSHPD Facility Number:206190689
Inserv. Ed Admin Medical Capital PropertyRecords Related Tax
Accumulated 98% 2%170 Costs 165 166 Total Of Total Of Total
29,451$ 29,451$ 1,680 1,680$
-$
0 3,184 176 10 3,370$ 3,289$ 81$ 0 0 0 0 0 0 00 0 1,918 109 2,027 1,979 490 0 0 0 0 0 00 0 45 3 47 46 10 0 302 17 319 311 80 0 656 37 693 676 170 0 0 0 0 0 00 0 0 0 0 0 00 0 105 6 111 108 30 0 0 0 0 0 00 0 0 0 0 0 0
0 201,614 26,142 1,492 229,248 223,741 5,507 *0 0 0 0 0 0 0 *0 0 0 0 0 0 0 *0 0 0 0 0 0 0 *0 0 0 0 0 0 0 *0 0 0 0 0 0 0 *0 0 0 0 0 0 0 *0 0 0 0 0 0 0 *0 0 0 0 0 0 0 *
0 0 0 0 0 0 00 3,921 108 6 4,035 3,938 970 0 0 0 0 0 0
-$ 208,719$ 29,451$ 1,680$ 239,850$ 234,088$ 5,762$
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(U
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STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:SANTA MONICA CONVALESCENT CENTER (UNIT II) JANUARY 1, 2011 THROUGH DECEMBER 31, 2011
Provider NPI: OSHPD Facility Number:1578649810 206190689
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER005 Plant Operations and Maintenance005 .01-.19 Salaries and Wages 6200 $ $ 0 $ 0 (Sch 3)005 .20-.39 Fringe Benefits 6200 0 0 (Sch 3)005 .79 Agency Staff 6200 0 0 (Sch 3)005 .40-.99 Other - Nonlabor 6200 90,272 (1,153) 89,119 (Sch 4)005 Plant Operations and Maintenance - Total 6200 $ 90,272 $ (1,153) $ 89,119
010 Housekeeping010 .01-.19 Salaries and Wages 6300 $ 64,511 $ 0 $ 64,511 (Sch 3)010 .20-.39 Fringe Benefits 6300 17,647 0 17,647 (Sch 3)010 .79 Agency Staff 6300 0 0 (Sch 3)010 .40-.99 Other - Nonlabor 6300 10,686 0 10,686 (Sch 4)010 Housekeeping - Total 6300 $ 92,844 $ 0 $ 92,844
015 Depreciation: Buildings and Improvements 7110 - 7120 $ $ 0 $ 0 (Sch 5)020 Depreciation: Leasehold Improvements 7130 9,241 0 9,241 (Sch 5)025 Depreciation: Equipment 7140 1,308 1,308 (Sch 5)030 Depreciation and Amortization - Other 7150 - 7160 0 0 (Sch 5)035 Leases and Rentals 7200 225,346 (1,807) 223,539 (Sch 5)040 Property Taxes 7300 5,762 0 5,762 (Sch 5)045 Property Insurance 7400 20,886 0 20,886 (Sch 6)050 Interest - Property, Plant, and Equipment 7500 0 0 (Sch 5)055 Interest - Other 7600 $ 3,374 $ 0 $ 3,374 (Sch 6)
057 Subtotal 005 - 055 $ 447,725 $ (1,652) $ 446,073
060 Laundry and Linen060 .01-.19 Salaries and Wages 6400 $ $ 0 $ 0 (Sch 3)060 .20-.39 Fringe Benefits 6400 0 0 (Sch 3)060 .79 Agency Staff 6400 0 0 (Sch 3)060 .40-.99 Other - Nonlabor 6400 7,927 (2,028) 5,899 (Sch 4)060 Laundry and Linen - Total 6400 $ 7,927 $ (2,028) $ 5,899
065 Dietary065 .01-.19 Salaries and Wages 6500 $ 89,562 $ 0 $ 89,562 (Sch 3)065 .20-.39 Fringe Benefits 6500 26,119 0 26,119 (Sch 3)065 .79 Agency Staff 6500 0 0 (Sch 3)065 .40-.99 Other - Nonlabor 6500 94,062 0 94,062 (Sch 4)065 Dietary - Total 6500 $ 209,743 $ 0 $ 209,743
070 Provision for Bad Debts 7700 $ 0 $ 0
Ancillary Services 075 Patient Supplies075 .01-.19 Salaries and Wages 8100 $ $ 0 $ 0 (Sch 2)075 .20-.39 Fringe Benefits 8100 0 0 (Sch 2)075 .79 Agency Staff 8100 0 0 (Sch 2)075 .40-.99 Other - Nonlabor 8100 41,656 0 41,656 (Sch 4)075 Patient Supplies - Total 8100 $ 41,656 $ 0 $ 41,656
077 Specialized Support Surfaces077 .01-.19 Salaries and Wages 8150 $ $ 0 $ 0 N/A077 .20-.39 Fringe Benefits 8150 0 0 N/A077 .79 Agency Staff 8150 0 0 N/A077 .40-.99 Other - Nonlabor 8150 0 0 (Sch 4)077 Specialized Support Surfaces - Total 8150 $ 0 $ 0 $ 0
REPORTEDAS AS
AUDITEDADJUSTMENTS
8A-1
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:SANTA MONICA CONVALESCENT CENTER (UNIT II) JANUARY 1, 2011 THROUGH DECEMBER 31, 2011
Provider NPI: OSHPD Facility Number:1578649810 206190689
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER REPORTED
AS ASAUDITED
ADJUSTMENTS8A-1
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
080 Physical Therapy080 .01-.19 Salaries and Wages 8200 $ $ 0 $ 0080 .20-.39 Fringe Benefits 8200 0 0080 .79 Agency Staff 8200 0 0080 .40-.99 Other - Nonlabor 8200 122,704 0 122,704080 Physical Therapy - Total 8200 $ 122,704 $ 0 $ 122,704
081 Respiratory Therapy081 .01-.19 Salaries and Wages 8220 $ $ 0 $ 0081 .20-.39 Fringe Benefits 8220 0 0081 .79 Agency Staff 8220 0 0081 .40-.99 Other - Nonlabor 8220 0 0081 Respiratory Therapy - Total 8220 $ 0 $ 0 $ 0
082 Occupational Therapy082 .01-.19 Salaries and Wages 8250 $ $ 0 $ 0082 .20-.39 Fringe Benefits 8250 0 0082 .79 Agency Staff 8250 0 0082 .40-.99 Other - Nonlabor 8250 2,870 0 2,870082 Occupational Therapy - Total 8250 $ 2,870 $ 0 $ 2,870
083 Speech Pathology083 .01-.19 Salaries and Wages 8280 $ $ 0 $ 0083 .20-.39 Fringe Benefits 8280 0 0083 .79 Agency Staff 8280 0 0083 .40-.99 Other - Nonlabor 8280 19,306 0 19,306083 Speech Pathology - Total 8280 $ 19,306 $ 0 $ 19,306
085 Pharmacy085 .01-.19 Salaries and Wages 8300 $ $ 0 $ 0085 .20-.39 Fringe Benefits 8300 0 0085 .79 Agency Staff 8300 0 0085 .40-.99 Other - Nonlabor 8300 41,949 0 41,949085 Pharmacy - Total 8300 $ 41,949 $ 0 $ 41,949
090 Laboratory090 .01-.19 Salaries and Wages 8400 $ $ 0 $ 0090 .20-.39 Fringe Benefits 8400 0 0090 .79 Agency Staff 8400 0 0090 .40-.99 Other - Nonlabor 8400 0 0090 Laboratory - Total 8400 $ 0 $ 0 $ 0
095 Home Health Services095 .01-.19 Salaries and Wages 8800 $ $ 0 $ 0095 .20-.39 Fringe Benefits 8800 0 0095 .79 Agency Staff 8800 0 0095 .40-.99 Other - Nonlabor 8800 0 0095 Home Health Services - Total 8800 $ 0 $ 0 $ 0
100 Other Ancillary Services100 .01-.19 Salaries and Wages 8900 $ $ 0 $ 0100 .20-.39 Fringe Benefits 8900 0 0100 .79 Agency Staff 8900 0 0100 .40-.99 Other - Nonlabor 8900 6,700 0 6,700100 Other Ancillary Services - Total 8900 $ 6,700 $ 0 $ 6,700
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:SANTA MONICA CONVALESCENT CENTER (UNIT II) JANUARY 1, 2011 THROUGH DECEMBER 31, 2011
Provider NPI: OSHPD Facility Number:1578649810 206190689
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER REPORTED
AS ASAUDITED
ADJUSTMENTS8A-1
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
101 Subacute Care Ancillary Services101 .01-.19 Salaries and Wages 8100-8900 $ $ 0 $ 0 (Sch 2)101 .20-.39 Fringe Benefits 8100-8900 0 0 (Sch 2)101 .79 Agency Staff 8100-8900 0 0 (Sch 2)101 .40-.99 Other - Nonlabor 8100-8900 0 0 (Sch 4)101 Subacute Care Ancillary Services - Total 8100-8900 $ 0 $ 0 $ 0
102 Subacute Care - Pediatric Ancillary Services102 .01-.19 Salaries and Wages 8100-8900 $ $ 0 $ 0 (Sch 2)102 .20-.39 Fringe Benefits 8100-8900 0 0 (Sch 2)102 .79 Agency Staff 8100-8900 0 0 (Sch 2)102 .40-.99 Other - Nonlabor 8100-8900 0 0 (Sch 4)102 Subacute Care - Pediatric Ancillary Services - Total 8100-8900 $ 0 $ 0 $ 0
104 Subtotal 075 - 102 $ 235,185 $ 0 $ 235,185
Routine Services105 Skilled Nursing Care105 .01-.19 Salaries and Wages 6110 $ 725,304 $ 0 $ 725,304 (Sch 2)105 .20-.39 Fringe Benefits 6110 201,445 6,365 207,810 (Sch 2)105 .49 Agency Staff 6110 0 0 (Sch 2)105 .40-.99 Other - Nonlabor 6110 35,230 0 35,230 (Sch 4)105 Skilled Nursing Care - Total 6110 $ 961,979 $ 6,365 $ 968,344
110 Intermediate Care110 .01-.19 Salaries and Wages 6120 $ $ 0 $ 0110 .20-.39 Fringe Benefits 6120 0 0110 .49 Agency Staff 6120 0 0110 .40-.99 Other - Nonlabor 6120 0 0110 Intermediate Care - Total 6120 $ 0 $ 0 $ 0 (Sch 2)
115 Mentally Disordered Care115 .01-.19 Salaries and Wages 6130 $ $ 0 $ 0115 .20-.39 Fringe Benefits 6130 0 0115 .49 Agency Staff 6130 0 0115 .40-.99 Other - Nonlabor 6130 0 0115 Mentally Disordered Care - Total 6130 $ 0 $ 0 $ 0 (Sch 2)
120 Developmentally Disabled Care120 .01-.19 Salaries and Wages 6140 $ $ 0 $ 0120 .20-.39 Fringe Benefits 6140 0 0120 .49 Agency Staff 6140 0 0120 .40-.99 Other - Nonlabor 6140 0 0120 Developmentally Disabled Care - Total 6140 $ 0 $ 0 $ 0 (Sch 2)
125 Subacute Care125 .01-.19 Salaries and Wages 6150 $ $ 0 $ 0 (Sch 2)125 .20-.39 Fringe Benefits 6150 0 0 (Sch 2)125 .49 Agency Staff 6150 0 0 (Sch 2)125 .40-.99 Other - Nonlabor 6150 0 0 (Sch 4)125 Subacute Care - Total 6150 $ 0 $ 0 $ 0
126 Subacute Care - Pediatric126 .01-.19 Salaries and Wages 6160 $ $ 0 $ 0 (Sch 2)126 .20-.39 Fringe Benefits 6160 0 0 (Sch 2)126 .49 Agency Staff 6160 0 0 (Sch 2)126 .40-.99 Other - Nonlabor 6160 0 0 (Sch 4)126 Subacute Care - Pediatric - Total 6160 $ 0 $ 0 $ 0
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:SANTA MONICA CONVALESCENT CENTER (UNIT II) JANUARY 1, 2011 THROUGH DECEMBER 31, 2011
Provider NPI: OSHPD Facility Number:1578649810 206190689
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER REPORTED
AS ASAUDITED
ADJUSTMENTS8A-1
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
128 Transitional Inpatient Care128 .01-.19 Salaries and Wages 6170 $ $ 0 $ 0128 .20-.39 Fringe Benefits 6170 0 0128 .49 Agency Staff 6170 0 0128 .40-.99 Other - Nonlabor 6170 0 0128 Transitional Inpatient Care - Total 6170 $ 0 $ 0 $ 0 (Sch 2)
130 Hospice Inpatient Care130 .01-.19 Salaries and Wages 6180 $ $ 0 $ 0130 .20-.39 Fringe Benefits 6180 0 0130 .49 Agency Staff 6180 0 0130 .40-.99 Other - Nonlabor 6180 0 0130 Hospice Inpatient Care - Total 6180 $ 0 $ 0 $ 0 (Sch 2)
135 Other Routine Services135 .01-.19 Salaries and Wages 6190 $ $ 0 $ 0135 .20-.39 Fringe Benefits 6190 0 0135 .49 Agency Staff 6190 0 0135 .40-.99 Other - Nonlabor 6190 0 0135 Other Routine Services - Total 6190 $ 0 $ 0 $ 0 (Sch 2)
Other Nonreimbursable139 Residential Care139 .01-.19 Salaries and Wages 9100 $ $ 0 $ 0 (Sch 2)139 .20-.39 Fringe Benefits 9100 0 0 (Sch 2)139 .49 Agency Staff 9100 0 0 (Sch 2)139 .40-.99 Other - Nonlabor 9100 0 0 (Sch 4)139 Residential Care - Total 9100 $ 0 $ 0 $ 0
140 Beauty and Barber140 .01-.19 Salaries and Wages 8900 $ $ 0 $ 0 (Sch 2)140 .20-.39 Fringe Benefits 8900 0 0 (Sch 2)140 .49 Agency Staff 8900 0 0 (Sch 2)140 .40-.99 Other - Nonlabor 8900 0 0 (Sch 4)140 Beauty and Barber - Total 8900 $ 0 $ 0 $ 0
145 Other Nonreimbursable145 .01-.19 Salaries and Wages 9100 $ $ 0 $ 0 (Sch 2)145 .20-.39 Fringe Benefits 9100 0 0 (Sch 2)145 .49 Agency Staff 9100 0 0 (Sch 2)145 .40-.99 Other - Nonlabor 9100 0 0 (Sch 4)145 Other Nonreimbursable - Total 9100 $ 0 $ 0 $ 0
146 Subtotal 105 - 145 $ 961,979 $ 6,365 $ 968,344
155 Social Services155 .01-.19 Salaries and Wages 6600 $ 10,535 $ 0 $ 10,535 (Sch 2)155 .20-.39 Fringe Benefits 6600 3,639 0 3,639 (Sch 2)155 .49 Agency Staff 6600 0 0 (Sch 2)155 .40-.99 Other - Nonlabor 6600 1,425 0 1,425 (Sch 4)155 Social Services - Total 6600 $ 15,599 $ 0 $ 15,599
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:SANTA MONICA CONVALESCENT CENTER (UNIT II) JANUARY 1, 2011 THROUGH DECEMBER 31, 2011
Provider NPI: OSHPD Facility Number:1578649810 206190689
Line Natural ACCOUNTNo. Class ACCOUNT TITLE NUMBER
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT
REPORTEDAS AS
AUDITEDADJUSTMENTS
8A-1160 Activities160 .01-.19 Salaries and Wages 6700 $ 38,394 $ 0 $ 38,394 (Sch 2)160 .20-.39 Fringe Benefits 6700 11,277 0 11,277 (Sch 2)160 .49 Agency Staff 6700 0 0 (Sch 2)160 .40-.99 Other - Nonlabor 6700 3,148 0 3,148 (Sch 4)160 Activities - Total 6700 $ 52,819 $ 0 $ 52,819
165 Administration165 .01-.19 Salaries and Wages 6900 $ 94,288 $ 0 $ 94,288 (Sch 6)165 .20-.39 Fringe Benefits 6900 26,753 0 26,753 (Sch 6)165 .49 Agency Staff 6900 0 0 (Sch 6)165 .40-.99 Other - Nonlabor 6900 68,738 5,801 74,539 (Sch 6)165 Administration - Total 6900 $ 189,779 $ 5,801 $ 195,580
166 Medical Records166 .01-.19 Salaries and Wages 6900 $ 17,460 $ 0 $ 17,460 (Sch 3)166 .20-.39 Fringe Benefits 6900 4,954 0 4,954 (Sch 3)166 .49 Agency Staff 6900 0 0 (Sch 3)166 .40-.99 Other - Nonlabor 6900 2,743 0 2,743 (Sch 4)166 Medical Records - Total 6900 $ 25,157 $ 0 $ 25,157
167 CDPH Licensing Fees 6900 $ 13,074 $ (1,960) $ 11,114 (Sch 6)168 Professional Liability Insurance 6900 $ 32,282 $ (335) $ 31,947 (Sch 6)169 Quality Assurance Fees 6900 $ 192,793 $ 0 $ 192,793 (Sch 6)
170 Inservice Education - Nursing170 .01-.19 Salaries and Wages 6800 $ 27,666 $ 0 $ 27,666 (Sch 3)170 .20-.39 Fringe Benefits 6800 8,267 (6,366) 1,901 (Sch 3)170 .49 Agency Staff 6800 0 0 (Sch 3)170 .40-.99 Other - Nonlabor 6800 0 0 (Sch 4)170 Inservice Education - Nursing - Total 6800 $ 35,933 $ (6,366) $ 29,567
174 Caregiver Training 174 .01-.19 Salaries and Wages 6900 $ $ 0 $ 0 (Sch 6)174 .20-.39 Fringe Benefits 6900 0 0 (Sch 6)174 .49 Agency Staff 6900 0 0 (Sch 6)174 .40-.99 Other - Nonlabor 6900 0 0 (Sch 6)174 Caregiver Training - Total 6900 $ 0 $ 0 $ 0
Subtotal 155 - 174 $ 557,436 $ (2,860) $ 554,576
200 Total $ 2,419,995 $ (175) $ 2,419,820
210 0.24 Total Facility Group Health Insurance (Adj 8)* 6900 $ 50,346
* For informational purposes only, this amount is included in various cost centers above. .
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