Provider Cost and Wage Survey (Full Survey) Rate Rebasing ... and... · Provider Cost and Wage Survey ("Full Survey") Rate Rebasing Project: Comprehensive, Supports, and Acquired

1. PROVIDER IDENTIFICATION

1 PROVIDER NAME:

2

3 CITY:

4 COUNTY:

5 CARF CERTIFICATION STATUS:

6 PROVIDER FISCAL YEAR BEGINNING:

7 PROVIDER FISCAL YEAR ENDING:

8 CONTACT PERSON:

9 TITLE:

10 PHONE NUMBER:

11 EMAIL ADDRESS:

3. PROVIDER SITES

SITE 1

12 CITY

13 COUNTY

14

PERCENT OF PARTICIPANTS THAT LIVE:

0-25 MILES FROM LOCATION


GREATER THAN 50 MILES FROM LOCATION

SITE 2

16 CITY

17 COUNTY

18

PERCENT OF PARTICIPANTS THAT LIVE WITHIN:




Yes

NUMBER OF WAIVER PARTICIPANTS SERVED DURING

PROVIDER FISCAL YEAR (ENTERED ABOVE)



2. CONTACT INFORMATION

XXX-XXX-XXXX

INSTRUCTIONS:

This survey should be completed by waiver providers with a $1,000,000 or more in SFY 2016 waiver revenues who have a NPI number.

The survey website provides additional copies of the survey along with a list of frequently asked questions:

https://public.navigant.com/sites/wyddsurvey. Providers earning less than $1,000,000 are asked to fill out a separate wage survey, but are

welcome to fill out the “full” cost and wage survey if they are able. Providers that do not designate wage rates do not need to complete a

survey; these are providers that do not have a business tax identification number, or used their social security number as a business tax

identification number. There is a separate survey for case management agencies.

Providers should use data from their most recent fiscal year unless otherwise noted (i.e., FYE 12/31/2016 or 6/30/2017).

Providers with multiple locations/sites are encouraged to submit one survey that encompasses data for all of their locations/sites; however,

providers may choose to submit a separate survey for each location/site if necessary.

15

19

Provider Name

XXXXXXPRIMARY NPI NUMBER:

City

County

[email protected]

Provider Cost and Wage Survey ("Full Survey")

Rate Rebasing Project: Comprehensive, Supports, and Acquired Brain Injury Medicaid Waiver Programs

Wyoming Department of Health, Behavioral Health Division

Ms. Doe

Chief Financial Officer

WORKSHEET A: PROVIDER INFORMATION

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mailto:[email protected]



INSTRUCTIONS:

This survey should be completed by waiver providers with a $1,000,000 or more in SFY 2016 waiver revenues who have a NPI number.

The survey website provides additional copies of the survey along with a list of frequently asked questions:

https://public.navigant.com/sites/wyddsurvey. Providers earning less than $1,000,000 are asked to fill out a separate wage survey, but are

welcome to fill out the “full” cost and wage survey if they are able. Providers that do not designate wage rates do not need to complete a

survey; these are providers that do not have a business tax identification number, or used their social security number as a business tax

identification number. There is a separate survey for case management agencies.

Providers should use data from their most recent fiscal year unless otherwise noted (i.e., FYE 12/31/2016 or 6/30/2017).

Providers with multiple locations/sites are encouraged to submit one survey that encompasses data for all of their locations/sites; however,

providers may choose to submit a separate survey for each location/site if necessary.




WORKSHEET A: PROVIDER INFORMATION

SITE 3

20 CITY

21 COUNTY

22





SITE 4

24 CITY

25 COUNTY

26





28 Are you completing this survey for a particular site?

29 If yes, please indicate the relevant site (from above).

4. PROVIDER STAFFING

30

31





TOTAL NUMBER OF FULL-TIME EMPLOYEES AT END OF

PROVIDER FISCAL YEAR

(30 or more hours/week or 130 hours/month)

27

If your organization has multiple provider sites and collects cost data individually for each site, you may choose to submit to

information for each site using separate surveys.

23

TOTAL NUMBER OF PART-TIME EMPLOYEES AT END OF

PROVIDER FISCAL YEAR

(Less than 30 hours/week or 130 hours/month)

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PROVIDER NAME: Provider Name

PROVIDER SITE:

PROVIDER FISCAL YEAR BEGINNING: 1/0/1900

PROVIDER FISCAL YEAR ENDING: 1/0/1900

WORKSHEET B: SERVICES PROVIDED BY AGENCY

Check all that apply.

Adult Day Services Personal Care

Behavioral Support Services Physical Therapy

Case Management Prevocational

Child Habilitation Services Residential Habilitation Host Homes

Community Integration Services Residential Habilitation Services

Companion Services Respite

Cognitive Retraining Self-Directed Goods

Crisis Intervention Support Skilled Nursing

Dietician Special Family Habilitation Home

Employment Discovery and Customization Speech, Language and Hearing Services

Environmental Modification Supported Employment

Homemaker Supported Employment Follow Along

Independent Support Broker Supported Living

Individual Habilitation Training Transportation Services

Occupational Therapy

Note: Definitions of each service area may be found on the Wyoming Department of Health website, specifically:https://health.wyo.gov/wp-content/uploads/2016/06/BHD-Service-Index-Revised-2.27.17.pdf

Please specify: all sites or a specific site

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https://health.wyo.gov/wp-content/uploads/2016/06/BHD-Service-Index-Revised-2.27.17.pdf
















PROVIDER SITE: Please specify: all sites or a specific site



2 3 4 5 6

All Non-Waiver Supports,

Uniform Costs from Program Comprehensive

Chart of Provider Costs and ABI Waiver

Line Accounts General Including Program

No. Code Ledger Room and Board Costs

Program Employee Salaries and Wages

1 Direct Care Workers 5010 -

2 Direct Care Trainers 5020 -

3 Shift and Unit Supervisors 5030 -

4 Case Managers 5040 -

5 Job Coaches and Vocational Trainers 5050 -

6 Dieticians 5060 -

7 Nurses 5070 -

8 Psychiatrists 5080 -

9 Psychologists 5090 -

10 Physical Therapists 5100 -

11 Occupational Therapists 5110 -

12 Speech Therapists 5120 -

13 Other Program Employees 5130 -

14 Total Program Employee Salaries and Wages - - -

(Specify)

1

WORKSHEET C: PROVIDER COSTS FROM Jan 00,1900 TO Jan 00,1900

Cost Centers

SALARIES AND WAGES

Additional Information

Check to confirm that Col. 5 does not include room and board

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2 3 4 5 6






1


Cost Centers Additional Information

15

5210-5240 -

Maintenance Employee Salaries and Wages

16 Maintenance Staff -- Vehicle 5310 -

17 Maintenance Staff -- All Other 5320-5340 -

18 Total Maintenance Employee Salaries and Wages - - -

Administration Employee Salaries and Wages

19 Administrator/CEO/Director 5410 -

20 Assistant Administrator/Director 5420 -

21 Employee Owners, Partners or Stockholders 5430 -

22 Board Member Compensation 5440 -

23 Administrative Staff (e.g., professional/clerical/IT staff) 5450-5470 -

24 Central Corporate Office Administration Staff Allocated to Local Level 5480 -

25 Fundraising Activity Personnel 5490 -

26 Other Administration Employee 5500 -

27 Total Administration Employee Salaries and Wages - - -

(Specify)

Program Support Employee Salaries and Wages

(e.g., program coordinators, quality assurance/data analysts, food/housekeeping staff) Check to confirm that Col. 5 does not include room and board



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2 3 4 5 6






1



Client and Other Salaries and Wages

28 Client Salaries and Wages 5610 -

29 Donated Services 5620 -

30 Other Salaries and Wages 5630 -

31 Total Client and Other Salaries and Wages - - -

32 - - -

Employee Payroll Taxes

33 FICA 5710 -

34 FUI 5720 -

35 SUI 5730 -

36 Workers Compensation and Other Payroll Taxes 5740-5750 -

37 Total Employee Payroll Taxes - - -

(Specify)

EMPLOYEE TAXES, INSURANCE AND BENEFITS

TOTAL SALARIES AND WAGES




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2 3 4 5 6






1



Employee Insurance

38 Employee Health Insurance 5810 -

39 Employee Vision Insurance 5860 -

40 Employee Dental 5820 -

41 Employee Life Insurance 5830 -

42 Employee Short-Term and Long-Term Disability Insurance 5840 -

43 Client Fringe Benefits 5850 - 44 Other Employee Insurance, excluding any categories listed above 5860 -

45 Total Employee Insurance - - -

Employee Other Benefits

46 Retirement 5910 -

47 Other Benefits 5920 -

48 Total Employee Other Benefits - - -

49 - - -

(Specify)

(Specify)

(Specify)

TOTAL EMPLOYEE TAXES, INSURANCE AND BENEFITS

Costs are included in Line 38; not possible to break out separately






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2 3 4 5 6






1



Contracted Program Services

50 Direct Care Workers Contracted Program Services 6010 -

51 Direct Care Trainers Contracted Program Services 6020 -

52 Contracted Shift and Unit Supervisor 6030 -

53 Case Managers Contracted Program Services 6040 -

54 Job Coaches and Vocational Trainers Contracted Program Services 6050 -

55 Dieticians Contracted Program Services 6060 -

56 Nurses Contracted Program Services 6070 -

57 Psychiatrists Contracted Program Services 6080 -

58 Psychologists Contracted Program Services 6090 -

59 Physical Therapists Contracted Program Services 6100 -

60 Occupational Therapists Contracted Program Services 6110 -

61 Speech Therapists Contracted Program Services 6120 -

62 Other Contracted Program Employees 6130 -

63 Total Contracted Program Services - - -

(Specify)

CONTRACTED SERVICES


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2 3 4 5 6






1



64 Contracted Maintenance Services (e.g., vehicle/equipment/plant) 6210-6240 -

65 Contracted Administration Services 6310-6360 -

66 - - -

Administration Expenses

67 Advertising 6710 -

68 Bank Service Charges / Fee 6720 -

69 CARF Survey 6730 -

70 Office Supplies and Services (e.g., office supplies/postage/shipping/printing) 6740-6760 -

71 Information Technology Expenses 6770 -

72 Central Corporate Office Other Administration Expenses Allocated to Local Level 6780 -

73 Dues, Memberships and Subscriptions 6790 -

74 Fundraising Activities 6800 -

75 Other Administrative Expenses (e.g., meeting expenses, etc.) 6820 -

76 Total Administration Expenses - - -

(Specify)

TOTAL CONTRACTED SERVICES

NON-PAYROLL ADMINISTRATION EXPENSES



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2 3 4 5 6






1



77 Licenses/Taxes 7010-7030 -

Liability and Other Insurance

78 Vehicle Related Insurance 7150 -

79 All Other Insurance 7110-7140, 7160 -

80 Total Liability and Other Insurance - - -

Non-Payroll Related Personnel Expenses

81 Background Checks / Drug Testing 6610 -

82 Recruitment 6620 -

83 Training 6630 -

84 Other Non-Payroll Personnel Expenses 6640 -

85 Total Non-Payroll Related Personnel Expenses - - -

86 - - -

(Specify)

TOTAL NON-PAYROLL ADMINISTRATION EXPENSES





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2 3 4 5 6






1



87 Supplies (related to materials used in client care or program support services) 6510-6590 -

Transportation

88 6910 -

89 Transportation/Travel - non-service related 6920 -

90 Total Transportation - - -

91 - - -

NON-PAYROLL PROGRAM SUPPORT EXPENSES

TOTAL NON-PAYROLL PROGRAM SUPPORT EXPENSES

Transportation - service related (providers must maintain detailed mileage records to support expenses reported)




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2 3 4 5 6






1



92 Rental and Property Expenses 7210-7270 -

93 Maintenance and Repairs 7310-7340 -

94 Depreciation and Amortization Expenses 7410-7460 -

95 Utilities 6410-6470 -

96 - - -

97 - - -

FACILITY, VEHICLE AND EQUIPMENT RELATED EXPENSES

TOTAL FACILITY, VEHICLE AND EQUIPMENT RELATED EXPENSES

GRAND TOTALS



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2 3 4 5 6






1



98 Total BHD Waiver Revenues (Comprehensive, Supports and ABI)

99 Total Targeted Case Management (TCM) Revenues, if applicable

100 Total Revenues from Other Sources, if applicable

101

(If you operate multiple sites, enter total revenues earned across all your sites)

TOTAL PROVIDER REVENUES

PROVIDER REVENUES

-

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2 3 4 5 6






1



ADDITIONAL QUESTION

102 Please explain if your agency incurred partial year expenses during the provider fiscal year reported for any services, operations, or facilities.

103 Has your agency experienced significant changes in costs since the fiscal year period for which you are reporting data? If so, please explain.

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

$15.00 $17.00 $19.00 0.00% 1.00% 1.00% 5.00% 3.00% 2.00% 20 20 1 2 Home health agencies Casper Wyoming Home Health Organization

Program Employee Salaries and Wages

1 Direct Care Workers - Daytime

2 Direct Care - Swing Shift/Overnight

3 Direct Care Workers - Overnight Workers Allowed to Sleep (if different)

4 Direct Care Trainers

5 Shift and Unit Supervisors

6 Case Managers

7 Job Coaches and Vocational Trainers

8 Dieticians

9 Nurses

10 Psychiatrists

11 Psychologists

12 Physical Therapists

13 Occupational Therapists

14 Speech Therapists

15 Other Program Employees Specify:

ADDITIONAL QUESTION

1. If you assign raises, when do they take effect? Check the applicable answer.

a. End of Provider Fiscal Year

b. End of Calendar Year

c. Other (please specify) (Specify)

Notes:

(1) If your employees are paid on a salary basis, you can calculate hourly wages by dividing the annual salary by 2,080 (the number of working hours in a year based on a 40-hour work week), or for part-time salaried positions, a reasonable estimate of the

number of hours worked over the course of a year. If your employees regularly work overtime, you may divide the salary by more than 2,080 as appropriate.

(2) To convert employee raises from a dollar amount to a percentage increase in wages, divide the average hourly raise amount by the average hourly wage

(3) To calculate percent bonus, take total annual average bonus amount and divide it by the annual average salary and wages prior to payroll deductions

(4) Paid Time Off is the allowed annual hours per full-time employee including vacation, holiday, and sick time hours

(5) If a particular industry as a whole is the competitor, then note the industry. For example, if all home health agencies is your primary competitor, you can note "Any home health agency".

Line

No. Average Lowest Highest

2014

to 2015

2015

to 2016

2016

to 2017

Example

City of Primary

Competitor

State of Primary

Competitor

Type of Business

(insert description)2014 2015 2016

Hourly Wage 1

Raises: Average Annual Percent

Increase in Wages 2

Paid Time Off 4

(Complete only if

agency policy

includes a set

amount of hours

per year )

Average

Annual Paid

Training

Hours per

Employee Full-Time Part-Time

Name of Primary Competitor for

Employees 5

Bonuses: Average Annual

Percent of

Salary and Wages 3




Description

WORKSHEET D: PROGRAM EMPLOYEE WAGES

Note: Please provide the below information based on the "snapshot" date of August 31, 2017.

REGULAR WAGES AS OF 8/31/2017

PAID TIME OFF AND

TRAINING HOURS AS OF

8/31/2017

UNFILLED POSITIONS AS

OF 8/31/2017 LABOR COMPETITION

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1 2 3 4 5 6 7 8

Number on

Payroll at End of

Fiscal Year

Number

Continuously

Employed

During Fiscal

Year

Number Who

Left the Agency

During the Fiscal

Year

Number on

Payroll at End of

Fiscal Year

Number

Continuously

Employed

During Fiscal

Year

Number Who

Left the Agency

During the Fiscal

Year

1

2

3

4

5 Job Coaches and Vocational Trainers

6

7

8

9

10

11

12

13

14 - - - - - - - -

WORKSHEET E: PROGRAM EMPLOYEE STAFFING AND TURNOVER

Line

No. Description

Full Time Employees Part Time Employees

NUMBER OF EMPLOYEES AND UNFILLED POSITIONS

(based on provider fiscal year listed above)

Physical Therapists

Occupational Therapists

Speech Therapists

Other Program Employees

TOTAL EMPLOYEES

Psychologists

Unfilled

Positions:

Full-Time

Unfilled

Positions:

Part-Time

Program Employees

Direct Care Workers

Direct Care Trainers

Shift and Unit Supervisors

Case Managers

Dieticians

Nurses

Psychiatrists

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ADDITIONAL QUESTIONS

1. What are the THREE most frequent reasons that employees cite for separation?

Mark "X" in the 3 boxes that apply.

1.1 Direct Care Employees (non-licensed):

Work location

Work schedule

Wage/Salary concerns

Sign up bonuses at new employer

Benefits package

Nature of the work

Co-worker conflicts

Relocation

Career advancement

Other (specify)

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1.2 Unit Supervisors, Staff Supervisors:

Work location

Work schedule

Wage/Salary concerns

Sign up bonuses at new employer

Benefits package

Nature of the work

Co-worker conflicts

Relocation

Career advancement

Other (specify)

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2. What are the THREE largest impacts of staff turnover on your organization?

Mark "X" in the 3 boxes that apply.

Reduced continuity of care

Reduced staff-to-client ratios

Increased safety risks

Difficulty meeting safety or health standards

Reduction in services (either amount or type) because of increased costs or lack of staff

Increased training costs

Increased hiring or recruitment costs

Inability to fulfill paperwork requirements

Burnout of existing staff

Inability to terminate undesirable or marginal staff

Lower qualification of new employees

Administrative staff working direct care

Reduced training for new employees

Other (specify)

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Please provide information from the current provider fiscal year.

Table 1: Questions for Organizations Currently Offering Health Insurance Coverage

2 3

Example Response

Example

1 Yes

2Health plan/insurance

broker

3 N/A

4 $500,000

5 Yes

6 $100.00

7 $400.00

On average, how much does a typical employee with single coverage contribute toward his/her own monthly premium?

WORKSHEET F: EMPLOYEE HEALTH INSURANCE BENEFITS

Complete only Table 1 if your organization currently offers health insurance . Complete only Table 2 if your organization does not currently offer health insurance.

Line

No.

1

Question

Employer contribution toward health insurance premiums

Does your organization currently offer health care coverage?

Does your organization purchase health insurance from a health plan or insurance broker (i.e., your organization does not

assume any risk beyond the premium), or self-insure?

If your organization self-insures, does your organization purchase stop-loss coverage?

If your organization self-insures, did you have any costs for lasering (e.g., costs related to a higher reinsurance deductible for a

particular individual) for the provider fiscal year reported on Worksheet C? If so, please report the lasering on this line less

what the normal stop loss threshold payment amount would be.

Does your organization contribute toward health insurance premiums?

On average, how much does your organization (the employer) contribute toward the monthly plan premium of one typical

employee with single coverage? If your organization self-insures any portion of the health insurance, report the premium

equivalent of self-insured costs plus any other premiums paid (e.g. stop-loss premiums, ASO fees).

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8 $500.00

9 $1,500

10 $3,000

11 Yes

12 12 months

13 30.00

14 17

15 10

16 15

17 8

18 6

19 1

20 1How many waiver program direct service staff receiving health insurance from your organization selected a family coverage

plan?

How many direct service employees work more than the minimum number of hours per week to be eligible for health

insurance?

How many waiver program direct service employees work less than the minimum number of hours per week to be eligible

for health insurance?

Of the waiver program direct service staff employed by your organization, how many are currently eligible for health

insurance (regardless of whether the eligible staff have signed up for coverage)?

How many waiver program direct service staff currently receive health insurance from your organization?

How many waiver program direct service staff receiving health insurance from your organization selected an employee-plus-

one coverage plan?

What is the average annual deductible for the health insurance offered for individual coverage?

What is the average annual deductible for the health insurance offered for family coverage?

Are direct service staff eligible to receive health insurance through your organization?

If yes, what is the waiting period before direct service staff are eligible for health insurance (in months)?

What is the minimum number of hours per week that a direct service employee must work to be eligible for health insurance?

How many waiver program direct service staff receiving health insurance from your organization selected a single coverage

plan?

On average, how much is the total monthly premium for a typical employee with single coverage (this number should equal the

sum of lines 5 and 6)?

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Table 2: Questions for Organizations that Do Not Currently Offer Coverage

2 3

Example

1 Yes

2016

June

3

a. Employer portion of the premium was too high 1

b. Employee portion of premium was too high; direct care staff could not afford it

c. 2

d.

e.

f. Concerns regarding the economy 3

g. Other Specify Insert comments

2If yes, when did your organization stop offering health care insurance to waiver program direct service staff (insert month

and year)

If yes, why did your organization stop offering health care insurance (rank the top three reasons)?

Concerns related to benefit requirements under the Affordable Care Act

Direct care staff have other offers of insurance (via family member, public program or

individual insurance market)

Anticipated/unpredictable increases in health insurance premiums


If your organization does not currently offer coverage, has your organization offered health insurance to waiver program

direct service staff in the past?

Line

No.

1

Category ResponseExample

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4

a. Employer portion of the premium is too high 1

b.

c. 2

d.

e.

f. Concerns regarding the economy 3


5 Yes

Concerns related to benefit requirements under the Affordable Care Act

If no, what are the reasons for not offering health care insurance (rank the top three reasons)?

Direct care staff have other offers of insurance (via family member, public program or

individual insurance market)

Employee portion of premium is too high; direct care staff can not afford it

Anticipated/unpredictable increases in health insurance premiums

If no, are you considering offering coverage to comply with Affordable Care Act legal requirements?

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CARF CERTIFICATION STATUS: 1/0/1900



Table 1: Questions for Organizations Currently Offering Retirement Benefits

2 3

Example Response

1 Yes

2 12 Months

330 hours/week OR

120/month

4 15

5 8

6 4.00%

Table 2: Questions for Organizations that Do Not Currently Offer Retirement Benefits

2 3

Example Response

Example

1 Yes

2016

June

What is the minimum number of hours per week/month that an employee must work to be eligible for retirement benefits?

Of the waiver program direct service staff employed by your organization, how many are currently eligible for retirement

benefits?

How many waiver program direct service staff received retirement contributions from your organization for the provider

fiscal year reported in Worksheet C?

What was your organization's average annual retirement contribution for waiver program direct service staff that are

participating in the retirement benefit as a percent of waiver program direct service staff salary and wages for the provider

fiscal year reported in Worksheet C?

WORKSHEET G: EMPLOYEE RETIREMENT BENEFITS

Line

No.

1

Question

Complete only Table 1 if your organization currently offers retirement benefit. Complete only Table 2 if your organization does not currently offer retirement benefit.


If your organization does not currently offer retirement benefits, has your organization offered retirement benefits to waiver

program direct service staff in the past?

2 If yes, when did your organization stop offering retirement benefits to direct service staff (insert month and year)

1

Does your organization contribute to a 401k, 403b or other retirement plan for your direct service staff?

Line

No. Category

If yes, what is the waiting period before staff are eligible for retirement contributions (in months)?

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CARF CERTIFICATION STATUS: 1/0/1900



WORKSHEET G: EMPLOYEE RETIREMENT BENEFITS

Complete only Table 1 if your organization currently offers retirement benefit. Complete only Table 2 if your organization does not currently offer retirement benefit.

3

a. Decrease in State funding of waiver programs 1

b. Concerns regarding the economy 3

c. 2

d.

e. Other Specify Insert comments

4

a. Decrease in State funding of waiver programs 1

b. Concerns regarding the economy

c. 2

d.


Need to maintain health insurance benefits over other benefits

Employees are not interested

Need to maintain health insurance benefits over other benefits

Employees are not interested

If no, what are the reasons for not offering retirement benefits (rank the top three reasons)?

If yes, why did your organization stop offering retirement benefits (rank the top three reasons)?

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2 3

Comprehensive

Targeted Supports

Line Case and ABI

No. Management Waiver Programs

1 How many participants does your organization currently serve?

2 0-3 hours per month



5 10+ hours per month

6

REASONS FOR VARIATION AMONG PARTICIPANTS

Other (Please describe):

What are the most common reasons for exceeding six hours of case management per month for a given

participant? Please select all that apply.

Looking at your total caseload, approximately how many participants require, on average, the

following amounts of case management per month:

WORKSHEET H: CASE MANAGEMENT QUESTIONS

1

Supplemental Information

PARTICIPANTS

Note: Complete this worksheet only if your organization provides waiver case management services, otherwise leave blank. Please provide information from the current provider

fiscal year.

Crisis Management

Communicating with Family and Guardians

Difficult Participant Behavior

Recurrent Medical Issues

Finding or Changing Providers

Documentation

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WORKSHEET H: CASE MANAGEMENT QUESTIONS

Note: Complete this worksheet only if your organization provides waiver case management services, otherwise leave blank. Please provide information from the current provider

fiscal year.

7 Monthly rate unit

8 15 minute rate unit

For how many participants do you currently bill for using a monthly and a 15-minute unit?

UNITS

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1 3 4 5

Worksheet Yes No Not Applicable

If you are completing this survey for a particular provider site, have you specified the site on Line 29?

B: Services Have you identified all the waiver services your organization (or relevant site) delivers to clients?

Have you included all of the costs from your general ledger in the appropriate cost center and line number?

Have you reported all of your non-waiver program costs in the appropriate cost center and line number in Column 4?

Have you accounted for room and board costs in Column 4, "Non-Waiver Program Costs"?

Did you check the boxes in Column 6 to indicate that your responses in column 5 do not include room and board costs?

Did you report average hourly wages, as of August 31, 2017, for each employee type in Column 1?

Did you report the lowest hourly wage paid to each employee type in Column 2 and the highest hourly wage in Column 3, as of August 31, 2017?

Did you report the average amount of paid time off allowed to each employee type in Column 10, including vacation, holiday, and sick time?

Did you report the average amount of paid training hours provided annually for each employee type in Column 11?

Did you provide the relevant information in Columns 12-13 regarding unfilled full-time and part-time positions?

Did you provide the relevant information in Columns 14-17 about your primary competitor for employees?

Did you complete "Additional Question" 1, if applicable?

WORKSHEET I: ERROR SELF-CHECK

2

A: Provider

Info

Did you enter the total number of full-time and part-time employees employed by your organization (not site-specific) at the end of your most recent fiscal year?

C: Costs

D: Wages

Did you report any raises you gave employees between 2015 and 2017 in the appropriate column (4-6) as a percentage increase from the previous year?

Did you input information for up to 4 provider sites operated by your organization, if applicable?

Did you input the number of waiver participants served at each provider site during the provider fiscal year entered in Worksheet A?

If you have reported costs in the "Other" expenses row within any of the cost centers, have you entered a description of the expense(s) in the box provided?

Did you report any bonuses you gave employees in 2014 to 2016 in the appropriate column (7-9) as a percentage from that year?

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1 3 4 5

WORKSHEET I: ERROR SELF-CHECK

2

E: Turnover

Did you report the number of unfilled full-time and part-time employees, by type, as of the end of your most recent fiscal year?

Did you complete "Additional Questions" 1 and 2?

Did you answer the questions in Table 1 if your agency currently offers health insurance benefits?

Did you answer the questions in Table 2 if your agency does not currently offer health insurance benefits?

G: Retirement Did you answer the questions on this worksheet, regardless of whether you offer retirement benefits?

H: CM

Questions

If your agency provides case management services, did you answer each question separately for individuals receiving TCM and waiver case management

services?

Did you report the number of full-time and part-time employees who were continuously employed during your most recent fiscal year in Columns 2 and 5,

respectively, for each employee type that you employ?

Did you report the number of full-time and part-time employees who left the agency during your most recent fiscal year in Columns 3 and 6, respectively, for

each employee type that you employ?

Did you report the number of full-time and part-time employees who were on the payroll as of the last day of your most recent fiscal year in Columns 1 and 4,

respectively, for each employee type that you employ?

F: Health

Insurance

Navigant -- 9/5/2017 29

Documents

Provider Cost and Wage Survey (Full Survey) Rate Rebasing ... and... · Provider Cost and Wage Survey ("Full Survey") Rate Rebasing Project: Comprehensive, Supports, and Acquired