Windsor Elmhaven Care Center - California Department of ... · PDF filereport on the rate setting audit windsor elmhaven care center stockton, california national provider identifier:

REPORT ON THE

RATE SETTING AUDIT

WINDSOR ELMHAVEN CARE CENTER STOCKTON CALIFORNIA

NATIONAL PROVIDER IDENTIFIER 1396881033

FISCAL PERIOD ENDED DECEMBER 31 2012

Audits SectionmdashBurbank Financial Audits Branch

Audits and InvestigationsDepartment of Health Care Services

Section Chief Allen Dervi Audit Supervisor Debra K BlakeAuditor Robert Miles

TOBY DOUGLAS DIRECTOR

EDMUND G BROWN JR GOVERNOR

State of CaliforniamdashHealth and Human Services Agency Department of Health Care Services

May 13 2014

Ash Chawla Vice President of Finance SnF Management Company Inc 9200 West Sunset Boulevard Suite 700 West Hollywood CA 90069

WINDSOR ELMHAVEN CARE CENTER NATIONAL PROVIDER IDENTIFIER (NPI) 1396881033 FISCAL PERIOD ENDED DECEMBER 31 2012

We have examined the facilitys Integrated Disclosure and Medi-Cal Cost Report for the above-referenced fiscal period We also examined the facilitys use of and Records of Noncovered Services deducted from patient share of cost Our examination was made under the authority of Section 14170 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

The audit adjustments identified in this audit report correct misrepresentations andor errors that were the subject of audit adjustments in the preceding audit report for this facility issued by the Financial Audits Branch The misrepresentations andor errors in question are not subject to a pending appeal You are hereby notified Civil Money Penalties may be imposed as permitted by Welfare and Institutions Code Section 1412325 if these misrepresentations and errors are found in future cost reports filed on behalf of this facility These penalties range from $100 to $1000 per adjustment to reported costs up to three times the amount for each item or service improperly claimed whichever is greater

In our opinion the data presented in the accompanying Summary of Audited Facility Cost per Patient Day represents a proper determination of the allowable costs patient days and use of share of cost for the above fiscal period in accordance with Medi-Cal reimbursement principles

Financial AuditsBurbankA amp I MS 2101 1405 North San Fernando Boulevard Room 203 Burbank CA 91504 Telephone (818) 295-2620 FAX (818) 563-3324

Internet Address wwwdhcscagov

Ash Chawla Page 2

This audit report includes the

1 Summary of Audited Facility Cost per Patient Day and supporting schedules

2 Audit adjustments that include a summary of the total due the State in the amount of $60217 which resulted from Medi-Cal overpayments

The audit settlement will be incorporated into a Statement(s) of Account Status which may reflect tentative retroactive adjustment determinations payments from the provider and other financial transactions initiated by the Department The Statement(s) of Account Status will be forwarded to the provider by the Statersquos fiscal intermediary Instructions regarding payment will be included with the Statement(s) of Account Status

Future Medi-Cal long-term care prospective rates may be affected by this examination The extent to which the rates change will be determined by the Departments Fee-For-Service Rates Development Division

Notwithstanding this audit report overpayments to the provider are subject to recovery pursuant to Section 514581 Article 6 of Division 3 Title 22 California Code of Regulations

If you disagree with the decision of the Department you may appeal by writing to

Lisa Alder Chief Department of Health Care Services Office of Administrative Hearings and Appeals MS 0017 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

Ash Chawla Page 3

United States Postal Service (USPS) Assistant Chief Counsel Department of Health Care Services Office of Legal Services MS 0010 PO Box 997413 Sacramento CA 95899

Courier (UPS FedEx etc) Assistant Chief Counsel Department of Health Care Services Office of Legal Services MS 0010 1501 Capitol Avenue Suite 715001 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 SectionmdashBurbank at (818) 295-2620

Original Signed By

Allen Dervi Chief Audits SectionmdashBurbank Financial Audits Branch

Certified

STATE OF CALIFORNIA SCHEDULE 1

SUMMARY OF AUDITED FACILITY COSTS COST PER PATIENT DAY

Provider Name Fiscal Period

W INDSOR ELMHAVEN CARE CENTER JANUARY 1 2012 THROUGH DECEMBER 31 2012

NPI OSHPD Facility No

1396881033 206390865

PROGRAM DESCRIPTION

AS REPORTED AS AUDITED PATIENT DAY

COST PER

AUDITED

SKILLED NURSING CARE

1 Cost of Direct Care - Labor (Sch 2 Ln 105) $ NA $ 4032878 $ 12560

2 Cost of Indirect Care - Labor (Sch 3 Ln 105) $ NA $ 851906 $ 2653

3 Cost of Direct and Indirect Nonlabor - Other (Sch 4 Ln 105) $ NA $ 825726 $ 2572

4 Cost of Capital Related (Sch 5 Ln 105) $ NA $ 518614 $ 1615

5 Property Taxes (Sch 5 Ln 105) $ NA $ 21800 $ 068

6 CDPH Licensing Fees (Sch 6 Ln 105) $ NA $ 18983 $ 059

7 Professional Liability Insurance (Sch 6 Ln 105) $ NA $ 69235 $ 216

8 Caregiver Training (Sch 6 Ln 105) $ NA $ 0 $ 000

9 Quality Assurance Fees (Sch 6 Ln 105) $ NA $ 324667 $ 1011

10 Cost of Administration (Sch 6 Ln 105) $ NA $ 892486 $ 2780

11 Cost of Routine ServiceAudited Total Costs $ 7330223 $ 7556298 $ 23534

12 Total Patient Days (Adj 34) 32029 32108

13 Cost Per Patient Day (Cost Divided by Days) $ 22886 $ 23534

14 Overpayments (Adjs 43 44 45) $ 0 $ (60217)

15 Medi-Cal Days (Adj 36) 19295 19312

16 Medi-Cal Managed Care Days (Adj 37) 232

INTERMEDIATE CARE

17 Cost of Routine Service (Sch 2 3 4 5 6) $ 0 $ 0

18 Total Patient Days (Adj ) 0 0

20 Overpayments (Adj ) $ 0 $ 0

21 Medi-Cal Days (Adj ) 0 0

MENTALLY DISORDERED CARE

DEVELOPMENTALLY DISABLED CARE

SUBACUTE CARE

31 Cost of Direct Care - Labor (Subacute Care Sch 1 Ln 25) $ NA $ 2522195 $ 21589

32 Cost of Indirect Care - Labor (Subacute Care Sch 1 Ln 26) $ NA $ 256389 $ 2195

33 Cost of Direct and Indirect Nonlabor - Other (Subacute Care Sch 1 Ln 27) $ NA $ 997934 $ 8542

34 Cost of Capital Related (Subacute Care Sch 1 Ln 28) $ NA $ 175671 $ 1504

35 Property Taxes (Subacute Care Sch 1 Ln 29) $ NA $ 7384 $ 063

36 CDPH Licensing Fees (Subacute Care Sch 1 Ln 30) $ NA $ 12025 $ 103

37 Professional Liability Insurance (Subacute Care Sch 1 Ln 31) $ NA $ 43856 $ 375

38 Quality Assurance Fees (Subacute Care Sch 1 Ln 32) $ NA $ 205657 $ 1760

39 Caregiver Training (Subacute Care Sch 1 Ln 33) $ NA $ 0 $ 000

40 Cost of Administration (Subacute Care Sch1 Ln 34) $ NA $ 565335 $ 4839

41 Total Cost of Subacute Service (Subacute Care Sch 1 Ln 35) $ 5576850 $ 4786445 $ 40969

42 Total Patient Days (Subacute Care Sch 1 Ln 36) 11761 11683

44 Amount Due Provider (State) (Subacute Care Sch 1 Ln 40) $ 0 $ 0

1396881033 206390865

PROGRAM DESCRIPTION

AS REPORTED AS AUDITED

AUDITED

COST PER

PATIENT DAY

SUBACUTE CARE - PEDIATRIC

45 Cost of Routine Service (Subacute Care - Pediatric Sch 1 Ln 3) $ 0 $ 0

46 Cost of Ancillary Service (Subacute Care - Pediatric Sch 1 Ln 1 + Ln 2) $ 0 $ 0

47 Total Cost of Subacute Care - Pediatric Service (Ln 43 + Ln 44) $ 0 $ 0

48 Total Patient Days (Subacute Care - Pediatric Sch 1 Ln 5) 0 0

50 Amount Due Provider (State) (Subacute Care - Pediatric Sch 1 Ln 9) $ 0 $ 0

TRANSITIONAL INPATIENT CARE

HOSPICE INPATIENT CARE

OTHER ROUTINE SERVICES

(From Subacute Care Schedule 1)

ALLOCATION OF GENERAL SERVICES DIRECT CARE LABOR

WINDSOR ELMHAVEN CARE CENTER JANUARY 1 2012 THROUGH DECEMBER 31 2012

1396881033 206390865

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8)

Soc Srvs

Activities

160 Total

GENERAL SERVICES

005 Plant Operations and Maintenance

010 Housekeeping

060 Laundry and Linen

065 Dietary

155 Social Services 59123 $ $ 59123

160 Activities 137462 $ 137462

165 Administration

166 Medical Records

170 Inservice Education - Nursing

ANCILLARY SERVICES

075 Patient Supplies 0 0 0 0

077 Specialized Support Surfaces NA 0 0 0

080 Physical Therapy 0 0 0 0

081 Respiratory Therapy 0 0 0 0

082 Occupational Therapy 0 0 0 0

083 Speech Pathology 0 0 0 0

085 Pharmacy 0 0 0 0

090 Laboratory 0 0 0 0

095 Home Health Services 0 0 0 0

100 Other Ancillary Services 0 0 0 0

101 Subacute Care Ancillary Services 0 0 0 0

102 Subacute Care - Pediatric Ancillary Services 0 0 0 0

ROUTINE SERVICES

105 Skilled Nursing Care 3917263 34771 80844 4032878

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 2441225 24352 56618 2522195

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 0

140 Beauty and Barber 0 0 0 0

145 Other Nonreimbursable 0 0 0 0

TOTAL 6555073 $ $ 59123 $ 137462 $ 6555073

(To Schedule 1)

(To Subacute Care Schedule 1)

ALLOCATION OF GENERAL SERVICES INDIRECT CARE LABOR

Provider Name NPI OSHPD Facility Number Fiscal Period

WINDSOR ELMHAVEN CARE CENTER 1396881033 206390865 JANUARY 1 2012 THROUGH DECEMBER 31 2012

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8)

Plant Ops

Hskpng

Laundry

Dietary

Soc Srvs

Activities

Inserv Ed

Accumulated

Medical

Records

166 Total

GENERAL SERVICES

005 Plant Operations and Maintenance 99682 $ 99682 $

010 Housekeeping 232006 142 $ 232148

060 Laundry and Linen 146247 1699 3962 151907 $

065 Dietary 414629 15518 36191 0 $ 466338

155 Social Services NA 779 1816 0 0 2594 $

160 Activities NA 637 1486 0 0 0 2123 $

165 Administration NA 4437 10348 0 0 0 0 14785 $ $ 14785

166 Medical Records 201588 991 2311 0 0 0 0 204890 204890 $

170 Inservice Education - Nursing 72701 354 825 0 0 0 0 73880 $

ANCILLARY SERVICES

075 Patient Supplies 0 0 0 0 0 0 0 0 91 1266 $ 1358

077 Specialized Support Surfaces 0 0 0 0 0 0 0 0 160 2221 2382

080 Physical Therapy 1964 4581 0 0 0 0 0 6545 815 11294 18654

081 Respiratory Therapy 0 0 0 0 0 0 0 0 0 0 0

082 Occupational Therapy 1889 4405 0 0 0 0 0 6294 783 10846 17922

083 Speech Pathology 1031 2404 0 0 0 0 0 3435 428 5930 9792

085 Pharmacy 0 0 0 0 0 0 0 0 580 8044 8624

090 Laboratory 0 0 0 0 0 0 0 0 131 1810 1940

095 Home Health Services 0 0 0 0 0 0 0 0 0 0 0

100 Other Ancillary Services 0 0 0 0 0 0 0 0 231 3195 3426

101 Subacute Care Ancillary Services 0 0 0 0 0 0 0 0 0 0 0

102 Subacute Care - Pediatric Ancillary Services 0 0 0 0 0 0 0 0 0 0 0

ROUTINE SERVICES

105 Skilled Nursing Care 50920 118756 111380 415439 1526 1248 43450 742720 7349 101838 851906

110 Intermediate Care 0 0 0 0 0 0 0 0 0 0 0

115 Mentally Disordered Care 0 0 0 0 0 0 0 0 0 0 0

120 Developmentally Disabled Care 0 0 0 0 0 0 0 0 0 0 0

125 Subacute Care 18579 43330 40528 50899 1069 874 30430 185709 4204 58263 248176

126 Subacute Care - Pediatric 0 0 0 0 0 0 0 0 0 0 0

128 Transitional Inpatient Care 0 0 0 0 0 0 0 0 0 0 0

130 Hospice Inpatient Care 0 0 0 0 0 0 0 0 0 0 0

135 Other Routine Services 0 0 0 0 0 0 0 0 0 0 0

NONREIMBURSABLE

139 Residential Care 0 0 0 0 0 0 0 0 0 0 0

140 Beauty and Barber 743 1733 0 0 0 0 0 2476 13 183 2672

145 Other Nonreimbursable 0 0 0 0 0 0 0 0 0 0 0

TOTAL 1166853 $ 99682 $ $ 232148 151907 $ $ 466338 2594 $ 2123 $ 73880 $ 947179 $ $ 14785 204890 $ $ 1166853

(To Schedule 1)

ALLOCATION OF GENERAL SERVICES OTHER - NONLABOR

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8)

Plant Ops

Hskpng

Laundry

Dietary

Soc Srvs

Activities

Inserv Ed

Accumulated

Medical

Records

166 Total

GENERAL SERVICES

010 Housekeeping 60705 433 $ 61138

065 Dietary 283285 47491 9531 0 $ 340308

155 Social Services 342 2383 478 0 0 3203 $

160 Activities 11768 1949 391 0 0 0 14109 $

166 Medical Records 0 3033 609 0 0 0 0 3641 3641 $

ANCILLARY SERVICES

075 Patient Supplies 75992 0 0 0 0 0 0 0 75992 101 23 $ 76115

077 Specialized Support Surfaces 133296 0 0 0 0 0 0 0 133296 177 39 133512

080 Physical Therapy 648743 6011 1206 0 0 0 0 0 655960 899 201 657060

081 Respiratory Therapy 0 0 0 0 0 0 0 0 0 0 0 0

082 Occupational Therapy 622924 5781 1160 0 0 0 0 0 629865 863 193 630921

083 Speech Pathology 340620 3154 633 0 0 0 0 0 344407 472 105 344985

085 Pharmacy 482690 0 0 0 0 0 0 0 482690 640 143 483473

090 Laboratory 108582 0 0 0 0 0 0 0 108582 144 32 108758

095 Home Health Services 0 0 0 0 0 0 0 0 0 0 0 0

100 Other Ancillary Services 191748 0 0 0 0 0 0 0 191748 254 57 192059

101 Subacute Care Ancillary Services 0 0 0 0 0 0 0 0 0 0 0 0

102 Subacute Care - Pediatric Ancillary Services 0 0 0 0 0 0 0 0 0 0 0 0

ROUTINE SERVICES

105 Skilled Nursing Care 274064 155836 31276 40527 303164 1884 8298 765 815813 8104 1810 825726

125 Subacute Care 494116 56860 11411 14746 37143 1319 5811 536 621943 4636 1035 627614

126 Subacute Care - Pediatric 0 0 0 0 0 0 0 0 0 0 0 0

NONREIMBURSABLE

139 Residential Care 0 0 0 0 0 0 0 0 0 0 0 0

140 Beauty and Barber 0 2274 456 0 0 0 0 0 2731 15 3 2749

145 Other Nonreimbursable 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL 4082972 $ 305066 $ $ 61138 55273 $ $ 340308 3203 $ 14109 $ 1300 $ 4063027 $ $ 16304 3641 $ $ 4082972

(To Schedule 1)

JANUARY 1 2012 THROUGH DECEMBER 31 2012

OSHPD Facility Number

ALLOCATION OF CAPITAL COSTS

Provider Name

WINDSOR ELMHAVEN CARE CENTER

1396881033

Fiscal Period

206390865

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8) Ratio

Inserv Ed

Accumulated

Medical

Records

166 Total

Capital

Property

Of Total

GENERAL SERVICES

Capital Related (excluding lines 40 amp 45) 740343$ 96

Property Tax (line 40) 31120 4

010 Housekeeping

065 Dietary

155 Social Services

160 Activities

165 Administration 34387$ $ 34387

166 Medical Records 7680 7680$

170 Inservice Education - Nursing 2743$

ANCILLARY SERVICES

075 Patient Supplies 0 0 213 47 $ 260 250$ 10$

077 Specialized Support Surfaces 0 0 373 83 456 438 18

080 Physical Therapy 0 15222 1896 423 17541 16833 708

081 Respiratory Therapy 0 0 0 0 0 0 0

082 Occupational Therapy 0 14639 1820 407 16866 16186 680

083 Speech Pathology 0 7988 995 222 9206 8834 371

085 Pharmacy 0 0 1350 302 1652 1585 67

090 Laboratory 0 0 304 68 372 357 15

095 Home Health Services 0 0 0 0 0 0 0

100 Other Ancillary Services 0 0 536 120 656 630 26

101 Subacute Care Ancillary Services 0 0 0 0 0 0 0

102 Subacute Care - Pediatric Ancillary Services 0 0 0 0 0 0 0

ROUTINE SERVICES

105 Skilled Nursing Care 1613 519505 17092 3817 540414 518614 21800

110 Intermediate Care 0 0 0 0 0 0 0

115 Mentally Disordered Care 0 0 0 0 0 0 0

120 Developmentally Disabled Care 0 0 0 0 0 0 0

125 Subacute Care 1130 166281 9778 2184 178243 171053 7190

126 Subacute Care - Pediatric 0 0 0 0 0 0 0

128 Transitional Inpatient Care 0 0 0 0 0 0 0

130 Hospice Inpatient Care 0 0 0 0 0 0 0

135 Other Routine Services 0 0 0 0 0 0 0

NONREIMBURSABLE

139 Residential Care 0 0 0 0 0 0 0

140 Beauty and Barber 0 5760 31 7 5797 5563 234

145 Other Nonreimbursable 0 0 0 0 0 0 0

TOTAL 771463$ 100 2743$ 729396$ $ 34387 7680$ $ 771463 740343$ 31120$

(To Schedule 1)

ALLOCATION OF ADMINISTRATION AND OTHER DIRECT PASS-THROUGH COSTS

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8) Ratio

(From Sch 2)

(From Sch 3)

(From Sch 4)

(From Sch 5)

Allocated

of Total

Licensing Fees

of Total

Professional

Liability Ins

of Total

Quality Assur

of Total

Caregiver

Training

of Total

GENERAL SERVICES

045 Property Insurance 8799 $

055 Interest - Other 84333

165 Administration (Salaries amp W ages Fringe Benefits

Agency Staff and Other - Nonlabor) 1702479

Total Costs Allocable as Administration 1795611 68

167 CDPH Licensing Fees 38193 1

168 Professional Liability Insurance 139296 5

169 Quality Assurance Fees 653205 25

174 Caregiver Training 0 0

Total 2626305 100 $ 2626305

ANCILLARY SERVICES

075 Patient Supplies 0$ 0$ 75992 $ 0$ $ 75992 16233 $ 11098 236$ 861$ 4037 $ $ 0

085 Pharmacy 0 0 482690 0 482690 103109 70496 1499 5469 25645 0

090 Laboratory 0 0 108582 0 108582 23195 15858 337 1230 5769 0

ROUTINE SERVICES

125 Subacute Care 2522195 185709 621943 166281 3496128 746819 510602 10861 39610 185746 0

NONREIMBURSABLE

SUBTOTAL 2626305 $ 6555073 $ 947179 $ 4063027 $ 729396 $ $ 12294675 $ 2626305

Total Administrative Costs $ 2626305

021361321

$ 1795611 38193 $ 139296 $ 653205 $ $ 0

Unit Cost Multiplier

Accumulated Administration Costs (Sch 2 thru 5) 219674 $ 19945 $ 42067 $ $ 281686

TOTAL FACILITY COSTS $ 15202666

(To Schedule 1)

STATISTICS FOR COST ALLOCATION

Provider Name

1396881033

206390865

Fiscal Period

DESCRIPTION

Capital

(SQ FT)

VARIOUS

Plant Ops

(SQ FT)

Hskpng

(SQ FT)

Laundry

Dietary

(MEALS)

Soc Srvs

(DIRECT EXP)

Activities

(DIRECT EXP)

Inserv Ed

(DIRECT EXP)

(TOTAL

Med Records

(TOTAL

(ACCUM

GENERAL SERVICES

(Adj 31) (Adj 31) (Adj 31) (Adj 32) (Adj 33) (Adj ) (Adj ) (Adj )

005 Plant Operations and Maintenance 1072

010 Housekeeping 32 32

060 Laundry and Linen 384 384 384

065 Dietary 3508 3508 3508

155 Social Services 176 176 176

160 Activities 144 144 144

165 Administration 1003 1003 1003

166 Medical Records 224 224 224

170 Inservice Education - Nursing 80 80 80

ANCILLARY SERVICES

075 Patient Supplies 75992 75992

077 Specialized Support Surfaces 133296 133296

080 Physical Therapy 444 444 444 677727 677727

081 Respiratory Therapy 0 0

082 Occupational Therapy 427 427 427 650798 650798

083 Speech Pathology 233 233 233 355830 355830

085 Pharmacy 482690 482690

090 Laboratory 108582 108582

095 Home Health Services 0 0

100 Other Ancillary Services 191748 191748

101 Subacute Care Ancillary Services 0 0

102 Subacute Care - Pediatric Ancillary Services 0 0

ROUTINE SERVICES

105 Skilled Nursing Care 11511 11511 11511 160536 94614 4191327 4191327 4191327 6110916 6110916

110 Intermediate Care 0 0 0 0 0

115 Mentally Disordered Care 0 0 0 0 0

120 Developmentally Disabled Care 0 0 0 0 0

125 Subacute Care 4200 4200 4200 58414 11592 2935341 2935341 2935341 3496128 3496128

126 Subacute Care - Pediatric 0 0 0 0 0

128 Transitional Inpatient Care 0 0 0 0 0

130 Hospice Inpatient Care 0 0 0 0 0

135 Other Routine Services 0 0 0 0 0

NONREIMBURSABLE

139 Residential Care 0 0

140 Beauty and Barber 168 168 168 10967 10967

145 Other Nonreimbursable 0 0

TOTAL STATISTICS 23606 22534 22502 218950 106206 7126668 7126668 7126668 12294675 12294675

TOTAL DIRECT SALARIES COSTS - SCH 2

UNIT COST MULTIPLIER (DIRECT SALARIES)

59123 $

0008296023

137462 $

0019288397

TOTAL INDIRECT SALARIES COSTS - SCH 3

UNIT COST MULTIPLIER (INDIRECT SALARIES)

99682 $

442362652

232148 $

1031675211

151907 $

069379907

466338 $

439088421

2594 $

000036403

2123 $

000029784

73880 $

001036673

$ 14785

000120252

204890 $

001666493

TOTAL INDIRECT OTHER COSTS - SCH 4

UNIT COST MULTIPLIER (INDIRECT OTHER)

305066 $

1353803142

61138 $

271701258

55273 $

025244548

340308 $

320422287

3203 $

000044942

14109 $

000197971

1300 $

000018247

$ 16304

000132609

3641 $

000029616

TOTAL CAPITAL COSTS - SCH 5

UNIT COST MULTIPLIER (CAPITAL COSTS)

$ 771463

3268080149

35034 $

155470929

1096 $

004868618

13165 $

006012848

120269 $

113241213

6034 $

000084668

4937 $

000069274

2743 $

000038486

$ 34387

000279691

7680 $

000062463

SUMMARY OF AUDITED PROGRAM EXPENSES

NPI OSHPD Facility Number

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER REPORTED

ADJUSTMENTS

AUDITED

005 01-19 Salaries and Wages 6200 $ 74327 $ 0 $ 74327

005 20-39 Fringe Benefits 6200 25355 0 25355

005 79 Agency Staff 6200 0 0 0

005 40-99 Other - Nonlabor 6200 277483 27583 305066

005 Plant Operations and Maintenance - Total 6200 $ 377165 $ 27583 $ 404748

010 Housekeeping

010 20-39 Fringe Benefits 6300 0 0 0

010 79 Agency Staff 6300 275148 (43142) 232006

010 40-99 Other - Nonlabor 6300 17563 43142 60705

010 Housekeeping - Total 6300 $ 292711 $ 0 $ 292711

015 Depreciation Buildings and Improvements 7110 - 7120 $ 0 $ 0 $ 0

020 Depreciation Leasehold Improvements 7130 64447 0 64447

025 Depreciation Equipment 7140 62723 0 62723

030 Depreciation and Amortization - Other 7150 - 7160 0 0 0

035 Leases and Rentals 7200 587111 26062 613173

040 Property Taxes 7300 26550 4570 31120

045 Property Insurance 7400 13941 (5142) 8799

050 Interest - Property Plant and Equipment 7500 0 0 0

055 Interest - Other 7600 90656 (6323) 84333

057 Subtotal 005 - 055 $ 1515304 $ 46750 $ 1562054

060 20-39 Fringe Benefits 6400 0 0 0

060 79 Agency Staff 6400 173797 (27550) 146247

060 40-99 Other - Nonlabor 6400 21481 27550 49031

060 Laundry and Linen - Total 6400 $ 195278 $ 0 $ 195278

065 Dietary

065 20-39 Fringe Benefits 6500 121973 0 121973

065 79 Agency Staff 6500 0 0 0

065 40-99 Other - Nonlabor 6500 268049 15236 283285

065 Dietary - Total 6500 $ 682678 $ 15236 $ 697914

070 Provision for Bad Debts 7700 $ 0 $ 0 $ 0

Ancillary Services

075 Patient Supplies

075 20-39 Fringe Benefits 8100 0 0 0

075 79 Agency Staff 8100 0 0 0

075 40-99 Other - Nonlabor 8100 209288 (133296) 75992

075 Patient Supplies - Total 8100 $ 209288 $ (133296) $ 75992

077 Specialized Support Surfaces

077 20-39 Fringe Benefits 8150 0 0 0

077 79 Agency Staff 8150 0 0 0

077 40-99 Other - Nonlabor 8150 0 133296 133296

077 Specialized Support Surfaces - Total 8150 $ 0 $ 133296 $ 133296

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 5)

(Sch 6)

(Sch 5)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

080 Physical Therapy

080 20-39 Fringe Benefits 8200 0 0 0

080 79 Agency Staff 8200 0 0 0

080 40-99 Other - Nonlabor 8200 648743 0 648743

080 Physical Therapy - Total 8200 $ 648743 $ 0 $ 648743

081 Respiratory Therapy

081 20-39 Fringe Benefits 8220 0 0 0

081 79 Agency Staff 8220 0 0 0

081 40-99 Other - Nonlabor 8220 0 0 0

081 Respiratory Therapy - Total 8220 $ 0 $ 0 $ 0

082 Occupational Therapy

082 20-39 Fringe Benefits 8250 0 0 0

082 79 Agency Staff 8250 0 0 0

082 40-99 Other - Nonlabor 8250 622924 0 622924

082 Occupational Therapy - Total 8250 $ 622924 $ 0 $ 622924

083 Speech Pathology

083 20-39 Fringe Benefits 8280 0 0 0

083 79 Agency Staff 8280 0 0 0

083 40-99 Other - Nonlabor 8280 340620 0 340620

083 Speech Pathology - Total 8280 $ 340620 $ 0 $ 340620

085 Pharmacy

085 20-39 Fringe Benefits 8300 0 0 0

085 79 Agency Staff 8300 0 0 0

085 40-99 Other - Nonlabor 8300 482690 0 482690

085 Pharmacy - Total 8300 $ 482690 $ 0 $ 482690

090 Laboratory

090 20-39 Fringe Benefits 8400 0 0 0

090 79 Agency Staff 8400 0 0 0

090 40-99 Other - Nonlabor 8400 108582 0 108582

090 Laboratory - Total 8400 $ 108582 $ 0 $ 108582

095 Home Health Services

095 20-39 Fringe Benefits 8800 0 0 0

095 79 Agency Staff 8800 0 0 0

095 40-99 Other - Nonlabor 8800 0 0 0

095 Home Health Services - Total 8800 $ 0 $ 0 $ 0

100 Other Ancillary Services

100 20-39 Fringe Benefits 8900 0 0 0

100 79 Agency Staff 8900 0 0 0

100 40-99 Other - Nonlabor 8900 189504 2244 191748

100 Other Ancillary Services - Total 8900 $ 189504 $ 2244 $ 191748

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

101 Subacute Care Ancillary Services

101 01-19 Salaries and Wages 8100-8900 $ 0 $ 0 $ 0

101 20-39 Fringe Benefits 8100-8900 0 0 0

101 79 Agency Staff 8100-8900 0 0 0

101 40-99 Other - Nonlabor 8100-8900 0 0 0

101 Subacute Care Ancillary Services - Total 8100-8900 $ 0 $ 0 $ 0

102 Subacute Care - Pediatric Ancillary Services

102 20-39 Fringe Benefits 8100-8900 0 0 0

102 79 Agency Staff 8100-8900 0 0 0

102 40-99 Other - Nonlabor 8100-8900 0 0 0

102 Subacute Care - Pediatric Ancillary Services - Total 8100-8900 $ 0 $ 0 $ 0

104 Subtotal 075 - 102 $ 2602351 $ 2244 $ 2604595

Routine Services

105 Skilled Nursing Care

105 01-19 Salaries and Wages 6110 $ 2998366 $ (33894) $ 2964472

105 20-39 Fringe Benefits 6110 957187 (4396) 952791

105 49 Agency Staff 6110 0 0 0

105 40-99 Other - Nonlabor 6110 406243 (132179) 274064

105 Skilled Nursing Care - Total 6110 $ 4361796 $ (170469) $ 4191327

110 Intermediate Care

110 20-39 Fringe Benefits 6120 0 0 0

110 49 Agency Staff 6120 0 0 0

110 40-99 Other - Nonlabor 6120 0 0 0

110 Intermediate Care - Total 6120 $ 0 $ 0 $ 0

115 Mentally Disordered Care

115 20-39 Fringe Benefits 6130 0 0 0

115 49 Agency Staff 6130 0 0 0

115 40-99 Other - Nonlabor 6130 0 0 0

115 Mentally Disordered Care - Total 6130 $ 0 $ 0 $ 0

120 Developmentally Disabled Care

120 20-39 Fringe Benefits 6140 0 0 0

120 49 Agency Staff 6140 0 0 0

120 40-99 Other - Nonlabor 6140 0 0 0

120 Developmentally Disabled Care - Total 6140 $ 0 $ 0 $ 0

125 Subacute Care

125 20-39 Fringe Benefits 6150 581593 0 581593

125 49 Agency Staff 6150 0 0 0

125 40-99 Other - Nonlabor 6150 763239 (269123) 494116

125 Subacute Care - Total 6150 $ 3204464 $ (269123) $ 2935341

126 Subacute Care - Pediatric

126 20-39 Fringe Benefits 6160 0 0 0

126 49 Agency Staff 6160 0 0 0

126 40-99 Other - Nonlabor 6160 0 0 0

126 Subacute Care - Pediatric - Total 6160 $ 0 $ 0 $ 0

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

128 Transitional Inpatient Care

128 20-39 Fringe Benefits 6170 0 0 0

128 49 Agency Staff 6170 0 0 0

128 40-99 Other - Nonlabor 6170 0 0 0

128 Transitional Inpatient Care - Total 6170 $ 0 $ 0 $ 0

130 Hospice Inpatient Care

130 20-39 Fringe Benefits 6180 0 0 0

130 49 Agency Staff 6180 0 0 0

130 40-99 Other - Nonlabor 6180 0 0 0

130 Hospice Inpatient Care - Total 6180 $ 0 $ 0 $ 0

135 Other Routine Services

135 20-39 Fringe Benefits 6190 0 0 0

135 49 Agency Staff 6190 0 0 0

135 40-99 Other - Nonlabor 6190 0 0 0

135 Other Routine Services - Total 6190 $ 0 $ 0 $ 0

Other Nonreimbursable

139 Residential Care

139 20-39 Fringe Benefits 9100 0 0 0

139 49 Agency Staff 9100 0 0 0

139 40-99 Other - Nonlabor 9100 0 0 0

139 Residential Care - Total 9100 $ 0 $ 0 $ 0

140 Beauty and Barber

140 20-39 Fringe Benefits 8900 0 0 0

140 49 Agency Staff 8900 0 0 0

140 40-99 Other - Nonlabor 8900 0 0 0

140 Beauty and Barber - Total 8900 $ 0 $ 0 $ 0

145 Other Nonreimbursable

145 20-39 Fringe Benefits 9100 0 0 0

145 49 Agency Staff 9100 0 0 0

145 40-99 Other - Nonlabor 9100 0 0 0

145 Other Nonreimbursable - Total 9100 $ 0 $ 0 $ 0

146 Subtotal 105 - 145 $ 7566260 $ (439592) $ 7126668

155 Social Services

155 20-39 Fringe Benefits 6600 15845 0 15845

155 49 Agency Staff 6600 342 (342) 0

155 40-99 Other - Nonlabor 6600 0 342 342

155 Social Services - Total 6600 $ 59465 $ 0 $ 59465

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

160 Activities

160 20-39 Fringe Benefits 6700 40781 0 40781

160 49 Agency Staff 6700 11768 (11768) 0

160 40-99 Other - Nonlabor 6700 0 11768 11768

160 Activities - Total 6700 $ 149230 $ 0 $ 149230

165 Administration

165 20-39 Fringe Benefits 6900 248558 (42772) 205786

165 49 Agency Staff 6900 0 0 0

165 40-99 Other - Nonlabor 6900 877263 99868 977131

165 Administration - Total 6900 $ 1791671 $ (89192) $ 1702479

166 Medical Records

166 20-39 Fringe Benefits 6900 36253 16254 52507

166 49 Agency Staff 6900 0 0 0

166 40-99 Other - Nonlabor 6900 0 0 0

166 Medical Records - Total 6900 $ 185334 $ 16254 $ 201588

167 CDPH Licensing Fees 6900 $ 55171 $ (16978) $ 38193

168 Professional Liability Insurance 6900 $ 143789 $ (4493) $ 139296

169 Quality Assurance Fees 6900 $ 653205 $ 0 $ 653205

170 20-39 Fringe Benefits 6800 13026 0 13026

170 49 Agency Staff 6800 0 0 0

170 40-99 Other - Nonlabor 6800 0 0 0

170 Inservice Education - Nursing - Total 6800 $ 72701 $ 0 $ 72701

174 Caregiver Training

174 20-39 Fringe Benefits 6900 0 0 0

174 49 Agency Staff 6900 0 0 0

174 40-99 Other - Nonlabor 6900 0 0 0

174 Caregiver Training - Total 6900 $ 0 $ 0 $ 0

Subtotal 155 - 174 $ 3110566 $ (94409) $ 3016157

200 Total $ 15672437 $ (469771) $ 15202666

(Sch 2)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

210 024 Total Facility Group Health Insurance (Adj 1) 6900 $ 494098

For informational purposes only this amount is included in various cost centers above

STATE OF CALIFORNIA RECLASSIFICATIONS ANDOR ADJUSTMENTS TO REPORTED COSTS Schedule 8A-1

W INDSOR ELMHAVEN CARE CENTER 1396881033 206390865 JANUARY 1 2012 THROUGH DECEMBER 31 2012

TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

Line Sub (Pages 123amp4) 2 3 4 5 6 7 8 9

005 1 Plant Operations and Maintenance - Salaries and W ages 0

005 2 Plant Operations and Maintenance - Fringe Benefits 0

005 3 Plant Operations and Maintenance - Agency Staff 0

005 4 Plant Operations and Maintenance - Other - Nonlabor 27583

010 1 Housekeeping - Salaries and W ages 0

010 2 Housekeeping - Fringe Benefits 0

010 3 Housekeeping - Agency Staff (43142) (40477) (2665)

010 4 Housekeeping - Other - Nonlabor 43142 40477 2665

015 4 Depreciation Buildings and Improvements 0

020 4 Depreciation Leasehold Improvements 0

025 4 Depreciation Equipment 0

030 4 Depreciation and Amortization - Other 0

035 4 Leases and Rentals 26062 1852

040 4 Property Taxes 4570 4570

045 4 Property Insurance (5142)

050 4 Interest - Property Plant and Equipment 0

055 4 Interest - Other (6323)

060 1 Laundry and Linen - Salaries and W ages 0

060 2 Laundry and Linen - Fringe Benefits 0

060 3 Laundry and Linen - Agency Staff (27550) (27550)

060 4 Laundry and Linen - Other - Nonlabor 27550 27550

065 1 Dietary - Salaries and Wages 0

065 2 Dietary - Fringe Benefits 0

065 3 Dietary - Agency Staff 0

065 4 Dietary - Other - Nonlabor 15236 (1852)

070 4 Provision for Bad Debts 0

075 1 Patient Supplies - Salaries and W ages 0

075 2 Patient Supplies - Fringe Benefits 0

075 3 Patient Supplies - Agency Staff 0

075 4 Patient Supplies - Other - Nonlabor (133296) (133296)

077 1 Specialized Support Surfaces - Salaries and W ages 0

077 2 Specialized Support Surfaces - Fringe Benefits 0

077 3 Specialized Support Surfaces - Agency Staff 0

077 4 Specialized Support Surfaces - Other - Nonlabor 133296 133296

080 1 Physical Therapy - Salaries and W ages 0

080 2 Physical Therapy - Fringe Benefits 0

080 3 Physical Therapy - Agency Staff 0

080 4 Physical Therapy - Other - Nonlabor 0

081 1 Respiratory Therapy - Salaries and W ages 0

081 2 Respiratory Therapy - Fringe Benefits 0

081 3 Respiratory Therapy - Agency Staff 0

081 4 Respiratory Therapy - Other - Nonlabor 0

082 1 Occupational Therapy - Salaries and W ages 0

082 2 Occupational Therapy - Fringe Benefits 0

082 3 Occupational Therapy - Agency Staff 0

082 4 Occupational Therapy - Other - Nonlabor 0

083 1 Speech Pathology - Salaries and W ages 0

083 2 Speech Pathology - Fringe Benefits 0

083 3 Speech Pathology - Agency Staff 0

083 4 Speech Pathology - Other - Nonlabor 0

085 1 Pharmacy - Salaries and Wages 0

085 2 Pharmacy - Fringe Benefits 0

085 3 Pharmacy - Agency Staff 0

085 4 Pharmacy - Other - Nonlabor 0

090 1 Laboratory - Salaries and W ages 0

090 2 Laboratory - Fringe Benefits 0

090 3 Laboratory - Agency Staff 0

090 4 Laboratory - Other - Nonlabor 0

095 1 Home Health Services - Salaries and W ages 0

095 2 Home Health Services - Fringe Benefits 0

095 3 Home Health Services - Agency Staff 0

095 4 Home Health Services - Other - Nonlabor 0

100 1 Other Ancillary Services - Salaries and W ages 0

100 2 Other Ancillary Services - Fringe Benefits 0

100 3 Other Ancillary Services - Agency Staff 0

100 4 Other Ancillary Services - Other - Nonlabor 2244 2244

101 1 Subacute Care Ancillary Services - Salaries and W ages 0

101 2 Subacute Care Ancillary Services - Fringe Benefits 0

101 3 Subacute Care Ancillary Services - Agency Staff 0

101 4 Subacute Care Ancillary Services - Other - Nonlabor 0

102 1 Subacute Pediatric Ancillary Services - Salaries and W ages 0

102 2 Subacute Pediatric Ancillary Services - Fringe Benefits 0

102 3 Subacute Pediatric Ancillary Services - Agency Staff 0

102 4 Subacute Pediatric Ancillary Services - Other - Nonlabor 0

105 1 Skilled Nursing Care - Salaries and W ages (33894)

105 2 Skilled Nursing Care - Fringe Benefits (4396)

105 3 Skilled Nursing Care - Agency Staff 0

105 4 Skilled Nursing Care - Other - Nonlabor (132179) (2244)

110 1 Intermediate Care - Salaries and W ages 0

110 2 Intermediate Care - Fringe Benefits 0

110 3 Intermediate Care - Agency Staff 0

110 4 Intermediate Care - Other - Nonlabor 0

115 1 Mentally Disordered Care - Salaries and W ages 0

115 2 Mentally Disordered Care - Fringe Benefits 0

115 3 Mentally Disordered Care - Agency Staff 0

115 4 Mentally Disordered Care - Other - Nonlabor 0

120 1 Developmentally Disabled Care - Salaries and W ages 0

120 2 Developmentally Disabled Care - Fringe Benefits 0

120 3 Developmentally Disabled Care - Agency Staff 0

120 4 Developmentally Disabled Care - Other - Nonlabor 0

125 1 Subacute Care - Salaries and W ages 0

125 2 Subacute Care - Fringe Benefits 0

125 3 Subacute Care - Agency Staff 0

125 4 Subacute Care - Other - Nonlabor (269123)

126 1 Subacute Care - Pediatric - Salaries and W ages 0

126 2 Subacute Care - Pediatric - Fringe Benefits 0

126 3 Subacute Care - Pediatric - Agency Staff 0

126 4 Subacute Care - Pediatric - Other - Nonlabor 0

128 1 Transitional Inpatient Care - Salaries and W ages 0

128 2 Transitional Inpatient Care - Fringe Benefits 0

128 3 Transitional Inpatient Care - Agency Staff 0

128 4 Transitional Inpatient Care - Other - Nonlabor 0

130 1 Hospice Inpatient Care - Salaries and W ages 0

130 2 Hospice Inpatient Care - Fringe Benefits 0

130 3 Hospice Inpatient Care - Agency Staff 0

130 4 Hospice Inpatient Care - Other - Nonlabor 0

135 1 Other Routine Services - Salaries and W ages 0

135 2 Other Routine Services - Fringe Benefits 0

135 3 Other Routine Services - Agency Staff 0

135 4 Other Routine Services - Other - Nonlabor 0

139 1 Residential Care - Salaries and W ages 0

139 2 Residential Care - Fringe Benefits 0

139 3 Residential Care - Agency Staff 0

139 4 Residential Care - Other - Nonlabor 0

140 1 Beauty and Barber - Salaries and W ages 0

140 2 Beauty and Barber - Fringe Benefits 0

140 3 Beauty and Barber - Agency Staff 0

140 4 Beauty and Barber - Other - Nonlabor 0

145 1 Other Nonreimbursable - Salaries and W ages 0

145 2 Other Nonreimbursable - Fringe Benefits 0

145 3 Other Nonreimbursable - Agency Staff 0

145 4 Other Nonreimbursable - Other - Nonlabor 0

155 1 Social Services - Salaries and W ages 0

155 2 Social Services - Fringe Benefits 0

155 3 Social Services - Agency Staff (342)

155 4 Social Services - Other - Nonlabor 342

160 1 Activities - Salaries and Wages 0

160 2 Activities - Fringe Benefits 0

160 3 Activities - Agency Staff (11768)

160 4 Activities - Other - Nonlabor 11768

165 1 Administration - Salaries and W ages (146288)

165 2 Administration - Fringe Benefits (42772)

165 3 Administration - Agency Staff 0

165 4 Administration - Other - Nonlabor 99868 16978 1358 (4570)

166 1 Medical Records - Salaries and W ages 0

166 2 Medical Records - Fringe Benefits 16254

166 3 Medical Records - Agency Staff 0

166 4 Medical Records - Other - Nonlabor 0

Provider Name

W INDSOR ELMHAVEN CARE CENTER

1396881033

OSHPD Facility Number Fiscal Period

206390865 JANUARY 1 2012 THROUGH DECEMBER 31 2012

4 CDPH Licensing Fees

4 Professional Liability Insurance

4 Quality Assurance Fees

1 Inservice Education - Nursing - Salaries and W ages

2 Inservice Education - Nursing - Fringe Benefits

3 Inservice Education - Nursing - Agency Staff

4 Inservice Education - Nursing - Other - Nonlabor

1 Caregiver Training - Salaries and W ages

2 Caregiver Training - Fringe Benefits

3 Caregiver Training - Agency Staff

4 Caregiver Training - Other - Nonlabor

TOTAL ADJ

(Pages 123amp4)

(16978)

(4493)

AUDIT ADJ

(16978)

AUDIT ADJ

(1358)

AUDIT ADJ

200 Total ($469771)

(To Sch 8)

0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

Line Sub 10 11 12 13 14 15 16 17 18

005 1 Plant Operations and Maintenance - Salaries and W ages

005 2 Plant Operations and Maintenance - Fringe Benefits

005 3 Plant Operations and Maintenance - Agency Staff

010 1 Housekeeping - Salaries and W ages

010 2 Housekeeping - Fringe Benefits

010 3 Housekeeping - Agency Staff

010 4 Housekeeping - Other - Nonlabor

015 4 Depreciation Buildings and Improvements

020 4 Depreciation Leasehold Improvements

025 4 Depreciation Equipment

030 4 Depreciation and Amortization - Other

040 4 Property Taxes

045 4 Property Insurance

050 4 Interest - Property Plant and Equipment

055 4 Interest - Other

060 1 Laundry and Linen - Salaries and W ages

060 2 Laundry and Linen - Fringe Benefits

060 3 Laundry and Linen - Agency Staff

060 4 Laundry and Linen - Other - Nonlabor

065 1 Dietary - Salaries and Wages

065 2 Dietary - Fringe Benefits

065 3 Dietary - Agency Staff

065 4 Dietary - Other - Nonlabor 17088

070 4 Provision for Bad Debts

075 1 Patient Supplies - Salaries and W ages

075 2 Patient Supplies - Fringe Benefits

075 3 Patient Supplies - Agency Staff

075 4 Patient Supplies - Other - Nonlabor

077 1 Specialized Support Surfaces - Salaries and W ages

077 2 Specialized Support Surfaces - Fringe Benefits

077 3 Specialized Support Surfaces - Agency Staff

077 4 Specialized Support Surfaces - Other - Nonlabor

080 1 Physical Therapy - Salaries and W ages

080 2 Physical Therapy - Fringe Benefits

080 3 Physical Therapy - Agency Staff

080 4 Physical Therapy - Other - Nonlabor

081 1 Respiratory Therapy - Salaries and W ages

081 2 Respiratory Therapy - Fringe Benefits

081 3 Respiratory Therapy - Agency Staff

081 4 Respiratory Therapy - Other - Nonlabor

082 1 Occupational Therapy - Salaries and W ages

082 2 Occupational Therapy - Fringe Benefits

082 3 Occupational Therapy - Agency Staff

082 4 Occupational Therapy - Other - Nonlabor

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

083 1 Speech Pathology - Salaries and W ages

083 2 Speech Pathology - Fringe Benefits

083 3 Speech Pathology - Agency Staff

083 4 Speech Pathology - Other - Nonlabor

085 1 Pharmacy - Salaries and Wages

085 2 Pharmacy - Fringe Benefits

085 3 Pharmacy - Agency Staff

085 4 Pharmacy - Other - Nonlabor

090 1 Laboratory - Salaries and W ages

090 2 Laboratory - Fringe Benefits

090 3 Laboratory - Agency Staff

090 4 Laboratory - Other - Nonlabor

095 1 Home Health Services - Salaries and W ages

095 2 Home Health Services - Fringe Benefits

095 3 Home Health Services - Agency Staff

095 4 Home Health Services - Other - Nonlabor

100 1 Other Ancillary Services - Salaries and W ages

100 2 Other Ancillary Services - Fringe Benefits

100 3 Other Ancillary Services - Agency Staff

100 4 Other Ancillary Services - Other - Nonlabor

101 1 Subacute Care Ancillary Services - Salaries and W ages

101 2 Subacute Care Ancillary Services - Fringe Benefits

101 3 Subacute Care Ancillary Services - Agency Staff

101 4 Subacute Care Ancillary Services - Other - Nonlabor

102 1 Subacute Pediatric Ancillary Services - Salaries and W ages

102 2 Subacute Pediatric Ancillary Services - Fringe Benefits

102 3 Subacute Pediatric Ancillary Services - Agency Staff

102 4 Subacute Pediatric Ancillary Services - Other - Nonlabor

105 1 Skilled Nursing Care - Salaries and W ages

105 2 Skilled Nursing Care - Fringe Benefits

105 3 Skilled Nursing Care - Agency Staff

105 4 Skilled Nursing Care - Other - Nonlabor (19706) (9250) (53730) (34425)

110 1 Intermediate Care - Salaries and W ages

110 2 Intermediate Care - Fringe Benefits

110 3 Intermediate Care - Agency Staff

110 4 Intermediate Care - Other - Nonlabor

115 1 Mentally Disordered Care - Salaries and W ages

115 2 Mentally Disordered Care - Fringe Benefits

115 3 Mentally Disordered Care - Agency Staff

115 4 Mentally Disordered Care - Other - Nonlabor

120 1 Developmentally Disabled Care - Salaries and W ages

120 2 Developmentally Disabled Care - Fringe Benefits

120 3 Developmentally Disabled Care - Agency Staff

120 4 Developmentally Disabled Care - Other - Nonlabor

125 1 Subacute Care - Salaries and W ages

125 2 Subacute Care - Fringe Benefits

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

125 3 Subacute Care - Agency Staff

125 4 Subacute Care - Other - Nonlabor (4504) (17088) (72000)

126 1 Subacute Care - Pediatric - Salaries and W ages

126 2 Subacute Care - Pediatric - Fringe Benefits

126 3 Subacute Care - Pediatric - Agency Staff

126 4 Subacute Care - Pediatric - Other - Nonlabor

128 1 Transitional Inpatient Care - Salaries and W ages

128 2 Transitional Inpatient Care - Fringe Benefits

128 3 Transitional Inpatient Care - Agency Staff

128 4 Transitional Inpatient Care - Other - Nonlabor

130 1 Hospice Inpatient Care - Salaries and W ages

130 2 Hospice Inpatient Care - Fringe Benefits

130 3 Hospice Inpatient Care - Agency Staff

130 4 Hospice Inpatient Care - Other - Nonlabor

135 1 Other Routine Services - Salaries and W ages

135 2 Other Routine Services - Fringe Benefits

135 3 Other Routine Services - Agency Staff

135 4 Other Routine Services - Other - Nonlabor

139 1 Residential Care - Salaries and W ages

139 2 Residential Care - Fringe Benefits

139 3 Residential Care - Agency Staff

139 4 Residential Care - Other - Nonlabor

140 1 Beauty and Barber - Salaries and W ages

140 2 Beauty and Barber - Fringe Benefits

140 3 Beauty and Barber - Agency Staff

140 4 Beauty and Barber - Other - Nonlabor

145 1 Other Nonreimbursable - Salaries and W ages

145 2 Other Nonreimbursable - Fringe Benefits

145 3 Other Nonreimbursable - Agency Staff

145 4 Other Nonreimbursable - Other - Nonlabor

155 1 Social Services - Salaries and W ages

155 2 Social Services - Fringe Benefits

160 1 Activities - Salaries and Wages

160 2 Activities - Fringe Benefits

165 1 Administration - Salaries and W ages

165 3 Administration - Agency Staff

165 4 Administration - Other - Nonlabor 9250 53730 72000

166 1 Medical Records - Salaries and W ages

166 3 Medical Records - Agency Staff

166 4 Medical Records - Other - Nonlabor

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

167 4 CDPH Licensing Fees

168 4 Professional Liability Insurance

169 4 Quality Assurance Fees

170 1 Inservice Education - Nursing - Salaries and W ages

170 2 Inservice Education - Nursing - Fringe Benefits

170 3 Inservice Education - Nursing - Agency Staff

170 4 Inservice Education - Nursing - Other - Nonlabor

174 1 Caregiver Training - Salaries and W ages

174 2 Caregiver Training - Fringe Benefits

174 3 Caregiver Training - Agency Staff

174 4 Caregiver Training - Other - Nonlabor

200 Total 0 0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

005 4 Plant Operations and Maintenance - Other - Nonlabor (1149) (4943) (750)

035 4 Leases and Rentals

065 4 Dietary - Other - Nonlabor

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

125 4 Subacute Care - Other - Nonlabor

155 3 Social Services - Agency Staff

155 4 Social Services - Other - Nonlabor

160 3 Activities - Agency Staff

160 4 Activities - Other - Nonlabor

165 4 Administration - Other - Nonlabor (48878)

166 2 Medical Records - Fringe Benefits

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

005 4 Plant Operations and Maintenance - Other - Nonlabor

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

165 2 Administration - Fringe Benefits

165 4 Administration - Other - Nonlabor

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

STATE OF CALIFORNIA SUBACUTE CARE SCHEDULE 1

SUMMARY OF AUDITED SUBACUTE CARE COSTS AND INFORMATION

1396881033 206390865

DESCRIPTION

AS REPORTED AS AUDITED PER PATIENT DAY

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE ROUTINE

3 Cost of Direct and Indirect NonLabor (Sch 4 Ln 125) $ NA $ 627614 $ 5372

11 Cost of Routine ServiceAudited Total Routine Costs $ 5015638 $ 4323047 $ 37003 12 Routine Cost Per Patient Day (Routine Cost Divided by Days) $ 42646 $ 37003

SUBACUTE CARE ANCILLARY

15 Cost of Direct and Indirect Nonlabor (Subacute Care Sch 2 Ln 124) $ NA $ 370319 $ 3170

16 Cost of Capital Related (Subacute Care Sch 2 Ln 125) $ NA $ 4618 $ 040 17 Property Taxes (Subacute Care Sch 2 Ln 126) $ NA $ 194 $ 002 18 CDPH Licensing Fees (Subacute Care Sch 2 Ln 127) $ NA $ 1164 $ 010 19 Professional Liability Insurance (Subacute Care Sch 2 Ln 128) $ NA $ 4246 $ 036 20 Quality Assurance Fees (Subacute Care Sch 2 Ln 129) $ NA $ 19911 $ 170 21 Caregiver Training (Subacute Care Sch 2 Ln 130) $ NA $ 0 $ 000

22 Cost of Administration (Subacute Care Sch 2 Ln 131) $ NA $ 54733 $ 468

23 Cost of Ancillary ServiceAudited Total Ancillary Costs $ 561212 $ 463398 $ 3966 24 Ancillary Cost Per Patient Day (Ancillary Cost Divided by Days) $ 4772 $ 3966

25 Cost of Direct Care - Labor (Line 1 + Line 13) $ NA $ 2522195 $ 21589

26 Cost of Indirect Care - Labor (Line 2 + Line 14) $ NA $ 256389 $ 2195

27 Cost of Direct and Indirect Nonlabor (Line 3 + Line 15) $ NA $ 997934 $ 8542

28 Cost of Capital Related (Line 4 + Line 16) $ NA $ 175671 $ 1504 29 Property Taxes (Line 5 + Line 17) $ NA $ 7384 $ 063 30 CDPH Licensing Fees (Line 6 + Line 18) $ NA $ 12025 $ 103 31 Professional Liability Insurance (Line 7 + Line 19) $ NA $ 43856 $ 375 32 Quality Assurance Fees (Line 8 + Line 20) $ NA $ 205657 $ 1760 33 Caregiver Training (Line 9 + Line 21) $ NA $ 0 $ 000

34 Cost of Administration (Line 10 + Line 22) $ NA $ 565335 $ 4839

35 Total Cost of Subacute Service (Line 11 + Line 23) $ 5576850 $ 4786445 $ 40969

37 Total Cost Per Patient Day (Total Cost Divided by Days) $ 47418 $ 40969

38 Medi-Cal Overpayments (Adj ) $ 0 $ 0

39 Medi-Cal Credit Balances (Adj ) $ 0 $ 0

40 Amount Due Provider (State) (Line 38 + Line 39) $ 0 $ 0

SUBACUTE CARE TOTAL

GENERAL INFORMATION

41 Contracted Number of Subacute Care Beds (Adj 46) 0 34

42 Total Licensed Nursing Facility Beds (Adj ) 128 128

43 Total Licensed Capacity (All levels) (Adj ) 128 128

44 Total Medi-Cal Subacute Care Patient Days (Adj 38) 9496 9121

CAPITAL RELATED COST

45 Direct Capital Related Cost (Adj ) $ NA $ 0

46 Indirect Capital Related Cost (Line 28) $ NA $ 175671

47 Total Capital Related Cost (Line 45 + Line 46) $ 0 $ 175671

VENTILATOR NONVENTILATOR (Adj )

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

48 Ventilator (Equipment Cost Only) $ 0 7740 6081

49 Nonventilator NA 3943 3040

50 TOTAL $ NA 11683 9121

(To Schedule 1)

SUMMARY OF TOTAL ALLOWABLE SUBACUTE CARE ANCILLARY COSTS

1396881033 206390865

DESCRIPTION ANCILLARY

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

1 Cost of Direct Care - Labor (Sch 2 Ln 75) $ 0 $ 0

2 Cost of Indirect Care - Labor (Sch 3 Ln 75) 1358 1145

3 Cost of Direct and Indirect Nonlabor (Sch 4 Ln 75) 76115 64172

4 Cost of Capital Related (Sch 5 Ln 75) 250 210

5 Property Taxes (Sch 5 Ln 75) 10 9

6 CDPH Licensing Fees (Sch 6 Ln 75) 236 199

7 Professional Liability Insurance (Sch 6 Ln 75) 861 726

8 Quality Assurance Fees (Sch 6 Ln 75) 4037 3404

9 Caregiver Training (Sch 6 Ln 75) 0 0

10 Cost of Administration (Sch 6 Ln 75) 11098 9357

11 Total Patient Supplies Ancillary Service $ 93966 $ 94104 0998533 $ 79338 $ 79222

SPECIALIZED SUPPORT SURFACES

12 Cost of Direct Care - Labor (Sch 2 Ln 77) $ 0 $ NA

22 Total Specialized Support Surfaces Ancillary Service $ 164824 $ 184589 0892923 $ 0 $ 0

PHYSICAL THERAPY

33 Total Physical Therapy Ancillary Service $ 838026 $ 1069151 0783824 $ 89712 $ 70318

RESPIRATORY THERAPY

44 Total Respiratory Ancillary Service $ 0 $ 0 0000000 $ 0 $ 0

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

OCCUPATIONAL THERAPY

55 Total Occupational Therapy Ancillary Service $ 804728 $ 1029158 0781929 $ 84932 $ 66411

SPEECH PATHOLOGY

66 Total Speech Pathology Ancillary Service $ 439993 $ 582780 0754989 $ 76175 $ 57511

PHARMACY

77 Total Pharmacy Ancillary Service $ 596858 $ 713350 0836697 $ 61282 $ 51274

LABORATORY

88 Total Laboratory Ancillary Service $ 134264 $ 205340 0653863 $ 137866 $ 90145

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

HOME HEALTH SERVICES

99 Total Home Health Services Ancillary Service $ 0 $ 0 0000000 $ 0 $ 0

OTHER ANCILLARY SERVICES

110 Total Other Ancillary Service $ 237101 $ 326478 0726239 $ 66806 $ 48517

SUBACUTE CARE ANCILLARY SERVICES

111 Cost of Direct Care - Labor (Sch 2 Ln 101) $ 0

112 Cost of Indirect Care - Labor (Sch 3 Ln 101) 0

113 Cost of Direct and Indirect Nonlabor (Sch 4 Ln 101) 0

114 Cost of Capital Related (Sch 5 Ln 101) 0

115 Property Taxes (Sch 5 Ln 101) 0

116 CDPH Licensing Fees (Sch 6 Ln 101) 0

117 Professional Liability Insurance (Sch 6 Ln 101) 0

118 Quality Assurance Fees (Sch 6 Ln 101) 0

119 Caregiver Training (Sch 6 Ln 101) 0

120 Cost of Administration (Sch 6 Ln 101) 0

121 Total Subacute Ancillary Service $ 0

TOTAL COST OF ANCILLARY SERVICES

122 Cost of Direct Care - Labor $ 0

123 Cost of Indirect Care - Labor 8213

124 Cost of Direct and Indirect Nonlabor 370319

125 Cost of Capital Related 4618

126 Property Taxes 194

127 CDPH Licensing Fees 1164

128 Professional Liability Insurance 4246

129 Quality Assurance Fees 19911

130 Caregiver Training 0

131 Cost of Administration 54733

132 Total Cost of Subacute Care Ancillary Services $ 463398

Total Ancillary Costs included in the rate (To Subacute Care Sch 1)

State of California Department of Health Care Services

Provider Name WINDSOR ELMHAVEN CARE CENTER

Fiscal Period JANUARY 1 2012 THROUGH DECEMBER 31 2012

Provider NPI 1396881033

Adjustments 46

Report References

Explanation of Audit Adjustments As

Reported Increase

(Decrease) As

Adjusted Adj No

Cost Report Audit Report MC530 Page or Exhibit Line Col Sch Line Sub No

MEMORANDUM ADJUSTMENT

1 Not Reported 8 210 Total Facility Group Health Insurance To include group health insurance in the audit report for informational purposes only 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

RECLASSIFICATIONS OF REPORTED COSTS

Housekeeping - Agency Staff Laundry and Linen - Agency Staff Housekeeping - Other - Nonlabor Laundry and Linen - Other - Nonlabor

To reclassify the non-labor portion of agency costs to the appropriate cost centers for proper cost determination 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 52502(c)(1)

Housekeeping - Agency Staff Housekeeping - Other - Nonlabor

To reclassify exterminator service costs to the appropriate cost center 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 52502(c)(1)

Administration - CDPH Licensing Fees Administration - Other - Nonlabor

To reclassify other licenses and taxes to the appropriate cost center 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 23024 and 23028 CCR Title 22 Sections 52000 and 52506

Administration - Professional Liability Insurance Administration - Other - Nonlabor

To reclassify all other insurance expenses to the appropriate cost center for proper cost determination 42 CFR 41324 CMS Pub 15-1 Sections 2304 and 2162 CCR Title 22 Sections 52000(b) 52501 and 52507

Balance carried forward from priorto subsequent adjustments

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

Administration - Other - Nonlabor Property Taxes

To reclassify personal property tax expenses to the appropriate cost center for proper cost determination 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 23024 and 23028

Dietary - Other - Nonlabor Leases and Rentals

To reclassify lease expenses to the appropriate cost center for proper cost determination 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 52000(e) and 52501

Patient Supplies - Other - Nonlabor Specialized Support Surfaces - Other - Nonlabor

To reclassify specialized supportive surfaces to the appropriate cost center 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 23024 and 23028

Skilled Nursing Care - Other - Nonlabor Other Ancillary Services - Other - Nonlabor

To reclassify oxygen expenses to an ancillary cost center for proper cost determination 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 22028 and 22032

Skilled Nursing Care - Other - Nonlabor Leases and Rentals

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

Subacute Care - Other - Nonlabor Leases and Rentals

Skilled Nursing Care - Other - Nonlabor Administration - Other - Nonlabor

To reclassify utilization review expenses to the appropriate cost center for proper cost determination 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 23024 and 23028

Subacute Care - Other - Nonlabor Dietary - Other - Nonlabor

To reclassify dietary expenses to the appropriate cost center for proper cost determination 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 23024 and 23028

To reclassify medical director fees to the appropriate cost center 42 CFR 48375(i)(2) 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 52000(b)

Subacute Care - Other - Nonlabor Administration - Other - Nonlabor

To reclassify utilization review expenses to the appropriate cost center 42 CFR 48375(i)(2) 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 52000(b)

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

Social Services - Agency Staff Activities - Agency Staff Social Services - Other - Nonlabor Activities - Other - Nonlabor

To reclassify other - nonlabor costs to the appropriate cost centers 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 23024 and 23028

Administration - Fringe Benefits Medical Records - Fringe Benefits

To reclassify the medical records fringe benefits to the medical records cost center for proper cost determination 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 52000

Skilled Nursing Care - Other - Nonlabor Plant Operations and Maintenance - Other - Nonlabor

To reclassify medical waste expenses to the appropriate cost center for proper cost determination 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 23024 and 23028

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

ADJUSTMENTS TO REPORTED COSTS

Property Insurance Interest - Other Skilled Nursing Care - Other - Nonlabor

To reconcile the reported expenses to agree with the providers trial balance 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

Skilled Nursing Care - Salaries and W ages Skilled Nursing Care - Fringe Benefits Administration - Salaries and W ages Administration - Fringe Benefits

To eliminate corporate clinical and administrative payroll expenses at the facility level because the expenses will be allocated through the home office audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 21503 2300 2304 and 2306

Administration - Professional Liability Insurance

To reconcile the reported expenses to agree with the providers general ledgers 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

To reconcile the reported expenses to agree with the providers liability insurance policies 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

Administration - Other - Nonlabor To adjust reported home office costs to agree with the SnF Management Company Inc home office audit report for fiscal period ended December 31 2012 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Plant Operations and Maintenance - Other - Nonlabor

To eliminate plant operations and maintenance expenses due to lack of documentation 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code Section 141242(b)

To eliminate nonallowable patient cable television costs 42 CFR 4139(c)(3) 41324 and 41350 CMS Pub 15-1 Sections 21061 and 2304

To eliminate prior years plumbing expenses 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

Skilled Nursing Care - Other - Nonlabor

To eliminate skilled nursing expenses due to insufficient documentation 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

To eliminate prior years consulting expenses 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

To eliminate items not included in the routine or subacute rate 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 51511 and 515115

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

30 105 125 4 8A-1 125 4 Subacute Care - Other - Nonlabor To eliminate quality assurance fees that was double booked on the cost report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 52100 52101 and 52506

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

NA NA NA

ADJUSTMENTS TO REPORTED STATISTICS

Plant Operations and Maintenance (Square Feet) Housekeeping Laundry and Linen Dietary Physical Therapy Occupational Therapy Speech Pathology Skilled Nursing Care Subacute Care Beauty and Barber Social Services Activities Administration Medical Records Inservice Education - Nursing Total Statistics - Square Feet Total Statistics - Square Feet Total Statistics - Square Feet

To adjust square footage statistics to agree with prior years audited amount 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306

Skilled Nursing Care (Clean Dry Pounds) Subacute Care Total Statistics - Clean Dry Pounds

To adjust pounds of laundry statistics for proper allocation of cost 42 CFR 41324 CMS Pub 15-1 Sections 2300 and 2306

Skilled Nursing Care (Number of Patient Meals) Subacute Care Total Statistics - Number of Patient Meals

To adjust patient meals statistics for proper allocation of cost 42 CFR 41324 CMS Pub 15-1 Sections 2300 and 2306

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

Subacute 1 Subacute 1

ADJUSTMENTS TO REPORTED PATIENT DAYS

Total Patient Days - Skilled Nursing Care Total Patient Days - Subacute Care

To adjust total patient days to agree with the providers patient census reports 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2205 2300 and 2304

Total Subacute Care Days - Ventilator Total Subacute Care Days - Nonventilator

To adjust total adult subacute ventilator and nonventilator days in the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 Medi-Cal Adult Subacute Contract No 10-10-70185

Medi-Cal Days - Skilled Nursing Care To adjust reported Medi-Cal Nursing Facility days based on the following Fiscal Intermediary Payment Data Service Period January 1 2012 through December 31 2012 Payment Period January 1 2012 through August 16 2013 Report Date August 19 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Section 51541

Medi-Cal Managed Care Days To include Medi-Cal Managed Care days to agree with the providers patient census records 42 CFR 41320 and 41350 CMS Pub 15-1 Sections 2205 and 2304

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

Subacute 1 Subacute 1 Subacute 1

48 49 44

NA NA NA

Medi-Cal Subacute Care Days - Ventilator Medi-Cal Subacute Care Days - Nonventilator Medi-Cal Subacute Care Days - Total

To reflect subacute Medi-Cal patient days based on the following Fiscal Intermediary Payment Data Service Period January 1 2012 through December 31 2012 Payment Period January 1 2012 through August 16 2013 Report Date August 19 2013 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 Medi-Cal Subacute Care Contract No 10-10-70185

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

ADJUSTMENTS TO REPORTED TOTAL CHARGES

Subacute Care Ancillary Charges - Patient Supplies To adjust subacute ancillary charges to agree with the providers trial balance 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 2304 and 2408 CCR Title 22 Section 515115

Total Ancillary Charges - Patient Supplies Total Ancillary Charges - Specialized Support Surfaces

To reclassify specialized support surfaces total ancillary charges to the appropriate cost center 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 22028 and 22032

Subacute Care Ancillary Charges - Patient Supplies To eliminate specialized support surfaces subacute care ancillary charges not covered in the rate 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 22028 and 22032 CCR Title 22 Section 515115

Subacute Care Ancillary Charges - Pharmacy To eliminate subacute care ancillary charges related to legend drugs not covered in the rate 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 22028 and 22032 CCR Title 22 Section 515115

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

ADJUSTMENTS TO OTHER MATTERS

Overpayments

To recover Medi-Cal share of cost overpayments due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 51476 W ampI Code Section 141242(b)

To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581

To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581

Contracted Number of Subacute Care Beds To reflect the number of subacute care contracted beds in the audit report 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304

$27053

32300 $60217

$60217

Title Page


Audit Supervisor Debra K Blake

Auditor Robert Miles

Transmittal Letter with Recoupment

1212206390865D Windsor Elmhaven Care Center

1212206390865AA1 Windsor Elmhaven Care Center













TOBY DOUGLAS DIRECTOR

EDMUND G BROWN JR GOVERNOR

State of CaliforniamdashHealth and Human Services Agency Department of Health Care Services

May 13 2014

Ash Chawla Vice President of Finance SnF Management Company Inc 9200 West Sunset Boulevard Suite 700 West Hollywood CA 90069

WINDSOR ELMHAVEN CARE CENTER NATIONAL PROVIDER IDENTIFIER (NPI) 1396881033 FISCAL PERIOD ENDED DECEMBER 31 2012

We have examined the facilitys Integrated Disclosure and Medi-Cal Cost Report for the above-referenced fiscal period We also examined the facilitys use of and Records of Noncovered Services deducted from patient share of cost Our examination was made under the authority of Section 14170 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

The audit adjustments identified in this audit report correct misrepresentations andor errors that were the subject of audit adjustments in the preceding audit report for this facility issued by the Financial Audits Branch The misrepresentations andor errors in question are not subject to a pending appeal You are hereby notified Civil Money Penalties may be imposed as permitted by Welfare and Institutions Code Section 1412325 if these misrepresentations and errors are found in future cost reports filed on behalf of this facility These penalties range from $100 to $1000 per adjustment to reported costs up to three times the amount for each item or service improperly claimed whichever is greater

In our opinion the data presented in the accompanying Summary of Audited Facility Cost per Patient Day represents a proper determination of the allowable costs patient days and use of share of cost for the above fiscal period in accordance with Medi-Cal reimbursement principles

Financial AuditsBurbankA amp I MS 2101 1405 North San Fernando Boulevard Room 203 Burbank CA 91504 Telephone (818) 295-2620 FAX (818) 563-3324

Internet Address wwwdhcscagov

Ash Chawla Page 2

Ash Chawla Page 3

Original Signed By

Certified

1396881033 206390865

PROGRAM DESCRIPTION

COST PER

AUDITED

15 Medi-Cal Days (Adj 36) 19295 19312

INTERMEDIATE CARE

SUBACUTE CARE

1396881033 206390865

PROGRAM DESCRIPTION

AUDITED

COST PER

PATIENT DAY

1396881033 206390865

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8)

Soc Srvs

Activities

160 Total

GENERAL SERVICES

010 Housekeeping

065 Dietary

160 Activities 137462 $ 137462

165 Administration

166 Medical Records

ANCILLARY SERVICES

ROUTINE SERVICES

125 Subacute Care 2441225 24352 56618 2522195

NONREIMBURSABLE

TOTAL 6555073 $ $ 59123 $ 137462 $ 6555073

(To Schedule 1)

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8)

Plant Ops

Hskpng

Laundry

Dietary

Soc Srvs

Activities

Inserv Ed

Accumulated

Medical

Records

166 Total

GENERAL SERVICES

010 Housekeeping 232006 142 $ 232148

065 Dietary 414629 15518 36191 0 $ 466338

160 Activities NA 637 1486 0 0 0 2123 $

166 Medical Records 201588 991 2311 0 0 0 0 204890 204890 $

ANCILLARY SERVICES

085 Pharmacy 0 0 0 0 0 0 0 0 580 8044 8624

090 Laboratory 0 0 0 0 0 0 0 0 131 1810 1940

ROUTINE SERVICES

125 Subacute Care 18579 43330 40528 50899 1069 874 30430 185709 4204 58263 248176

NONREIMBURSABLE

TOTAL 1166853 $ 99682 $ $ 232148 151907 $ $ 466338 2594 $ 2123 $ 73880 $ 947179 $ $ 14785 204890 $ $ 1166853

(To Schedule 1)

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8)

Plant Ops

Hskpng

Laundry

Dietary

Soc Srvs

Activities

Inserv Ed

Accumulated

Medical

Records

166 Total

GENERAL SERVICES

010 Housekeeping 60705 433 $ 61138

065 Dietary 283285 47491 9531 0 $ 340308

155 Social Services 342 2383 478 0 0 3203 $

160 Activities 11768 1949 391 0 0 0 14109 $

166 Medical Records 0 3033 609 0 0 0 0 3641 3641 $

ANCILLARY SERVICES

085 Pharmacy 482690 0 0 0 0 0 0 0 482690 640 143 483473

090 Laboratory 108582 0 0 0 0 0 0 0 108582 144 32 108758

ROUTINE SERVICES

125 Subacute Care 494116 56860 11411 14746 37143 1319 5811 536 621943 4636 1035 627614

NONREIMBURSABLE

TOTAL 4082972 $ 305066 $ $ 61138 55273 $ $ 340308 3203 $ 14109 $ 1300 $ 4063027 $ $ 16304 3641 $ $ 4082972

(To Schedule 1)

Provider Name

1396881033

Fiscal Period

206390865

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8) Ratio

Inserv Ed

Accumulated

Medical

Records

166 Total

Capital

Property

Of Total

GENERAL SERVICES

010 Housekeeping

065 Dietary

155 Social Services

160 Activities

ANCILLARY SERVICES

085 Pharmacy 0 0 1350 302 1652 1585 67

090 Laboratory 0 0 304 68 372 357 15

ROUTINE SERVICES

125 Subacute Care 1130 166281 9778 2184 178243 171053 7190

NONREIMBURSABLE

TOTAL 771463$ 100 2743$ 729396$ $ 34387 7680$ $ 771463 740343$ 31120$

(To Schedule 1)

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8) Ratio

(From Sch 2)

(From Sch 3)

(From Sch 4)

(From Sch 5)

Allocated

of Total

Licensing Fees

of Total

Professional

Liability Ins

of Total

Quality Assur

of Total

Caregiver

Training

of Total

GENERAL SERVICES

Total 2626305 100 $ 2626305

ANCILLARY SERVICES

085 Pharmacy 0 0 482690 0 482690 103109 70496 1499 5469 25645 0

090 Laboratory 0 0 108582 0 108582 23195 15858 337 1230 5769 0

ROUTINE SERVICES

125 Subacute Care 2522195 185709 621943 166281 3496128 746819 510602 10861 39610 185746 0

NONREIMBURSABLE

SUBTOTAL 2626305 $ 6555073 $ 947179 $ 4063027 $ 729396 $ $ 12294675 $ 2626305

021361321

$ 1795611 38193 $ 139296 $ 653205 $ $ 0

(To Schedule 1)

Provider Name

1396881033

206390865

Fiscal Period

DESCRIPTION

Capital

(SQ FT)

VARIOUS

Plant Ops

(SQ FT)

Hskpng

(SQ FT)

Laundry

Dietary

(MEALS)

Soc Srvs

(DIRECT EXP)

Activities

(DIRECT EXP)

Inserv Ed

(DIRECT EXP)

(TOTAL

Med Records

(TOTAL

(ACCUM

GENERAL SERVICES

065 Dietary 3508 3508 3508

160 Activities 144 144 144

ANCILLARY SERVICES

085 Pharmacy 482690 482690

090 Laboratory 108582 108582

ROUTINE SERVICES

125 Subacute Care 4200 4200 4200 58414 11592 2935341 2935341 2935341 3496128 3496128

NONREIMBURSABLE

59123 $

0008296023

137462 $

0019288397

99682 $

442362652

232148 $

1031675211

151907 $

069379907

466338 $

439088421

2594 $

000036403

2123 $

000029784

73880 $

001036673

$ 14785

000120252

204890 $

001666493

305066 $

1353803142

61138 $

271701258

55273 $

025244548

340308 $

320422287

3203 $

000044942

14109 $

000197971

1300 $

000018247

$ 16304

000132609

3641 $

000029616

$ 771463

3268080149

35034 $

155470929

1096 $

004868618

13165 $

006012848

120269 $

113241213

6034 $

000084668

4937 $

000069274

2743 $

000038486

$ 34387

000279691

7680 $

000062463

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER REPORTED

ADJUSTMENTS

AUDITED

005 20-39 Fringe Benefits 6200 25355 0 25355

005 79 Agency Staff 6200 0 0 0

005 40-99 Other - Nonlabor 6200 277483 27583 305066

010 Housekeeping

010 20-39 Fringe Benefits 6300 0 0 0

010 79 Agency Staff 6300 275148 (43142) 232006

010 40-99 Other - Nonlabor 6300 17563 43142 60705

040 Property Taxes 7300 26550 4570 31120

055 Interest - Other 7600 90656 (6323) 84333

057 Subtotal 005 - 055 $ 1515304 $ 46750 $ 1562054

060 20-39 Fringe Benefits 6400 0 0 0

060 79 Agency Staff 6400 173797 (27550) 146247

060 40-99 Other - Nonlabor 6400 21481 27550 49031

065 Dietary

065 20-39 Fringe Benefits 6500 121973 0 121973

065 79 Agency Staff 6500 0 0 0

065 40-99 Other - Nonlabor 6500 268049 15236 283285

065 Dietary - Total 6500 $ 682678 $ 15236 $ 697914

Ancillary Services

075 20-39 Fringe Benefits 8100 0 0 0

075 79 Agency Staff 8100 0 0 0

075 40-99 Other - Nonlabor 8100 209288 (133296) 75992

077 20-39 Fringe Benefits 8150 0 0 0

077 79 Agency Staff 8150 0 0 0

077 40-99 Other - Nonlabor 8150 0 133296 133296

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 5)

(Sch 6)

(Sch 5)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

080 20-39 Fringe Benefits 8200 0 0 0

080 79 Agency Staff 8200 0 0 0

080 40-99 Other - Nonlabor 8200 648743 0 648743

081 20-39 Fringe Benefits 8220 0 0 0

081 79 Agency Staff 8220 0 0 0

081 40-99 Other - Nonlabor 8220 0 0 0

082 20-39 Fringe Benefits 8250 0 0 0

082 79 Agency Staff 8250 0 0 0

082 40-99 Other - Nonlabor 8250 622924 0 622924

083 20-39 Fringe Benefits 8280 0 0 0

083 79 Agency Staff 8280 0 0 0

083 40-99 Other - Nonlabor 8280 340620 0 340620

085 Pharmacy

085 20-39 Fringe Benefits 8300 0 0 0

085 79 Agency Staff 8300 0 0 0

085 40-99 Other - Nonlabor 8300 482690 0 482690

085 Pharmacy - Total 8300 $ 482690 $ 0 $ 482690

090 Laboratory

090 20-39 Fringe Benefits 8400 0 0 0

090 79 Agency Staff 8400 0 0 0

090 40-99 Other - Nonlabor 8400 108582 0 108582

095 20-39 Fringe Benefits 8800 0 0 0

095 79 Agency Staff 8800 0 0 0

095 40-99 Other - Nonlabor 8800 0 0 0

100 20-39 Fringe Benefits 8900 0 0 0

100 79 Agency Staff 8900 0 0 0

100 40-99 Other - Nonlabor 8900 189504 2244 191748

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

101 20-39 Fringe Benefits 8100-8900 0 0 0

101 79 Agency Staff 8100-8900 0 0 0

101 40-99 Other - Nonlabor 8100-8900 0 0 0

102 20-39 Fringe Benefits 8100-8900 0 0 0

102 79 Agency Staff 8100-8900 0 0 0

102 40-99 Other - Nonlabor 8100-8900 0 0 0

104 Subtotal 075 - 102 $ 2602351 $ 2244 $ 2604595

Routine Services

105 20-39 Fringe Benefits 6110 957187 (4396) 952791

105 49 Agency Staff 6110 0 0 0

105 40-99 Other - Nonlabor 6110 406243 (132179) 274064

110 20-39 Fringe Benefits 6120 0 0 0

110 49 Agency Staff 6120 0 0 0

110 40-99 Other - Nonlabor 6120 0 0 0

115 20-39 Fringe Benefits 6130 0 0 0

115 49 Agency Staff 6130 0 0 0

115 40-99 Other - Nonlabor 6130 0 0 0

120 20-39 Fringe Benefits 6140 0 0 0

120 49 Agency Staff 6140 0 0 0

120 40-99 Other - Nonlabor 6140 0 0 0

125 Subacute Care

125 20-39 Fringe Benefits 6150 581593 0 581593

125 49 Agency Staff 6150 0 0 0

125 40-99 Other - Nonlabor 6150 763239 (269123) 494116

126 20-39 Fringe Benefits 6160 0 0 0

126 49 Agency Staff 6160 0 0 0

126 40-99 Other - Nonlabor 6160 0 0 0

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

128 20-39 Fringe Benefits 6170 0 0 0

128 49 Agency Staff 6170 0 0 0

128 40-99 Other - Nonlabor 6170 0 0 0

130 20-39 Fringe Benefits 6180 0 0 0

130 49 Agency Staff 6180 0 0 0

130 40-99 Other - Nonlabor 6180 0 0 0

135 20-39 Fringe Benefits 6190 0 0 0

135 49 Agency Staff 6190 0 0 0

135 40-99 Other - Nonlabor 6190 0 0 0

139 20-39 Fringe Benefits 9100 0 0 0

139 49 Agency Staff 9100 0 0 0

139 40-99 Other - Nonlabor 9100 0 0 0

140 20-39 Fringe Benefits 8900 0 0 0

140 49 Agency Staff 8900 0 0 0

140 40-99 Other - Nonlabor 8900 0 0 0

145 20-39 Fringe Benefits 9100 0 0 0

145 49 Agency Staff 9100 0 0 0

145 40-99 Other - Nonlabor 9100 0 0 0

146 Subtotal 105 - 145 $ 7566260 $ (439592) $ 7126668

155 Social Services

155 20-39 Fringe Benefits 6600 15845 0 15845

155 49 Agency Staff 6600 342 (342) 0

155 40-99 Other - Nonlabor 6600 0 342 342

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

160 Activities

160 20-39 Fringe Benefits 6700 40781 0 40781

160 49 Agency Staff 6700 11768 (11768) 0

160 40-99 Other - Nonlabor 6700 0 11768 11768

165 Administration

165 20-39 Fringe Benefits 6900 248558 (42772) 205786

165 49 Agency Staff 6900 0 0 0

165 40-99 Other - Nonlabor 6900 877263 99868 977131

166 Medical Records

166 20-39 Fringe Benefits 6900 36253 16254 52507

166 49 Agency Staff 6900 0 0 0

166 40-99 Other - Nonlabor 6900 0 0 0

170 20-39 Fringe Benefits 6800 13026 0 13026

170 49 Agency Staff 6800 0 0 0

170 40-99 Other - Nonlabor 6800 0 0 0

174 20-39 Fringe Benefits 6900 0 0 0

174 49 Agency Staff 6900 0 0 0

174 40-99 Other - Nonlabor 6900 0 0 0

Subtotal 155 - 174 $ 3110566 $ (94409) $ 3016157

200 Total $ 15672437 $ (469771) $ 15202666

(Sch 2)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

Provider Name

1396881033

TOTAL ADJ

(Pages 123amp4)

(16978)

(4493)

AUDIT ADJ

(16978)

AUDIT ADJ

(1358)

AUDIT ADJ

200 Total ($469771)

(To Sch 8)

0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

200 Total 0 0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Ash Chawla Page 2

Ash Chawla Page 3

Original Signed By

Certified

1396881033 206390865

PROGRAM DESCRIPTION

COST PER

AUDITED

15 Medi-Cal Days (Adj 36) 19295 19312

INTERMEDIATE CARE

SUBACUTE CARE

1396881033 206390865

PROGRAM DESCRIPTION

AUDITED

COST PER

PATIENT DAY

1396881033 206390865

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8)

Soc Srvs

Activities

160 Total

GENERAL SERVICES

010 Housekeeping

065 Dietary

160 Activities 137462 $ 137462

165 Administration

166 Medical Records

ANCILLARY SERVICES

ROUTINE SERVICES

125 Subacute Care 2441225 24352 56618 2522195

NONREIMBURSABLE

TOTAL 6555073 $ $ 59123 $ 137462 $ 6555073

(To Schedule 1)

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8)

Plant Ops

Hskpng

Laundry

Dietary

Soc Srvs

Activities

Inserv Ed

Accumulated

Medical

Records

166 Total

GENERAL SERVICES

010 Housekeeping 232006 142 $ 232148

065 Dietary 414629 15518 36191 0 $ 466338

160 Activities NA 637 1486 0 0 0 2123 $

166 Medical Records 201588 991 2311 0 0 0 0 204890 204890 $

ANCILLARY SERVICES

085 Pharmacy 0 0 0 0 0 0 0 0 580 8044 8624

090 Laboratory 0 0 0 0 0 0 0 0 131 1810 1940

ROUTINE SERVICES

125 Subacute Care 18579 43330 40528 50899 1069 874 30430 185709 4204 58263 248176

NONREIMBURSABLE

TOTAL 1166853 $ 99682 $ $ 232148 151907 $ $ 466338 2594 $ 2123 $ 73880 $ 947179 $ $ 14785 204890 $ $ 1166853

(To Schedule 1)

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8)

Plant Ops

Hskpng

Laundry

Dietary

Soc Srvs

Activities

Inserv Ed

Accumulated

Medical

Records

166 Total

GENERAL SERVICES

010 Housekeeping 60705 433 $ 61138

065 Dietary 283285 47491 9531 0 $ 340308

155 Social Services 342 2383 478 0 0 3203 $

160 Activities 11768 1949 391 0 0 0 14109 $

166 Medical Records 0 3033 609 0 0 0 0 3641 3641 $

ANCILLARY SERVICES

085 Pharmacy 482690 0 0 0 0 0 0 0 482690 640 143 483473

090 Laboratory 108582 0 0 0 0 0 0 0 108582 144 32 108758

ROUTINE SERVICES

125 Subacute Care 494116 56860 11411 14746 37143 1319 5811 536 621943 4636 1035 627614

NONREIMBURSABLE

TOTAL 4082972 $ 305066 $ $ 61138 55273 $ $ 340308 3203 $ 14109 $ 1300 $ 4063027 $ $ 16304 3641 $ $ 4082972

(To Schedule 1)

Provider Name

1396881033

Fiscal Period

206390865

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8) Ratio

Inserv Ed

Accumulated

Medical

Records

166 Total

Capital

Property

Of Total

GENERAL SERVICES

010 Housekeeping

065 Dietary

155 Social Services

160 Activities

ANCILLARY SERVICES

085 Pharmacy 0 0 1350 302 1652 1585 67

090 Laboratory 0 0 304 68 372 357 15

ROUTINE SERVICES

125 Subacute Care 1130 166281 9778 2184 178243 171053 7190

NONREIMBURSABLE

TOTAL 771463$ 100 2743$ 729396$ $ 34387 7680$ $ 771463 740343$ 31120$

(To Schedule 1)

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8) Ratio

(From Sch 2)

(From Sch 3)

(From Sch 4)

(From Sch 5)

Allocated

of Total

Licensing Fees

of Total

Professional

Liability Ins

of Total

Quality Assur

of Total

Caregiver

Training

of Total

GENERAL SERVICES

Total 2626305 100 $ 2626305

ANCILLARY SERVICES

085 Pharmacy 0 0 482690 0 482690 103109 70496 1499 5469 25645 0

090 Laboratory 0 0 108582 0 108582 23195 15858 337 1230 5769 0

ROUTINE SERVICES

125 Subacute Care 2522195 185709 621943 166281 3496128 746819 510602 10861 39610 185746 0

NONREIMBURSABLE

SUBTOTAL 2626305 $ 6555073 $ 947179 $ 4063027 $ 729396 $ $ 12294675 $ 2626305

021361321

$ 1795611 38193 $ 139296 $ 653205 $ $ 0

(To Schedule 1)

Provider Name

1396881033

206390865

Fiscal Period

DESCRIPTION

Capital

(SQ FT)

VARIOUS

Plant Ops

(SQ FT)

Hskpng

(SQ FT)

Laundry

Dietary

(MEALS)

Soc Srvs

(DIRECT EXP)

Activities

(DIRECT EXP)

Inserv Ed

(DIRECT EXP)

(TOTAL

Med Records

(TOTAL

(ACCUM

GENERAL SERVICES

065 Dietary 3508 3508 3508

160 Activities 144 144 144

ANCILLARY SERVICES

085 Pharmacy 482690 482690

090 Laboratory 108582 108582

ROUTINE SERVICES

125 Subacute Care 4200 4200 4200 58414 11592 2935341 2935341 2935341 3496128 3496128

NONREIMBURSABLE

59123 $

0008296023

137462 $

0019288397

99682 $

442362652

232148 $

1031675211

151907 $

069379907

466338 $

439088421

2594 $

000036403

2123 $

000029784

73880 $

001036673

$ 14785

000120252

204890 $

001666493

305066 $

1353803142

61138 $

271701258

55273 $

025244548

340308 $

320422287

3203 $

000044942

14109 $

000197971

1300 $

000018247

$ 16304

000132609

3641 $

000029616

$ 771463

3268080149

35034 $

155470929

1096 $

004868618

13165 $

006012848

120269 $

113241213

6034 $

000084668

4937 $

000069274

2743 $

000038486

$ 34387

000279691

7680 $

000062463

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER REPORTED

ADJUSTMENTS

AUDITED

005 20-39 Fringe Benefits 6200 25355 0 25355

005 79 Agency Staff 6200 0 0 0

005 40-99 Other - Nonlabor 6200 277483 27583 305066

010 Housekeeping

010 20-39 Fringe Benefits 6300 0 0 0

010 79 Agency Staff 6300 275148 (43142) 232006

010 40-99 Other - Nonlabor 6300 17563 43142 60705

040 Property Taxes 7300 26550 4570 31120

055 Interest - Other 7600 90656 (6323) 84333

057 Subtotal 005 - 055 $ 1515304 $ 46750 $ 1562054

060 20-39 Fringe Benefits 6400 0 0 0

060 79 Agency Staff 6400 173797 (27550) 146247

060 40-99 Other - Nonlabor 6400 21481 27550 49031

065 Dietary

065 20-39 Fringe Benefits 6500 121973 0 121973

065 79 Agency Staff 6500 0 0 0

065 40-99 Other - Nonlabor 6500 268049 15236 283285

065 Dietary - Total 6500 $ 682678 $ 15236 $ 697914

Ancillary Services

075 20-39 Fringe Benefits 8100 0 0 0

075 79 Agency Staff 8100 0 0 0

075 40-99 Other - Nonlabor 8100 209288 (133296) 75992

077 20-39 Fringe Benefits 8150 0 0 0

077 79 Agency Staff 8150 0 0 0

077 40-99 Other - Nonlabor 8150 0 133296 133296

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 5)

(Sch 6)

(Sch 5)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

080 20-39 Fringe Benefits 8200 0 0 0

080 79 Agency Staff 8200 0 0 0

080 40-99 Other - Nonlabor 8200 648743 0 648743

081 20-39 Fringe Benefits 8220 0 0 0

081 79 Agency Staff 8220 0 0 0

081 40-99 Other - Nonlabor 8220 0 0 0

082 20-39 Fringe Benefits 8250 0 0 0

082 79 Agency Staff 8250 0 0 0

082 40-99 Other - Nonlabor 8250 622924 0 622924

083 20-39 Fringe Benefits 8280 0 0 0

083 79 Agency Staff 8280 0 0 0

083 40-99 Other - Nonlabor 8280 340620 0 340620

085 Pharmacy

085 20-39 Fringe Benefits 8300 0 0 0

085 79 Agency Staff 8300 0 0 0

085 40-99 Other - Nonlabor 8300 482690 0 482690

085 Pharmacy - Total 8300 $ 482690 $ 0 $ 482690

090 Laboratory

090 20-39 Fringe Benefits 8400 0 0 0

090 79 Agency Staff 8400 0 0 0

090 40-99 Other - Nonlabor 8400 108582 0 108582

095 20-39 Fringe Benefits 8800 0 0 0

095 79 Agency Staff 8800 0 0 0

095 40-99 Other - Nonlabor 8800 0 0 0

100 20-39 Fringe Benefits 8900 0 0 0

100 79 Agency Staff 8900 0 0 0

100 40-99 Other - Nonlabor 8900 189504 2244 191748

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

101 20-39 Fringe Benefits 8100-8900 0 0 0

101 79 Agency Staff 8100-8900 0 0 0

101 40-99 Other - Nonlabor 8100-8900 0 0 0

102 20-39 Fringe Benefits 8100-8900 0 0 0

102 79 Agency Staff 8100-8900 0 0 0

102 40-99 Other - Nonlabor 8100-8900 0 0 0

104 Subtotal 075 - 102 $ 2602351 $ 2244 $ 2604595

Routine Services

105 20-39 Fringe Benefits 6110 957187 (4396) 952791

105 49 Agency Staff 6110 0 0 0

105 40-99 Other - Nonlabor 6110 406243 (132179) 274064

110 20-39 Fringe Benefits 6120 0 0 0

110 49 Agency Staff 6120 0 0 0

110 40-99 Other - Nonlabor 6120 0 0 0

115 20-39 Fringe Benefits 6130 0 0 0

115 49 Agency Staff 6130 0 0 0

115 40-99 Other - Nonlabor 6130 0 0 0

120 20-39 Fringe Benefits 6140 0 0 0

120 49 Agency Staff 6140 0 0 0

120 40-99 Other - Nonlabor 6140 0 0 0

125 Subacute Care

125 20-39 Fringe Benefits 6150 581593 0 581593

125 49 Agency Staff 6150 0 0 0

125 40-99 Other - Nonlabor 6150 763239 (269123) 494116

126 20-39 Fringe Benefits 6160 0 0 0

126 49 Agency Staff 6160 0 0 0

126 40-99 Other - Nonlabor 6160 0 0 0

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

128 20-39 Fringe Benefits 6170 0 0 0

128 49 Agency Staff 6170 0 0 0

128 40-99 Other - Nonlabor 6170 0 0 0

130 20-39 Fringe Benefits 6180 0 0 0

130 49 Agency Staff 6180 0 0 0

130 40-99 Other - Nonlabor 6180 0 0 0

135 20-39 Fringe Benefits 6190 0 0 0

135 49 Agency Staff 6190 0 0 0

135 40-99 Other - Nonlabor 6190 0 0 0

139 20-39 Fringe Benefits 9100 0 0 0

139 49 Agency Staff 9100 0 0 0

139 40-99 Other - Nonlabor 9100 0 0 0

140 20-39 Fringe Benefits 8900 0 0 0

140 49 Agency Staff 8900 0 0 0

140 40-99 Other - Nonlabor 8900 0 0 0

145 20-39 Fringe Benefits 9100 0 0 0

145 49 Agency Staff 9100 0 0 0

145 40-99 Other - Nonlabor 9100 0 0 0

146 Subtotal 105 - 145 $ 7566260 $ (439592) $ 7126668

155 Social Services

155 20-39 Fringe Benefits 6600 15845 0 15845

155 49 Agency Staff 6600 342 (342) 0

155 40-99 Other - Nonlabor 6600 0 342 342

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

160 Activities

160 20-39 Fringe Benefits 6700 40781 0 40781

160 49 Agency Staff 6700 11768 (11768) 0

160 40-99 Other - Nonlabor 6700 0 11768 11768

165 Administration

165 20-39 Fringe Benefits 6900 248558 (42772) 205786

165 49 Agency Staff 6900 0 0 0

165 40-99 Other - Nonlabor 6900 877263 99868 977131

166 Medical Records

166 20-39 Fringe Benefits 6900 36253 16254 52507

166 49 Agency Staff 6900 0 0 0

166 40-99 Other - Nonlabor 6900 0 0 0

170 20-39 Fringe Benefits 6800 13026 0 13026

170 49 Agency Staff 6800 0 0 0

170 40-99 Other - Nonlabor 6800 0 0 0

174 20-39 Fringe Benefits 6900 0 0 0

174 49 Agency Staff 6900 0 0 0

174 40-99 Other - Nonlabor 6900 0 0 0

Subtotal 155 - 174 $ 3110566 $ (94409) $ 3016157

200 Total $ 15672437 $ (469771) $ 15202666

(Sch 2)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

Provider Name

1396881033

TOTAL ADJ

(Pages 123amp4)

(16978)

(4493)

AUDIT ADJ

(16978)

AUDIT ADJ

(1358)

AUDIT ADJ

200 Total ($469771)

(To Sch 8)

0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

200 Total 0 0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Ash Chawla Page 3

Original Signed By

Certified

1396881033 206390865

PROGRAM DESCRIPTION

COST PER

AUDITED

15 Medi-Cal Days (Adj 36) 19295 19312

INTERMEDIATE CARE

SUBACUTE CARE

1396881033 206390865

PROGRAM DESCRIPTION

AUDITED

COST PER

PATIENT DAY

1396881033 206390865

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8)

Soc Srvs

Activities

160 Total

GENERAL SERVICES

010 Housekeeping

065 Dietary

160 Activities 137462 $ 137462

165 Administration

166 Medical Records

ANCILLARY SERVICES

ROUTINE SERVICES

125 Subacute Care 2441225 24352 56618 2522195

NONREIMBURSABLE

TOTAL 6555073 $ $ 59123 $ 137462 $ 6555073

(To Schedule 1)

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8)

Plant Ops

Hskpng

Laundry

Dietary

Soc Srvs

Activities

Inserv Ed

Accumulated

Medical

Records

166 Total

GENERAL SERVICES

010 Housekeeping 232006 142 $ 232148

065 Dietary 414629 15518 36191 0 $ 466338

160 Activities NA 637 1486 0 0 0 2123 $

166 Medical Records 201588 991 2311 0 0 0 0 204890 204890 $

ANCILLARY SERVICES

085 Pharmacy 0 0 0 0 0 0 0 0 580 8044 8624

090 Laboratory 0 0 0 0 0 0 0 0 131 1810 1940

ROUTINE SERVICES

125 Subacute Care 18579 43330 40528 50899 1069 874 30430 185709 4204 58263 248176

NONREIMBURSABLE

TOTAL 1166853 $ 99682 $ $ 232148 151907 $ $ 466338 2594 $ 2123 $ 73880 $ 947179 $ $ 14785 204890 $ $ 1166853

(To Schedule 1)

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8)

Plant Ops

Hskpng

Laundry

Dietary

Soc Srvs

Activities

Inserv Ed

Accumulated

Medical

Records

166 Total

GENERAL SERVICES

010 Housekeeping 60705 433 $ 61138

065 Dietary 283285 47491 9531 0 $ 340308

155 Social Services 342 2383 478 0 0 3203 $

160 Activities 11768 1949 391 0 0 0 14109 $

166 Medical Records 0 3033 609 0 0 0 0 3641 3641 $

ANCILLARY SERVICES

085 Pharmacy 482690 0 0 0 0 0 0 0 482690 640 143 483473

090 Laboratory 108582 0 0 0 0 0 0 0 108582 144 32 108758

ROUTINE SERVICES

125 Subacute Care 494116 56860 11411 14746 37143 1319 5811 536 621943 4636 1035 627614

NONREIMBURSABLE

TOTAL 4082972 $ 305066 $ $ 61138 55273 $ $ 340308 3203 $ 14109 $ 1300 $ 4063027 $ $ 16304 3641 $ $ 4082972

(To Schedule 1)

Provider Name

1396881033

Fiscal Period

206390865

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8) Ratio

Inserv Ed

Accumulated

Medical

Records

166 Total

Capital

Property

Of Total

GENERAL SERVICES

010 Housekeeping

065 Dietary

155 Social Services

160 Activities

ANCILLARY SERVICES

085 Pharmacy 0 0 1350 302 1652 1585 67

090 Laboratory 0 0 304 68 372 357 15

ROUTINE SERVICES

125 Subacute Care 1130 166281 9778 2184 178243 171053 7190

NONREIMBURSABLE

TOTAL 771463$ 100 2743$ 729396$ $ 34387 7680$ $ 771463 740343$ 31120$

(To Schedule 1)

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8) Ratio

(From Sch 2)

(From Sch 3)

(From Sch 4)

(From Sch 5)

Allocated

of Total

Licensing Fees

of Total

Professional

Liability Ins

of Total

Quality Assur

of Total

Caregiver

Training

of Total

GENERAL SERVICES

Total 2626305 100 $ 2626305

ANCILLARY SERVICES

085 Pharmacy 0 0 482690 0 482690 103109 70496 1499 5469 25645 0

090 Laboratory 0 0 108582 0 108582 23195 15858 337 1230 5769 0

ROUTINE SERVICES

125 Subacute Care 2522195 185709 621943 166281 3496128 746819 510602 10861 39610 185746 0

NONREIMBURSABLE

SUBTOTAL 2626305 $ 6555073 $ 947179 $ 4063027 $ 729396 $ $ 12294675 $ 2626305

021361321

$ 1795611 38193 $ 139296 $ 653205 $ $ 0

(To Schedule 1)

Provider Name

1396881033

206390865

Fiscal Period

DESCRIPTION

Capital

(SQ FT)

VARIOUS

Plant Ops

(SQ FT)

Hskpng

(SQ FT)

Laundry

Dietary

(MEALS)

Soc Srvs

(DIRECT EXP)

Activities

(DIRECT EXP)

Inserv Ed

(DIRECT EXP)

(TOTAL

Med Records

(TOTAL

(ACCUM

GENERAL SERVICES

065 Dietary 3508 3508 3508

160 Activities 144 144 144

ANCILLARY SERVICES

085 Pharmacy 482690 482690

090 Laboratory 108582 108582

ROUTINE SERVICES

125 Subacute Care 4200 4200 4200 58414 11592 2935341 2935341 2935341 3496128 3496128

NONREIMBURSABLE

59123 $

0008296023

137462 $

0019288397

99682 $

442362652

232148 $

1031675211

151907 $

069379907

466338 $

439088421

2594 $

000036403

2123 $

000029784

73880 $

001036673

$ 14785

000120252

204890 $

001666493

305066 $

1353803142

61138 $

271701258

55273 $

025244548

340308 $

320422287

3203 $

000044942

14109 $

000197971

1300 $

000018247

$ 16304

000132609

3641 $

000029616

$ 771463

3268080149

35034 $

155470929

1096 $

004868618

13165 $

006012848

120269 $

113241213

6034 $

000084668

4937 $

000069274

2743 $

000038486

$ 34387

000279691

7680 $

000062463

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER REPORTED

ADJUSTMENTS

AUDITED

005 20-39 Fringe Benefits 6200 25355 0 25355

005 79 Agency Staff 6200 0 0 0

005 40-99 Other - Nonlabor 6200 277483 27583 305066

010 Housekeeping

010 20-39 Fringe Benefits 6300 0 0 0

010 79 Agency Staff 6300 275148 (43142) 232006

010 40-99 Other - Nonlabor 6300 17563 43142 60705

040 Property Taxes 7300 26550 4570 31120

055 Interest - Other 7600 90656 (6323) 84333

057 Subtotal 005 - 055 $ 1515304 $ 46750 $ 1562054

060 20-39 Fringe Benefits 6400 0 0 0

060 79 Agency Staff 6400 173797 (27550) 146247

060 40-99 Other - Nonlabor 6400 21481 27550 49031

065 Dietary

065 20-39 Fringe Benefits 6500 121973 0 121973

065 79 Agency Staff 6500 0 0 0

065 40-99 Other - Nonlabor 6500 268049 15236 283285

065 Dietary - Total 6500 $ 682678 $ 15236 $ 697914

Ancillary Services

075 20-39 Fringe Benefits 8100 0 0 0

075 79 Agency Staff 8100 0 0 0

075 40-99 Other - Nonlabor 8100 209288 (133296) 75992

077 20-39 Fringe Benefits 8150 0 0 0

077 79 Agency Staff 8150 0 0 0

077 40-99 Other - Nonlabor 8150 0 133296 133296

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 5)

(Sch 6)

(Sch 5)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

080 20-39 Fringe Benefits 8200 0 0 0

080 79 Agency Staff 8200 0 0 0

080 40-99 Other - Nonlabor 8200 648743 0 648743

081 20-39 Fringe Benefits 8220 0 0 0

081 79 Agency Staff 8220 0 0 0

081 40-99 Other - Nonlabor 8220 0 0 0

082 20-39 Fringe Benefits 8250 0 0 0

082 79 Agency Staff 8250 0 0 0

082 40-99 Other - Nonlabor 8250 622924 0 622924

083 20-39 Fringe Benefits 8280 0 0 0

083 79 Agency Staff 8280 0 0 0

083 40-99 Other - Nonlabor 8280 340620 0 340620

085 Pharmacy

085 20-39 Fringe Benefits 8300 0 0 0

085 79 Agency Staff 8300 0 0 0

085 40-99 Other - Nonlabor 8300 482690 0 482690

085 Pharmacy - Total 8300 $ 482690 $ 0 $ 482690

090 Laboratory

090 20-39 Fringe Benefits 8400 0 0 0

090 79 Agency Staff 8400 0 0 0

090 40-99 Other - Nonlabor 8400 108582 0 108582

095 20-39 Fringe Benefits 8800 0 0 0

095 79 Agency Staff 8800 0 0 0

095 40-99 Other - Nonlabor 8800 0 0 0

100 20-39 Fringe Benefits 8900 0 0 0

100 79 Agency Staff 8900 0 0 0

100 40-99 Other - Nonlabor 8900 189504 2244 191748

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

101 20-39 Fringe Benefits 8100-8900 0 0 0

101 79 Agency Staff 8100-8900 0 0 0

101 40-99 Other - Nonlabor 8100-8900 0 0 0

102 20-39 Fringe Benefits 8100-8900 0 0 0

102 79 Agency Staff 8100-8900 0 0 0

102 40-99 Other - Nonlabor 8100-8900 0 0 0

104 Subtotal 075 - 102 $ 2602351 $ 2244 $ 2604595

Routine Services

105 20-39 Fringe Benefits 6110 957187 (4396) 952791

105 49 Agency Staff 6110 0 0 0

105 40-99 Other - Nonlabor 6110 406243 (132179) 274064

110 20-39 Fringe Benefits 6120 0 0 0

110 49 Agency Staff 6120 0 0 0

110 40-99 Other - Nonlabor 6120 0 0 0

115 20-39 Fringe Benefits 6130 0 0 0

115 49 Agency Staff 6130 0 0 0

115 40-99 Other - Nonlabor 6130 0 0 0

120 20-39 Fringe Benefits 6140 0 0 0

120 49 Agency Staff 6140 0 0 0

120 40-99 Other - Nonlabor 6140 0 0 0

125 Subacute Care

125 20-39 Fringe Benefits 6150 581593 0 581593

125 49 Agency Staff 6150 0 0 0

125 40-99 Other - Nonlabor 6150 763239 (269123) 494116

126 20-39 Fringe Benefits 6160 0 0 0

126 49 Agency Staff 6160 0 0 0

126 40-99 Other - Nonlabor 6160 0 0 0

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

128 20-39 Fringe Benefits 6170 0 0 0

128 49 Agency Staff 6170 0 0 0

128 40-99 Other - Nonlabor 6170 0 0 0

130 20-39 Fringe Benefits 6180 0 0 0

130 49 Agency Staff 6180 0 0 0

130 40-99 Other - Nonlabor 6180 0 0 0

135 20-39 Fringe Benefits 6190 0 0 0

135 49 Agency Staff 6190 0 0 0

135 40-99 Other - Nonlabor 6190 0 0 0

139 20-39 Fringe Benefits 9100 0 0 0

139 49 Agency Staff 9100 0 0 0

139 40-99 Other - Nonlabor 9100 0 0 0

140 20-39 Fringe Benefits 8900 0 0 0

140 49 Agency Staff 8900 0 0 0

140 40-99 Other - Nonlabor 8900 0 0 0

145 20-39 Fringe Benefits 9100 0 0 0

145 49 Agency Staff 9100 0 0 0

145 40-99 Other - Nonlabor 9100 0 0 0

146 Subtotal 105 - 145 $ 7566260 $ (439592) $ 7126668

155 Social Services

155 20-39 Fringe Benefits 6600 15845 0 15845

155 49 Agency Staff 6600 342 (342) 0

155 40-99 Other - Nonlabor 6600 0 342 342

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

160 Activities

160 20-39 Fringe Benefits 6700 40781 0 40781

160 49 Agency Staff 6700 11768 (11768) 0

160 40-99 Other - Nonlabor 6700 0 11768 11768

165 Administration

165 20-39 Fringe Benefits 6900 248558 (42772) 205786

165 49 Agency Staff 6900 0 0 0

165 40-99 Other - Nonlabor 6900 877263 99868 977131

166 Medical Records

166 20-39 Fringe Benefits 6900 36253 16254 52507

166 49 Agency Staff 6900 0 0 0

166 40-99 Other - Nonlabor 6900 0 0 0

170 20-39 Fringe Benefits 6800 13026 0 13026

170 49 Agency Staff 6800 0 0 0

170 40-99 Other - Nonlabor 6800 0 0 0

174 20-39 Fringe Benefits 6900 0 0 0

174 49 Agency Staff 6900 0 0 0

174 40-99 Other - Nonlabor 6900 0 0 0

Subtotal 155 - 174 $ 3110566 $ (94409) $ 3016157

200 Total $ 15672437 $ (469771) $ 15202666

(Sch 2)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

Provider Name

1396881033

TOTAL ADJ

(Pages 123amp4)

(16978)

(4493)

AUDIT ADJ

(16978)

AUDIT ADJ

(1358)

AUDIT ADJ

200 Total ($469771)

(To Sch 8)

0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

200 Total 0 0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

1396881033 206390865

PROGRAM DESCRIPTION

COST PER

AUDITED

15 Medi-Cal Days (Adj 36) 19295 19312

INTERMEDIATE CARE

SUBACUTE CARE

1396881033 206390865

PROGRAM DESCRIPTION

AUDITED

COST PER

PATIENT DAY

1396881033 206390865

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8)

Soc Srvs

Activities

160 Total

GENERAL SERVICES

010 Housekeeping

065 Dietary

160 Activities 137462 $ 137462

165 Administration

166 Medical Records

ANCILLARY SERVICES

ROUTINE SERVICES

125 Subacute Care 2441225 24352 56618 2522195

NONREIMBURSABLE

TOTAL 6555073 $ $ 59123 $ 137462 $ 6555073

(To Schedule 1)

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8)

Plant Ops

Hskpng

Laundry

Dietary

Soc Srvs

Activities

Inserv Ed

Accumulated

Medical

Records

166 Total

GENERAL SERVICES

010 Housekeeping 232006 142 $ 232148

065 Dietary 414629 15518 36191 0 $ 466338

160 Activities NA 637 1486 0 0 0 2123 $

166 Medical Records 201588 991 2311 0 0 0 0 204890 204890 $

ANCILLARY SERVICES

085 Pharmacy 0 0 0 0 0 0 0 0 580 8044 8624

090 Laboratory 0 0 0 0 0 0 0 0 131 1810 1940

ROUTINE SERVICES

125 Subacute Care 18579 43330 40528 50899 1069 874 30430 185709 4204 58263 248176

NONREIMBURSABLE

TOTAL 1166853 $ 99682 $ $ 232148 151907 $ $ 466338 2594 $ 2123 $ 73880 $ 947179 $ $ 14785 204890 $ $ 1166853

(To Schedule 1)

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8)

Plant Ops

Hskpng

Laundry

Dietary

Soc Srvs

Activities

Inserv Ed

Accumulated

Medical

Records

166 Total

GENERAL SERVICES

010 Housekeeping 60705 433 $ 61138

065 Dietary 283285 47491 9531 0 $ 340308

155 Social Services 342 2383 478 0 0 3203 $

160 Activities 11768 1949 391 0 0 0 14109 $

166 Medical Records 0 3033 609 0 0 0 0 3641 3641 $

ANCILLARY SERVICES

085 Pharmacy 482690 0 0 0 0 0 0 0 482690 640 143 483473

090 Laboratory 108582 0 0 0 0 0 0 0 108582 144 32 108758

ROUTINE SERVICES

125 Subacute Care 494116 56860 11411 14746 37143 1319 5811 536 621943 4636 1035 627614

NONREIMBURSABLE

TOTAL 4082972 $ 305066 $ $ 61138 55273 $ $ 340308 3203 $ 14109 $ 1300 $ 4063027 $ $ 16304 3641 $ $ 4082972

(To Schedule 1)

Provider Name

1396881033

Fiscal Period

206390865

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8) Ratio

Inserv Ed

Accumulated

Medical

Records

166 Total

Capital

Property

Of Total

GENERAL SERVICES

010 Housekeeping

065 Dietary

155 Social Services

160 Activities

ANCILLARY SERVICES

085 Pharmacy 0 0 1350 302 1652 1585 67

090 Laboratory 0 0 304 68 372 357 15

ROUTINE SERVICES

125 Subacute Care 1130 166281 9778 2184 178243 171053 7190

NONREIMBURSABLE

TOTAL 771463$ 100 2743$ 729396$ $ 34387 7680$ $ 771463 740343$ 31120$

(To Schedule 1)

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8) Ratio

(From Sch 2)

(From Sch 3)

(From Sch 4)

(From Sch 5)

Allocated

of Total

Licensing Fees

of Total

Professional

Liability Ins

of Total

Quality Assur

of Total

Caregiver

Training

of Total

GENERAL SERVICES

Total 2626305 100 $ 2626305

ANCILLARY SERVICES

085 Pharmacy 0 0 482690 0 482690 103109 70496 1499 5469 25645 0

090 Laboratory 0 0 108582 0 108582 23195 15858 337 1230 5769 0

ROUTINE SERVICES

125 Subacute Care 2522195 185709 621943 166281 3496128 746819 510602 10861 39610 185746 0

NONREIMBURSABLE

SUBTOTAL 2626305 $ 6555073 $ 947179 $ 4063027 $ 729396 $ $ 12294675 $ 2626305

021361321

$ 1795611 38193 $ 139296 $ 653205 $ $ 0

(To Schedule 1)

Provider Name

1396881033

206390865

Fiscal Period

DESCRIPTION

Capital

(SQ FT)

VARIOUS

Plant Ops

(SQ FT)

Hskpng

(SQ FT)

Laundry

Dietary

(MEALS)

Soc Srvs

(DIRECT EXP)

Activities

(DIRECT EXP)

Inserv Ed

(DIRECT EXP)

(TOTAL

Med Records

(TOTAL

(ACCUM

GENERAL SERVICES

065 Dietary 3508 3508 3508

160 Activities 144 144 144

ANCILLARY SERVICES

085 Pharmacy 482690 482690

090 Laboratory 108582 108582

ROUTINE SERVICES

125 Subacute Care 4200 4200 4200 58414 11592 2935341 2935341 2935341 3496128 3496128

NONREIMBURSABLE

59123 $

0008296023

137462 $

0019288397

99682 $

442362652

232148 $

1031675211

151907 $

069379907

466338 $

439088421

2594 $

000036403

2123 $

000029784

73880 $

001036673

$ 14785

000120252

204890 $

001666493

305066 $

1353803142

61138 $

271701258

55273 $

025244548

340308 $

320422287

3203 $

000044942

14109 $

000197971

1300 $

000018247

$ 16304

000132609

3641 $

000029616

$ 771463

3268080149

35034 $

155470929

1096 $

004868618

13165 $

006012848

120269 $

113241213

6034 $

000084668

4937 $

000069274

2743 $

000038486

$ 34387

000279691

7680 $

000062463

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER REPORTED

ADJUSTMENTS

AUDITED

005 20-39 Fringe Benefits 6200 25355 0 25355

005 79 Agency Staff 6200 0 0 0

005 40-99 Other - Nonlabor 6200 277483 27583 305066

010 Housekeeping

010 20-39 Fringe Benefits 6300 0 0 0

010 79 Agency Staff 6300 275148 (43142) 232006

010 40-99 Other - Nonlabor 6300 17563 43142 60705

040 Property Taxes 7300 26550 4570 31120

055 Interest - Other 7600 90656 (6323) 84333

057 Subtotal 005 - 055 $ 1515304 $ 46750 $ 1562054

060 20-39 Fringe Benefits 6400 0 0 0

060 79 Agency Staff 6400 173797 (27550) 146247

060 40-99 Other - Nonlabor 6400 21481 27550 49031

065 Dietary

065 20-39 Fringe Benefits 6500 121973 0 121973

065 79 Agency Staff 6500 0 0 0

065 40-99 Other - Nonlabor 6500 268049 15236 283285

065 Dietary - Total 6500 $ 682678 $ 15236 $ 697914

Ancillary Services

075 20-39 Fringe Benefits 8100 0 0 0

075 79 Agency Staff 8100 0 0 0

075 40-99 Other - Nonlabor 8100 209288 (133296) 75992

077 20-39 Fringe Benefits 8150 0 0 0

077 79 Agency Staff 8150 0 0 0

077 40-99 Other - Nonlabor 8150 0 133296 133296

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 5)

(Sch 6)

(Sch 5)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

080 20-39 Fringe Benefits 8200 0 0 0

080 79 Agency Staff 8200 0 0 0

080 40-99 Other - Nonlabor 8200 648743 0 648743

081 20-39 Fringe Benefits 8220 0 0 0

081 79 Agency Staff 8220 0 0 0

081 40-99 Other - Nonlabor 8220 0 0 0

082 20-39 Fringe Benefits 8250 0 0 0

082 79 Agency Staff 8250 0 0 0

082 40-99 Other - Nonlabor 8250 622924 0 622924

083 20-39 Fringe Benefits 8280 0 0 0

083 79 Agency Staff 8280 0 0 0

083 40-99 Other - Nonlabor 8280 340620 0 340620

085 Pharmacy

085 20-39 Fringe Benefits 8300 0 0 0

085 79 Agency Staff 8300 0 0 0

085 40-99 Other - Nonlabor 8300 482690 0 482690

085 Pharmacy - Total 8300 $ 482690 $ 0 $ 482690

090 Laboratory

090 20-39 Fringe Benefits 8400 0 0 0

090 79 Agency Staff 8400 0 0 0

090 40-99 Other - Nonlabor 8400 108582 0 108582

095 20-39 Fringe Benefits 8800 0 0 0

095 79 Agency Staff 8800 0 0 0

095 40-99 Other - Nonlabor 8800 0 0 0

100 20-39 Fringe Benefits 8900 0 0 0

100 79 Agency Staff 8900 0 0 0

100 40-99 Other - Nonlabor 8900 189504 2244 191748

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

101 20-39 Fringe Benefits 8100-8900 0 0 0

101 79 Agency Staff 8100-8900 0 0 0

101 40-99 Other - Nonlabor 8100-8900 0 0 0

102 20-39 Fringe Benefits 8100-8900 0 0 0

102 79 Agency Staff 8100-8900 0 0 0

102 40-99 Other - Nonlabor 8100-8900 0 0 0

104 Subtotal 075 - 102 $ 2602351 $ 2244 $ 2604595

Routine Services

105 20-39 Fringe Benefits 6110 957187 (4396) 952791

105 49 Agency Staff 6110 0 0 0

105 40-99 Other - Nonlabor 6110 406243 (132179) 274064

110 20-39 Fringe Benefits 6120 0 0 0

110 49 Agency Staff 6120 0 0 0

110 40-99 Other - Nonlabor 6120 0 0 0

115 20-39 Fringe Benefits 6130 0 0 0

115 49 Agency Staff 6130 0 0 0

115 40-99 Other - Nonlabor 6130 0 0 0

120 20-39 Fringe Benefits 6140 0 0 0

120 49 Agency Staff 6140 0 0 0

120 40-99 Other - Nonlabor 6140 0 0 0

125 Subacute Care

125 20-39 Fringe Benefits 6150 581593 0 581593

125 49 Agency Staff 6150 0 0 0

125 40-99 Other - Nonlabor 6150 763239 (269123) 494116

126 20-39 Fringe Benefits 6160 0 0 0

126 49 Agency Staff 6160 0 0 0

126 40-99 Other - Nonlabor 6160 0 0 0

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

128 20-39 Fringe Benefits 6170 0 0 0

128 49 Agency Staff 6170 0 0 0

128 40-99 Other - Nonlabor 6170 0 0 0

130 20-39 Fringe Benefits 6180 0 0 0

130 49 Agency Staff 6180 0 0 0

130 40-99 Other - Nonlabor 6180 0 0 0

135 20-39 Fringe Benefits 6190 0 0 0

135 49 Agency Staff 6190 0 0 0

135 40-99 Other - Nonlabor 6190 0 0 0

139 20-39 Fringe Benefits 9100 0 0 0

139 49 Agency Staff 9100 0 0 0

139 40-99 Other - Nonlabor 9100 0 0 0

140 20-39 Fringe Benefits 8900 0 0 0

140 49 Agency Staff 8900 0 0 0

140 40-99 Other - Nonlabor 8900 0 0 0

145 20-39 Fringe Benefits 9100 0 0 0

145 49 Agency Staff 9100 0 0 0

145 40-99 Other - Nonlabor 9100 0 0 0

146 Subtotal 105 - 145 $ 7566260 $ (439592) $ 7126668

155 Social Services

155 20-39 Fringe Benefits 6600 15845 0 15845

155 49 Agency Staff 6600 342 (342) 0

155 40-99 Other - Nonlabor 6600 0 342 342

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

160 Activities

160 20-39 Fringe Benefits 6700 40781 0 40781

160 49 Agency Staff 6700 11768 (11768) 0

160 40-99 Other - Nonlabor 6700 0 11768 11768

165 Administration

165 20-39 Fringe Benefits 6900 248558 (42772) 205786

165 49 Agency Staff 6900 0 0 0

165 40-99 Other - Nonlabor 6900 877263 99868 977131

166 Medical Records

166 20-39 Fringe Benefits 6900 36253 16254 52507

166 49 Agency Staff 6900 0 0 0

166 40-99 Other - Nonlabor 6900 0 0 0

170 20-39 Fringe Benefits 6800 13026 0 13026

170 49 Agency Staff 6800 0 0 0

170 40-99 Other - Nonlabor 6800 0 0 0

174 20-39 Fringe Benefits 6900 0 0 0

174 49 Agency Staff 6900 0 0 0

174 40-99 Other - Nonlabor 6900 0 0 0

Subtotal 155 - 174 $ 3110566 $ (94409) $ 3016157

200 Total $ 15672437 $ (469771) $ 15202666

(Sch 2)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

Provider Name

1396881033

TOTAL ADJ

(Pages 123amp4)

(16978)

(4493)

AUDIT ADJ

(16978)

AUDIT ADJ

(1358)

AUDIT ADJ

200 Total ($469771)

(To Sch 8)

0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

200 Total 0 0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

1396881033 206390865

PROGRAM DESCRIPTION

AUDITED

COST PER

PATIENT DAY

1396881033 206390865

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8)

Soc Srvs

Activities

160 Total

GENERAL SERVICES

010 Housekeeping

065 Dietary

160 Activities 137462 $ 137462

165 Administration

166 Medical Records

ANCILLARY SERVICES

ROUTINE SERVICES

125 Subacute Care 2441225 24352 56618 2522195

NONREIMBURSABLE

TOTAL 6555073 $ $ 59123 $ 137462 $ 6555073

(To Schedule 1)

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8)

Plant Ops

Hskpng

Laundry

Dietary

Soc Srvs

Activities

Inserv Ed

Accumulated

Medical

Records

166 Total

GENERAL SERVICES

010 Housekeeping 232006 142 $ 232148

065 Dietary 414629 15518 36191 0 $ 466338

160 Activities NA 637 1486 0 0 0 2123 $

166 Medical Records 201588 991 2311 0 0 0 0 204890 204890 $

ANCILLARY SERVICES

085 Pharmacy 0 0 0 0 0 0 0 0 580 8044 8624

090 Laboratory 0 0 0 0 0 0 0 0 131 1810 1940

ROUTINE SERVICES

125 Subacute Care 18579 43330 40528 50899 1069 874 30430 185709 4204 58263 248176

NONREIMBURSABLE

TOTAL 1166853 $ 99682 $ $ 232148 151907 $ $ 466338 2594 $ 2123 $ 73880 $ 947179 $ $ 14785 204890 $ $ 1166853

(To Schedule 1)

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8)

Plant Ops

Hskpng

Laundry

Dietary

Soc Srvs

Activities

Inserv Ed

Accumulated

Medical

Records

166 Total

GENERAL SERVICES

010 Housekeeping 60705 433 $ 61138

065 Dietary 283285 47491 9531 0 $ 340308

155 Social Services 342 2383 478 0 0 3203 $

160 Activities 11768 1949 391 0 0 0 14109 $

166 Medical Records 0 3033 609 0 0 0 0 3641 3641 $

ANCILLARY SERVICES

085 Pharmacy 482690 0 0 0 0 0 0 0 482690 640 143 483473

090 Laboratory 108582 0 0 0 0 0 0 0 108582 144 32 108758

ROUTINE SERVICES

125 Subacute Care 494116 56860 11411 14746 37143 1319 5811 536 621943 4636 1035 627614

NONREIMBURSABLE

TOTAL 4082972 $ 305066 $ $ 61138 55273 $ $ 340308 3203 $ 14109 $ 1300 $ 4063027 $ $ 16304 3641 $ $ 4082972

(To Schedule 1)

Provider Name

1396881033

Fiscal Period

206390865

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8) Ratio

Inserv Ed

Accumulated

Medical

Records

166 Total

Capital

Property

Of Total

GENERAL SERVICES

010 Housekeeping

065 Dietary

155 Social Services

160 Activities

ANCILLARY SERVICES

085 Pharmacy 0 0 1350 302 1652 1585 67

090 Laboratory 0 0 304 68 372 357 15

ROUTINE SERVICES

125 Subacute Care 1130 166281 9778 2184 178243 171053 7190

NONREIMBURSABLE

TOTAL 771463$ 100 2743$ 729396$ $ 34387 7680$ $ 771463 740343$ 31120$

(To Schedule 1)

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8) Ratio

(From Sch 2)

(From Sch 3)

(From Sch 4)

(From Sch 5)

Allocated

of Total

Licensing Fees

of Total

Professional

Liability Ins

of Total

Quality Assur

of Total

Caregiver

Training

of Total

GENERAL SERVICES

Total 2626305 100 $ 2626305

ANCILLARY SERVICES

085 Pharmacy 0 0 482690 0 482690 103109 70496 1499 5469 25645 0

090 Laboratory 0 0 108582 0 108582 23195 15858 337 1230 5769 0

ROUTINE SERVICES

125 Subacute Care 2522195 185709 621943 166281 3496128 746819 510602 10861 39610 185746 0

NONREIMBURSABLE

SUBTOTAL 2626305 $ 6555073 $ 947179 $ 4063027 $ 729396 $ $ 12294675 $ 2626305

021361321

$ 1795611 38193 $ 139296 $ 653205 $ $ 0

(To Schedule 1)

Provider Name

1396881033

206390865

Fiscal Period

DESCRIPTION

Capital

(SQ FT)

VARIOUS

Plant Ops

(SQ FT)

Hskpng

(SQ FT)

Laundry

Dietary

(MEALS)

Soc Srvs

(DIRECT EXP)

Activities

(DIRECT EXP)

Inserv Ed

(DIRECT EXP)

(TOTAL

Med Records

(TOTAL

(ACCUM

GENERAL SERVICES

065 Dietary 3508 3508 3508

160 Activities 144 144 144

ANCILLARY SERVICES

085 Pharmacy 482690 482690

090 Laboratory 108582 108582

ROUTINE SERVICES

125 Subacute Care 4200 4200 4200 58414 11592 2935341 2935341 2935341 3496128 3496128

NONREIMBURSABLE

59123 $

0008296023

137462 $

0019288397

99682 $

442362652

232148 $

1031675211

151907 $

069379907

466338 $

439088421

2594 $

000036403

2123 $

000029784

73880 $

001036673

$ 14785

000120252

204890 $

001666493

305066 $

1353803142

61138 $

271701258

55273 $

025244548

340308 $

320422287

3203 $

000044942

14109 $

000197971

1300 $

000018247

$ 16304

000132609

3641 $

000029616

$ 771463

3268080149

35034 $

155470929

1096 $

004868618

13165 $

006012848

120269 $

113241213

6034 $

000084668

4937 $

000069274

2743 $

000038486

$ 34387

000279691

7680 $

000062463

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER REPORTED

ADJUSTMENTS

AUDITED

005 20-39 Fringe Benefits 6200 25355 0 25355

005 79 Agency Staff 6200 0 0 0

005 40-99 Other - Nonlabor 6200 277483 27583 305066

010 Housekeeping

010 20-39 Fringe Benefits 6300 0 0 0

010 79 Agency Staff 6300 275148 (43142) 232006

010 40-99 Other - Nonlabor 6300 17563 43142 60705

040 Property Taxes 7300 26550 4570 31120

055 Interest - Other 7600 90656 (6323) 84333

057 Subtotal 005 - 055 $ 1515304 $ 46750 $ 1562054

060 20-39 Fringe Benefits 6400 0 0 0

060 79 Agency Staff 6400 173797 (27550) 146247

060 40-99 Other - Nonlabor 6400 21481 27550 49031

065 Dietary

065 20-39 Fringe Benefits 6500 121973 0 121973

065 79 Agency Staff 6500 0 0 0

065 40-99 Other - Nonlabor 6500 268049 15236 283285

065 Dietary - Total 6500 $ 682678 $ 15236 $ 697914

Ancillary Services

075 20-39 Fringe Benefits 8100 0 0 0

075 79 Agency Staff 8100 0 0 0

075 40-99 Other - Nonlabor 8100 209288 (133296) 75992

077 20-39 Fringe Benefits 8150 0 0 0

077 79 Agency Staff 8150 0 0 0

077 40-99 Other - Nonlabor 8150 0 133296 133296

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 5)

(Sch 6)

(Sch 5)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

080 20-39 Fringe Benefits 8200 0 0 0

080 79 Agency Staff 8200 0 0 0

080 40-99 Other - Nonlabor 8200 648743 0 648743

081 20-39 Fringe Benefits 8220 0 0 0

081 79 Agency Staff 8220 0 0 0

081 40-99 Other - Nonlabor 8220 0 0 0

082 20-39 Fringe Benefits 8250 0 0 0

082 79 Agency Staff 8250 0 0 0

082 40-99 Other - Nonlabor 8250 622924 0 622924

083 20-39 Fringe Benefits 8280 0 0 0

083 79 Agency Staff 8280 0 0 0

083 40-99 Other - Nonlabor 8280 340620 0 340620

085 Pharmacy

085 20-39 Fringe Benefits 8300 0 0 0

085 79 Agency Staff 8300 0 0 0

085 40-99 Other - Nonlabor 8300 482690 0 482690

085 Pharmacy - Total 8300 $ 482690 $ 0 $ 482690

090 Laboratory

090 20-39 Fringe Benefits 8400 0 0 0

090 79 Agency Staff 8400 0 0 0

090 40-99 Other - Nonlabor 8400 108582 0 108582

095 20-39 Fringe Benefits 8800 0 0 0

095 79 Agency Staff 8800 0 0 0

095 40-99 Other - Nonlabor 8800 0 0 0

100 20-39 Fringe Benefits 8900 0 0 0

100 79 Agency Staff 8900 0 0 0

100 40-99 Other - Nonlabor 8900 189504 2244 191748

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

101 20-39 Fringe Benefits 8100-8900 0 0 0

101 79 Agency Staff 8100-8900 0 0 0

101 40-99 Other - Nonlabor 8100-8900 0 0 0

102 20-39 Fringe Benefits 8100-8900 0 0 0

102 79 Agency Staff 8100-8900 0 0 0

102 40-99 Other - Nonlabor 8100-8900 0 0 0

104 Subtotal 075 - 102 $ 2602351 $ 2244 $ 2604595

Routine Services

105 20-39 Fringe Benefits 6110 957187 (4396) 952791

105 49 Agency Staff 6110 0 0 0

105 40-99 Other - Nonlabor 6110 406243 (132179) 274064

110 20-39 Fringe Benefits 6120 0 0 0

110 49 Agency Staff 6120 0 0 0

110 40-99 Other - Nonlabor 6120 0 0 0

115 20-39 Fringe Benefits 6130 0 0 0

115 49 Agency Staff 6130 0 0 0

115 40-99 Other - Nonlabor 6130 0 0 0

120 20-39 Fringe Benefits 6140 0 0 0

120 49 Agency Staff 6140 0 0 0

120 40-99 Other - Nonlabor 6140 0 0 0

125 Subacute Care

125 20-39 Fringe Benefits 6150 581593 0 581593

125 49 Agency Staff 6150 0 0 0

125 40-99 Other - Nonlabor 6150 763239 (269123) 494116

126 20-39 Fringe Benefits 6160 0 0 0

126 49 Agency Staff 6160 0 0 0

126 40-99 Other - Nonlabor 6160 0 0 0

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

128 20-39 Fringe Benefits 6170 0 0 0

128 49 Agency Staff 6170 0 0 0

128 40-99 Other - Nonlabor 6170 0 0 0

130 20-39 Fringe Benefits 6180 0 0 0

130 49 Agency Staff 6180 0 0 0

130 40-99 Other - Nonlabor 6180 0 0 0

135 20-39 Fringe Benefits 6190 0 0 0

135 49 Agency Staff 6190 0 0 0

135 40-99 Other - Nonlabor 6190 0 0 0

139 20-39 Fringe Benefits 9100 0 0 0

139 49 Agency Staff 9100 0 0 0

139 40-99 Other - Nonlabor 9100 0 0 0

140 20-39 Fringe Benefits 8900 0 0 0

140 49 Agency Staff 8900 0 0 0

140 40-99 Other - Nonlabor 8900 0 0 0

145 20-39 Fringe Benefits 9100 0 0 0

145 49 Agency Staff 9100 0 0 0

145 40-99 Other - Nonlabor 9100 0 0 0

146 Subtotal 105 - 145 $ 7566260 $ (439592) $ 7126668

155 Social Services

155 20-39 Fringe Benefits 6600 15845 0 15845

155 49 Agency Staff 6600 342 (342) 0

155 40-99 Other - Nonlabor 6600 0 342 342

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

160 Activities

160 20-39 Fringe Benefits 6700 40781 0 40781

160 49 Agency Staff 6700 11768 (11768) 0

160 40-99 Other - Nonlabor 6700 0 11768 11768

165 Administration

165 20-39 Fringe Benefits 6900 248558 (42772) 205786

165 49 Agency Staff 6900 0 0 0

165 40-99 Other - Nonlabor 6900 877263 99868 977131

166 Medical Records

166 20-39 Fringe Benefits 6900 36253 16254 52507

166 49 Agency Staff 6900 0 0 0

166 40-99 Other - Nonlabor 6900 0 0 0

170 20-39 Fringe Benefits 6800 13026 0 13026

170 49 Agency Staff 6800 0 0 0

170 40-99 Other - Nonlabor 6800 0 0 0

174 20-39 Fringe Benefits 6900 0 0 0

174 49 Agency Staff 6900 0 0 0

174 40-99 Other - Nonlabor 6900 0 0 0

Subtotal 155 - 174 $ 3110566 $ (94409) $ 3016157

200 Total $ 15672437 $ (469771) $ 15202666

(Sch 2)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

Provider Name

1396881033

TOTAL ADJ

(Pages 123amp4)

(16978)

(4493)

AUDIT ADJ

(16978)

AUDIT ADJ

(1358)

AUDIT ADJ

200 Total ($469771)

(To Sch 8)

0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

200 Total 0 0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

1396881033 206390865

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8)

Soc Srvs

Activities

160 Total

GENERAL SERVICES

010 Housekeeping

065 Dietary

160 Activities 137462 $ 137462

165 Administration

166 Medical Records

ANCILLARY SERVICES

ROUTINE SERVICES

125 Subacute Care 2441225 24352 56618 2522195

NONREIMBURSABLE

TOTAL 6555073 $ $ 59123 $ 137462 $ 6555073

(To Schedule 1)

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8)

Plant Ops

Hskpng

Laundry

Dietary

Soc Srvs

Activities

Inserv Ed

Accumulated

Medical

Records

166 Total

GENERAL SERVICES

010 Housekeeping 232006 142 $ 232148

065 Dietary 414629 15518 36191 0 $ 466338

160 Activities NA 637 1486 0 0 0 2123 $

166 Medical Records 201588 991 2311 0 0 0 0 204890 204890 $

ANCILLARY SERVICES

085 Pharmacy 0 0 0 0 0 0 0 0 580 8044 8624

090 Laboratory 0 0 0 0 0 0 0 0 131 1810 1940

ROUTINE SERVICES

125 Subacute Care 18579 43330 40528 50899 1069 874 30430 185709 4204 58263 248176

NONREIMBURSABLE

TOTAL 1166853 $ 99682 $ $ 232148 151907 $ $ 466338 2594 $ 2123 $ 73880 $ 947179 $ $ 14785 204890 $ $ 1166853

(To Schedule 1)

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8)

Plant Ops

Hskpng

Laundry

Dietary

Soc Srvs

Activities

Inserv Ed

Accumulated

Medical

Records

166 Total

GENERAL SERVICES

010 Housekeeping 60705 433 $ 61138

065 Dietary 283285 47491 9531 0 $ 340308

155 Social Services 342 2383 478 0 0 3203 $

160 Activities 11768 1949 391 0 0 0 14109 $

166 Medical Records 0 3033 609 0 0 0 0 3641 3641 $

ANCILLARY SERVICES

085 Pharmacy 482690 0 0 0 0 0 0 0 482690 640 143 483473

090 Laboratory 108582 0 0 0 0 0 0 0 108582 144 32 108758

ROUTINE SERVICES

125 Subacute Care 494116 56860 11411 14746 37143 1319 5811 536 621943 4636 1035 627614

NONREIMBURSABLE

TOTAL 4082972 $ 305066 $ $ 61138 55273 $ $ 340308 3203 $ 14109 $ 1300 $ 4063027 $ $ 16304 3641 $ $ 4082972

(To Schedule 1)

Provider Name

1396881033

Fiscal Period

206390865

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8) Ratio

Inserv Ed

Accumulated

Medical

Records

166 Total

Capital

Property

Of Total

GENERAL SERVICES

010 Housekeeping

065 Dietary

155 Social Services

160 Activities

ANCILLARY SERVICES

085 Pharmacy 0 0 1350 302 1652 1585 67

090 Laboratory 0 0 304 68 372 357 15

ROUTINE SERVICES

125 Subacute Care 1130 166281 9778 2184 178243 171053 7190

NONREIMBURSABLE

TOTAL 771463$ 100 2743$ 729396$ $ 34387 7680$ $ 771463 740343$ 31120$

(To Schedule 1)

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8) Ratio

(From Sch 2)

(From Sch 3)

(From Sch 4)

(From Sch 5)

Allocated

of Total

Licensing Fees

of Total

Professional

Liability Ins

of Total

Quality Assur

of Total

Caregiver

Training

of Total

GENERAL SERVICES

Total 2626305 100 $ 2626305

ANCILLARY SERVICES

085 Pharmacy 0 0 482690 0 482690 103109 70496 1499 5469 25645 0

090 Laboratory 0 0 108582 0 108582 23195 15858 337 1230 5769 0

ROUTINE SERVICES

125 Subacute Care 2522195 185709 621943 166281 3496128 746819 510602 10861 39610 185746 0

NONREIMBURSABLE

SUBTOTAL 2626305 $ 6555073 $ 947179 $ 4063027 $ 729396 $ $ 12294675 $ 2626305

021361321

$ 1795611 38193 $ 139296 $ 653205 $ $ 0

(To Schedule 1)

Provider Name

1396881033

206390865

Fiscal Period

DESCRIPTION

Capital

(SQ FT)

VARIOUS

Plant Ops

(SQ FT)

Hskpng

(SQ FT)

Laundry

Dietary

(MEALS)

Soc Srvs

(DIRECT EXP)

Activities

(DIRECT EXP)

Inserv Ed

(DIRECT EXP)

(TOTAL

Med Records

(TOTAL

(ACCUM

GENERAL SERVICES

065 Dietary 3508 3508 3508

160 Activities 144 144 144

ANCILLARY SERVICES

085 Pharmacy 482690 482690

090 Laboratory 108582 108582

ROUTINE SERVICES

125 Subacute Care 4200 4200 4200 58414 11592 2935341 2935341 2935341 3496128 3496128

NONREIMBURSABLE

59123 $

0008296023

137462 $

0019288397

99682 $

442362652

232148 $

1031675211

151907 $

069379907

466338 $

439088421

2594 $

000036403

2123 $

000029784

73880 $

001036673

$ 14785

000120252

204890 $

001666493

305066 $

1353803142

61138 $

271701258

55273 $

025244548

340308 $

320422287

3203 $

000044942

14109 $

000197971

1300 $

000018247

$ 16304

000132609

3641 $

000029616

$ 771463

3268080149

35034 $

155470929

1096 $

004868618

13165 $

006012848

120269 $

113241213

6034 $

000084668

4937 $

000069274

2743 $

000038486

$ 34387

000279691

7680 $

000062463

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER REPORTED

ADJUSTMENTS

AUDITED

005 20-39 Fringe Benefits 6200 25355 0 25355

005 79 Agency Staff 6200 0 0 0

005 40-99 Other - Nonlabor 6200 277483 27583 305066

010 Housekeeping

010 20-39 Fringe Benefits 6300 0 0 0

010 79 Agency Staff 6300 275148 (43142) 232006

010 40-99 Other - Nonlabor 6300 17563 43142 60705

040 Property Taxes 7300 26550 4570 31120

055 Interest - Other 7600 90656 (6323) 84333

057 Subtotal 005 - 055 $ 1515304 $ 46750 $ 1562054

060 20-39 Fringe Benefits 6400 0 0 0

060 79 Agency Staff 6400 173797 (27550) 146247

060 40-99 Other - Nonlabor 6400 21481 27550 49031

065 Dietary

065 20-39 Fringe Benefits 6500 121973 0 121973

065 79 Agency Staff 6500 0 0 0

065 40-99 Other - Nonlabor 6500 268049 15236 283285

065 Dietary - Total 6500 $ 682678 $ 15236 $ 697914

Ancillary Services

075 20-39 Fringe Benefits 8100 0 0 0

075 79 Agency Staff 8100 0 0 0

075 40-99 Other - Nonlabor 8100 209288 (133296) 75992

077 20-39 Fringe Benefits 8150 0 0 0

077 79 Agency Staff 8150 0 0 0

077 40-99 Other - Nonlabor 8150 0 133296 133296

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 5)

(Sch 6)

(Sch 5)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

080 20-39 Fringe Benefits 8200 0 0 0

080 79 Agency Staff 8200 0 0 0

080 40-99 Other - Nonlabor 8200 648743 0 648743

081 20-39 Fringe Benefits 8220 0 0 0

081 79 Agency Staff 8220 0 0 0

081 40-99 Other - Nonlabor 8220 0 0 0

082 20-39 Fringe Benefits 8250 0 0 0

082 79 Agency Staff 8250 0 0 0

082 40-99 Other - Nonlabor 8250 622924 0 622924

083 20-39 Fringe Benefits 8280 0 0 0

083 79 Agency Staff 8280 0 0 0

083 40-99 Other - Nonlabor 8280 340620 0 340620

085 Pharmacy

085 20-39 Fringe Benefits 8300 0 0 0

085 79 Agency Staff 8300 0 0 0

085 40-99 Other - Nonlabor 8300 482690 0 482690

085 Pharmacy - Total 8300 $ 482690 $ 0 $ 482690

090 Laboratory

090 20-39 Fringe Benefits 8400 0 0 0

090 79 Agency Staff 8400 0 0 0

090 40-99 Other - Nonlabor 8400 108582 0 108582

095 20-39 Fringe Benefits 8800 0 0 0

095 79 Agency Staff 8800 0 0 0

095 40-99 Other - Nonlabor 8800 0 0 0

100 20-39 Fringe Benefits 8900 0 0 0

100 79 Agency Staff 8900 0 0 0

100 40-99 Other - Nonlabor 8900 189504 2244 191748

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

101 20-39 Fringe Benefits 8100-8900 0 0 0

101 79 Agency Staff 8100-8900 0 0 0

101 40-99 Other - Nonlabor 8100-8900 0 0 0

102 20-39 Fringe Benefits 8100-8900 0 0 0

102 79 Agency Staff 8100-8900 0 0 0

102 40-99 Other - Nonlabor 8100-8900 0 0 0

104 Subtotal 075 - 102 $ 2602351 $ 2244 $ 2604595

Routine Services

105 20-39 Fringe Benefits 6110 957187 (4396) 952791

105 49 Agency Staff 6110 0 0 0

105 40-99 Other - Nonlabor 6110 406243 (132179) 274064

110 20-39 Fringe Benefits 6120 0 0 0

110 49 Agency Staff 6120 0 0 0

110 40-99 Other - Nonlabor 6120 0 0 0

115 20-39 Fringe Benefits 6130 0 0 0

115 49 Agency Staff 6130 0 0 0

115 40-99 Other - Nonlabor 6130 0 0 0

120 20-39 Fringe Benefits 6140 0 0 0

120 49 Agency Staff 6140 0 0 0

120 40-99 Other - Nonlabor 6140 0 0 0

125 Subacute Care

125 20-39 Fringe Benefits 6150 581593 0 581593

125 49 Agency Staff 6150 0 0 0

125 40-99 Other - Nonlabor 6150 763239 (269123) 494116

126 20-39 Fringe Benefits 6160 0 0 0

126 49 Agency Staff 6160 0 0 0

126 40-99 Other - Nonlabor 6160 0 0 0

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

128 20-39 Fringe Benefits 6170 0 0 0

128 49 Agency Staff 6170 0 0 0

128 40-99 Other - Nonlabor 6170 0 0 0

130 20-39 Fringe Benefits 6180 0 0 0

130 49 Agency Staff 6180 0 0 0

130 40-99 Other - Nonlabor 6180 0 0 0

135 20-39 Fringe Benefits 6190 0 0 0

135 49 Agency Staff 6190 0 0 0

135 40-99 Other - Nonlabor 6190 0 0 0

139 20-39 Fringe Benefits 9100 0 0 0

139 49 Agency Staff 9100 0 0 0

139 40-99 Other - Nonlabor 9100 0 0 0

140 20-39 Fringe Benefits 8900 0 0 0

140 49 Agency Staff 8900 0 0 0

140 40-99 Other - Nonlabor 8900 0 0 0

145 20-39 Fringe Benefits 9100 0 0 0

145 49 Agency Staff 9100 0 0 0

145 40-99 Other - Nonlabor 9100 0 0 0

146 Subtotal 105 - 145 $ 7566260 $ (439592) $ 7126668

155 Social Services

155 20-39 Fringe Benefits 6600 15845 0 15845

155 49 Agency Staff 6600 342 (342) 0

155 40-99 Other - Nonlabor 6600 0 342 342

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

160 Activities

160 20-39 Fringe Benefits 6700 40781 0 40781

160 49 Agency Staff 6700 11768 (11768) 0

160 40-99 Other - Nonlabor 6700 0 11768 11768

165 Administration

165 20-39 Fringe Benefits 6900 248558 (42772) 205786

165 49 Agency Staff 6900 0 0 0

165 40-99 Other - Nonlabor 6900 877263 99868 977131

166 Medical Records

166 20-39 Fringe Benefits 6900 36253 16254 52507

166 49 Agency Staff 6900 0 0 0

166 40-99 Other - Nonlabor 6900 0 0 0

170 20-39 Fringe Benefits 6800 13026 0 13026

170 49 Agency Staff 6800 0 0 0

170 40-99 Other - Nonlabor 6800 0 0 0

174 20-39 Fringe Benefits 6900 0 0 0

174 49 Agency Staff 6900 0 0 0

174 40-99 Other - Nonlabor 6900 0 0 0

Subtotal 155 - 174 $ 3110566 $ (94409) $ 3016157

200 Total $ 15672437 $ (469771) $ 15202666

(Sch 2)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

Provider Name

1396881033

TOTAL ADJ

(Pages 123amp4)

(16978)

(4493)

AUDIT ADJ

(16978)

AUDIT ADJ

(1358)

AUDIT ADJ

200 Total ($469771)

(To Sch 8)

0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

200 Total 0 0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8)

Plant Ops

Hskpng

Laundry

Dietary

Soc Srvs

Activities

Inserv Ed

Accumulated

Medical

Records

166 Total

GENERAL SERVICES

010 Housekeeping 232006 142 $ 232148

065 Dietary 414629 15518 36191 0 $ 466338

160 Activities NA 637 1486 0 0 0 2123 $

166 Medical Records 201588 991 2311 0 0 0 0 204890 204890 $

ANCILLARY SERVICES

085 Pharmacy 0 0 0 0 0 0 0 0 580 8044 8624

090 Laboratory 0 0 0 0 0 0 0 0 131 1810 1940

ROUTINE SERVICES

125 Subacute Care 18579 43330 40528 50899 1069 874 30430 185709 4204 58263 248176

NONREIMBURSABLE

TOTAL 1166853 $ 99682 $ $ 232148 151907 $ $ 466338 2594 $ 2123 $ 73880 $ 947179 $ $ 14785 204890 $ $ 1166853

(To Schedule 1)

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8)

Plant Ops

Hskpng

Laundry

Dietary

Soc Srvs

Activities

Inserv Ed

Accumulated

Medical

Records

166 Total

GENERAL SERVICES

010 Housekeeping 60705 433 $ 61138

065 Dietary 283285 47491 9531 0 $ 340308

155 Social Services 342 2383 478 0 0 3203 $

160 Activities 11768 1949 391 0 0 0 14109 $

166 Medical Records 0 3033 609 0 0 0 0 3641 3641 $

ANCILLARY SERVICES

085 Pharmacy 482690 0 0 0 0 0 0 0 482690 640 143 483473

090 Laboratory 108582 0 0 0 0 0 0 0 108582 144 32 108758

ROUTINE SERVICES

125 Subacute Care 494116 56860 11411 14746 37143 1319 5811 536 621943 4636 1035 627614

NONREIMBURSABLE

TOTAL 4082972 $ 305066 $ $ 61138 55273 $ $ 340308 3203 $ 14109 $ 1300 $ 4063027 $ $ 16304 3641 $ $ 4082972

(To Schedule 1)

Provider Name

1396881033

Fiscal Period

206390865

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8) Ratio

Inserv Ed

Accumulated

Medical

Records

166 Total

Capital

Property

Of Total

GENERAL SERVICES

010 Housekeeping

065 Dietary

155 Social Services

160 Activities

ANCILLARY SERVICES

085 Pharmacy 0 0 1350 302 1652 1585 67

090 Laboratory 0 0 304 68 372 357 15

ROUTINE SERVICES

125 Subacute Care 1130 166281 9778 2184 178243 171053 7190

NONREIMBURSABLE

TOTAL 771463$ 100 2743$ 729396$ $ 34387 7680$ $ 771463 740343$ 31120$

(To Schedule 1)

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8) Ratio

(From Sch 2)

(From Sch 3)

(From Sch 4)

(From Sch 5)

Allocated

of Total

Licensing Fees

of Total

Professional

Liability Ins

of Total

Quality Assur

of Total

Caregiver

Training

of Total

GENERAL SERVICES

Total 2626305 100 $ 2626305

ANCILLARY SERVICES

085 Pharmacy 0 0 482690 0 482690 103109 70496 1499 5469 25645 0

090 Laboratory 0 0 108582 0 108582 23195 15858 337 1230 5769 0

ROUTINE SERVICES

125 Subacute Care 2522195 185709 621943 166281 3496128 746819 510602 10861 39610 185746 0

NONREIMBURSABLE

SUBTOTAL 2626305 $ 6555073 $ 947179 $ 4063027 $ 729396 $ $ 12294675 $ 2626305

021361321

$ 1795611 38193 $ 139296 $ 653205 $ $ 0

(To Schedule 1)

Provider Name

1396881033

206390865

Fiscal Period

DESCRIPTION

Capital

(SQ FT)

VARIOUS

Plant Ops

(SQ FT)

Hskpng

(SQ FT)

Laundry

Dietary

(MEALS)

Soc Srvs

(DIRECT EXP)

Activities

(DIRECT EXP)

Inserv Ed

(DIRECT EXP)

(TOTAL

Med Records

(TOTAL

(ACCUM

GENERAL SERVICES

065 Dietary 3508 3508 3508

160 Activities 144 144 144

ANCILLARY SERVICES

085 Pharmacy 482690 482690

090 Laboratory 108582 108582

ROUTINE SERVICES

125 Subacute Care 4200 4200 4200 58414 11592 2935341 2935341 2935341 3496128 3496128

NONREIMBURSABLE

59123 $

0008296023

137462 $

0019288397

99682 $

442362652

232148 $

1031675211

151907 $

069379907

466338 $

439088421

2594 $

000036403

2123 $

000029784

73880 $

001036673

$ 14785

000120252

204890 $

001666493

305066 $

1353803142

61138 $

271701258

55273 $

025244548

340308 $

320422287

3203 $

000044942

14109 $

000197971

1300 $

000018247

$ 16304

000132609

3641 $

000029616

$ 771463

3268080149

35034 $

155470929

1096 $

004868618

13165 $

006012848

120269 $

113241213

6034 $

000084668

4937 $

000069274

2743 $

000038486

$ 34387

000279691

7680 $

000062463

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER REPORTED

ADJUSTMENTS

AUDITED

005 20-39 Fringe Benefits 6200 25355 0 25355

005 79 Agency Staff 6200 0 0 0

005 40-99 Other - Nonlabor 6200 277483 27583 305066

010 Housekeeping

010 20-39 Fringe Benefits 6300 0 0 0

010 79 Agency Staff 6300 275148 (43142) 232006

010 40-99 Other - Nonlabor 6300 17563 43142 60705

040 Property Taxes 7300 26550 4570 31120

055 Interest - Other 7600 90656 (6323) 84333

057 Subtotal 005 - 055 $ 1515304 $ 46750 $ 1562054

060 20-39 Fringe Benefits 6400 0 0 0

060 79 Agency Staff 6400 173797 (27550) 146247

060 40-99 Other - Nonlabor 6400 21481 27550 49031

065 Dietary

065 20-39 Fringe Benefits 6500 121973 0 121973

065 79 Agency Staff 6500 0 0 0

065 40-99 Other - Nonlabor 6500 268049 15236 283285

065 Dietary - Total 6500 $ 682678 $ 15236 $ 697914

Ancillary Services

075 20-39 Fringe Benefits 8100 0 0 0

075 79 Agency Staff 8100 0 0 0

075 40-99 Other - Nonlabor 8100 209288 (133296) 75992

077 20-39 Fringe Benefits 8150 0 0 0

077 79 Agency Staff 8150 0 0 0

077 40-99 Other - Nonlabor 8150 0 133296 133296

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 5)

(Sch 6)

(Sch 5)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

080 20-39 Fringe Benefits 8200 0 0 0

080 79 Agency Staff 8200 0 0 0

080 40-99 Other - Nonlabor 8200 648743 0 648743

081 20-39 Fringe Benefits 8220 0 0 0

081 79 Agency Staff 8220 0 0 0

081 40-99 Other - Nonlabor 8220 0 0 0

082 20-39 Fringe Benefits 8250 0 0 0

082 79 Agency Staff 8250 0 0 0

082 40-99 Other - Nonlabor 8250 622924 0 622924

083 20-39 Fringe Benefits 8280 0 0 0

083 79 Agency Staff 8280 0 0 0

083 40-99 Other - Nonlabor 8280 340620 0 340620

085 Pharmacy

085 20-39 Fringe Benefits 8300 0 0 0

085 79 Agency Staff 8300 0 0 0

085 40-99 Other - Nonlabor 8300 482690 0 482690

085 Pharmacy - Total 8300 $ 482690 $ 0 $ 482690

090 Laboratory

090 20-39 Fringe Benefits 8400 0 0 0

090 79 Agency Staff 8400 0 0 0

090 40-99 Other - Nonlabor 8400 108582 0 108582

095 20-39 Fringe Benefits 8800 0 0 0

095 79 Agency Staff 8800 0 0 0

095 40-99 Other - Nonlabor 8800 0 0 0

100 20-39 Fringe Benefits 8900 0 0 0

100 79 Agency Staff 8900 0 0 0

100 40-99 Other - Nonlabor 8900 189504 2244 191748

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

101 20-39 Fringe Benefits 8100-8900 0 0 0

101 79 Agency Staff 8100-8900 0 0 0

101 40-99 Other - Nonlabor 8100-8900 0 0 0

102 20-39 Fringe Benefits 8100-8900 0 0 0

102 79 Agency Staff 8100-8900 0 0 0

102 40-99 Other - Nonlabor 8100-8900 0 0 0

104 Subtotal 075 - 102 $ 2602351 $ 2244 $ 2604595

Routine Services

105 20-39 Fringe Benefits 6110 957187 (4396) 952791

105 49 Agency Staff 6110 0 0 0

105 40-99 Other - Nonlabor 6110 406243 (132179) 274064

110 20-39 Fringe Benefits 6120 0 0 0

110 49 Agency Staff 6120 0 0 0

110 40-99 Other - Nonlabor 6120 0 0 0

115 20-39 Fringe Benefits 6130 0 0 0

115 49 Agency Staff 6130 0 0 0

115 40-99 Other - Nonlabor 6130 0 0 0

120 20-39 Fringe Benefits 6140 0 0 0

120 49 Agency Staff 6140 0 0 0

120 40-99 Other - Nonlabor 6140 0 0 0

125 Subacute Care

125 20-39 Fringe Benefits 6150 581593 0 581593

125 49 Agency Staff 6150 0 0 0

125 40-99 Other - Nonlabor 6150 763239 (269123) 494116

126 20-39 Fringe Benefits 6160 0 0 0

126 49 Agency Staff 6160 0 0 0

126 40-99 Other - Nonlabor 6160 0 0 0

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

128 20-39 Fringe Benefits 6170 0 0 0

128 49 Agency Staff 6170 0 0 0

128 40-99 Other - Nonlabor 6170 0 0 0

130 20-39 Fringe Benefits 6180 0 0 0

130 49 Agency Staff 6180 0 0 0

130 40-99 Other - Nonlabor 6180 0 0 0

135 20-39 Fringe Benefits 6190 0 0 0

135 49 Agency Staff 6190 0 0 0

135 40-99 Other - Nonlabor 6190 0 0 0

139 20-39 Fringe Benefits 9100 0 0 0

139 49 Agency Staff 9100 0 0 0

139 40-99 Other - Nonlabor 9100 0 0 0

140 20-39 Fringe Benefits 8900 0 0 0

140 49 Agency Staff 8900 0 0 0

140 40-99 Other - Nonlabor 8900 0 0 0

145 20-39 Fringe Benefits 9100 0 0 0

145 49 Agency Staff 9100 0 0 0

145 40-99 Other - Nonlabor 9100 0 0 0

146 Subtotal 105 - 145 $ 7566260 $ (439592) $ 7126668

155 Social Services

155 20-39 Fringe Benefits 6600 15845 0 15845

155 49 Agency Staff 6600 342 (342) 0

155 40-99 Other - Nonlabor 6600 0 342 342

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

160 Activities

160 20-39 Fringe Benefits 6700 40781 0 40781

160 49 Agency Staff 6700 11768 (11768) 0

160 40-99 Other - Nonlabor 6700 0 11768 11768

165 Administration

165 20-39 Fringe Benefits 6900 248558 (42772) 205786

165 49 Agency Staff 6900 0 0 0

165 40-99 Other - Nonlabor 6900 877263 99868 977131

166 Medical Records

166 20-39 Fringe Benefits 6900 36253 16254 52507

166 49 Agency Staff 6900 0 0 0

166 40-99 Other - Nonlabor 6900 0 0 0

170 20-39 Fringe Benefits 6800 13026 0 13026

170 49 Agency Staff 6800 0 0 0

170 40-99 Other - Nonlabor 6800 0 0 0

174 20-39 Fringe Benefits 6900 0 0 0

174 49 Agency Staff 6900 0 0 0

174 40-99 Other - Nonlabor 6900 0 0 0

Subtotal 155 - 174 $ 3110566 $ (94409) $ 3016157

200 Total $ 15672437 $ (469771) $ 15202666

(Sch 2)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

Provider Name

1396881033

TOTAL ADJ

(Pages 123amp4)

(16978)

(4493)

AUDIT ADJ

(16978)

AUDIT ADJ

(1358)

AUDIT ADJ

200 Total ($469771)

(To Sch 8)

0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

200 Total 0 0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8)

Plant Ops

Hskpng

Laundry

Dietary

Soc Srvs

Activities

Inserv Ed

Accumulated

Medical

Records

166 Total

GENERAL SERVICES

010 Housekeeping 60705 433 $ 61138

065 Dietary 283285 47491 9531 0 $ 340308

155 Social Services 342 2383 478 0 0 3203 $

160 Activities 11768 1949 391 0 0 0 14109 $

166 Medical Records 0 3033 609 0 0 0 0 3641 3641 $

ANCILLARY SERVICES

085 Pharmacy 482690 0 0 0 0 0 0 0 482690 640 143 483473

090 Laboratory 108582 0 0 0 0 0 0 0 108582 144 32 108758

ROUTINE SERVICES

125 Subacute Care 494116 56860 11411 14746 37143 1319 5811 536 621943 4636 1035 627614

NONREIMBURSABLE

TOTAL 4082972 $ 305066 $ $ 61138 55273 $ $ 340308 3203 $ 14109 $ 1300 $ 4063027 $ $ 16304 3641 $ $ 4082972

(To Schedule 1)

Provider Name

1396881033

Fiscal Period

206390865

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8) Ratio

Inserv Ed

Accumulated

Medical

Records

166 Total

Capital

Property

Of Total

GENERAL SERVICES

010 Housekeeping

065 Dietary

155 Social Services

160 Activities

ANCILLARY SERVICES

085 Pharmacy 0 0 1350 302 1652 1585 67

090 Laboratory 0 0 304 68 372 357 15

ROUTINE SERVICES

125 Subacute Care 1130 166281 9778 2184 178243 171053 7190

NONREIMBURSABLE

TOTAL 771463$ 100 2743$ 729396$ $ 34387 7680$ $ 771463 740343$ 31120$

(To Schedule 1)

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8) Ratio

(From Sch 2)

(From Sch 3)

(From Sch 4)

(From Sch 5)

Allocated

of Total

Licensing Fees

of Total

Professional

Liability Ins

of Total

Quality Assur

of Total

Caregiver

Training

of Total

GENERAL SERVICES

Total 2626305 100 $ 2626305

ANCILLARY SERVICES

085 Pharmacy 0 0 482690 0 482690 103109 70496 1499 5469 25645 0

090 Laboratory 0 0 108582 0 108582 23195 15858 337 1230 5769 0

ROUTINE SERVICES

125 Subacute Care 2522195 185709 621943 166281 3496128 746819 510602 10861 39610 185746 0

NONREIMBURSABLE

SUBTOTAL 2626305 $ 6555073 $ 947179 $ 4063027 $ 729396 $ $ 12294675 $ 2626305

021361321

$ 1795611 38193 $ 139296 $ 653205 $ $ 0

(To Schedule 1)

Provider Name

1396881033

206390865

Fiscal Period

DESCRIPTION

Capital

(SQ FT)

VARIOUS

Plant Ops

(SQ FT)

Hskpng

(SQ FT)

Laundry

Dietary

(MEALS)

Soc Srvs

(DIRECT EXP)

Activities

(DIRECT EXP)

Inserv Ed

(DIRECT EXP)

(TOTAL

Med Records

(TOTAL

(ACCUM

GENERAL SERVICES

065 Dietary 3508 3508 3508

160 Activities 144 144 144

ANCILLARY SERVICES

085 Pharmacy 482690 482690

090 Laboratory 108582 108582

ROUTINE SERVICES

125 Subacute Care 4200 4200 4200 58414 11592 2935341 2935341 2935341 3496128 3496128

NONREIMBURSABLE

59123 $

0008296023

137462 $

0019288397

99682 $

442362652

232148 $

1031675211

151907 $

069379907

466338 $

439088421

2594 $

000036403

2123 $

000029784

73880 $

001036673

$ 14785

000120252

204890 $

001666493

305066 $

1353803142

61138 $

271701258

55273 $

025244548

340308 $

320422287

3203 $

000044942

14109 $

000197971

1300 $

000018247

$ 16304

000132609

3641 $

000029616

$ 771463

3268080149

35034 $

155470929

1096 $

004868618

13165 $

006012848

120269 $

113241213

6034 $

000084668

4937 $

000069274

2743 $

000038486

$ 34387

000279691

7680 $

000062463

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER REPORTED

ADJUSTMENTS

AUDITED

005 20-39 Fringe Benefits 6200 25355 0 25355

005 79 Agency Staff 6200 0 0 0

005 40-99 Other - Nonlabor 6200 277483 27583 305066

010 Housekeeping

010 20-39 Fringe Benefits 6300 0 0 0

010 79 Agency Staff 6300 275148 (43142) 232006

010 40-99 Other - Nonlabor 6300 17563 43142 60705

040 Property Taxes 7300 26550 4570 31120

055 Interest - Other 7600 90656 (6323) 84333

057 Subtotal 005 - 055 $ 1515304 $ 46750 $ 1562054

060 20-39 Fringe Benefits 6400 0 0 0

060 79 Agency Staff 6400 173797 (27550) 146247

060 40-99 Other - Nonlabor 6400 21481 27550 49031

065 Dietary

065 20-39 Fringe Benefits 6500 121973 0 121973

065 79 Agency Staff 6500 0 0 0

065 40-99 Other - Nonlabor 6500 268049 15236 283285

065 Dietary - Total 6500 $ 682678 $ 15236 $ 697914

Ancillary Services

075 20-39 Fringe Benefits 8100 0 0 0

075 79 Agency Staff 8100 0 0 0

075 40-99 Other - Nonlabor 8100 209288 (133296) 75992

077 20-39 Fringe Benefits 8150 0 0 0

077 79 Agency Staff 8150 0 0 0

077 40-99 Other - Nonlabor 8150 0 133296 133296

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 5)

(Sch 6)

(Sch 5)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

080 20-39 Fringe Benefits 8200 0 0 0

080 79 Agency Staff 8200 0 0 0

080 40-99 Other - Nonlabor 8200 648743 0 648743

081 20-39 Fringe Benefits 8220 0 0 0

081 79 Agency Staff 8220 0 0 0

081 40-99 Other - Nonlabor 8220 0 0 0

082 20-39 Fringe Benefits 8250 0 0 0

082 79 Agency Staff 8250 0 0 0

082 40-99 Other - Nonlabor 8250 622924 0 622924

083 20-39 Fringe Benefits 8280 0 0 0

083 79 Agency Staff 8280 0 0 0

083 40-99 Other - Nonlabor 8280 340620 0 340620

085 Pharmacy

085 20-39 Fringe Benefits 8300 0 0 0

085 79 Agency Staff 8300 0 0 0

085 40-99 Other - Nonlabor 8300 482690 0 482690

085 Pharmacy - Total 8300 $ 482690 $ 0 $ 482690

090 Laboratory

090 20-39 Fringe Benefits 8400 0 0 0

090 79 Agency Staff 8400 0 0 0

090 40-99 Other - Nonlabor 8400 108582 0 108582

095 20-39 Fringe Benefits 8800 0 0 0

095 79 Agency Staff 8800 0 0 0

095 40-99 Other - Nonlabor 8800 0 0 0

100 20-39 Fringe Benefits 8900 0 0 0

100 79 Agency Staff 8900 0 0 0

100 40-99 Other - Nonlabor 8900 189504 2244 191748

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

101 20-39 Fringe Benefits 8100-8900 0 0 0

101 79 Agency Staff 8100-8900 0 0 0

101 40-99 Other - Nonlabor 8100-8900 0 0 0

102 20-39 Fringe Benefits 8100-8900 0 0 0

102 79 Agency Staff 8100-8900 0 0 0

102 40-99 Other - Nonlabor 8100-8900 0 0 0

104 Subtotal 075 - 102 $ 2602351 $ 2244 $ 2604595

Routine Services

105 20-39 Fringe Benefits 6110 957187 (4396) 952791

105 49 Agency Staff 6110 0 0 0

105 40-99 Other - Nonlabor 6110 406243 (132179) 274064

110 20-39 Fringe Benefits 6120 0 0 0

110 49 Agency Staff 6120 0 0 0

110 40-99 Other - Nonlabor 6120 0 0 0

115 20-39 Fringe Benefits 6130 0 0 0

115 49 Agency Staff 6130 0 0 0

115 40-99 Other - Nonlabor 6130 0 0 0

120 20-39 Fringe Benefits 6140 0 0 0

120 49 Agency Staff 6140 0 0 0

120 40-99 Other - Nonlabor 6140 0 0 0

125 Subacute Care

125 20-39 Fringe Benefits 6150 581593 0 581593

125 49 Agency Staff 6150 0 0 0

125 40-99 Other - Nonlabor 6150 763239 (269123) 494116

126 20-39 Fringe Benefits 6160 0 0 0

126 49 Agency Staff 6160 0 0 0

126 40-99 Other - Nonlabor 6160 0 0 0

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

128 20-39 Fringe Benefits 6170 0 0 0

128 49 Agency Staff 6170 0 0 0

128 40-99 Other - Nonlabor 6170 0 0 0

130 20-39 Fringe Benefits 6180 0 0 0

130 49 Agency Staff 6180 0 0 0

130 40-99 Other - Nonlabor 6180 0 0 0

135 20-39 Fringe Benefits 6190 0 0 0

135 49 Agency Staff 6190 0 0 0

135 40-99 Other - Nonlabor 6190 0 0 0

139 20-39 Fringe Benefits 9100 0 0 0

139 49 Agency Staff 9100 0 0 0

139 40-99 Other - Nonlabor 9100 0 0 0

140 20-39 Fringe Benefits 8900 0 0 0

140 49 Agency Staff 8900 0 0 0

140 40-99 Other - Nonlabor 8900 0 0 0

145 20-39 Fringe Benefits 9100 0 0 0

145 49 Agency Staff 9100 0 0 0

145 40-99 Other - Nonlabor 9100 0 0 0

146 Subtotal 105 - 145 $ 7566260 $ (439592) $ 7126668

155 Social Services

155 20-39 Fringe Benefits 6600 15845 0 15845

155 49 Agency Staff 6600 342 (342) 0

155 40-99 Other - Nonlabor 6600 0 342 342

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

160 Activities

160 20-39 Fringe Benefits 6700 40781 0 40781

160 49 Agency Staff 6700 11768 (11768) 0

160 40-99 Other - Nonlabor 6700 0 11768 11768

165 Administration

165 20-39 Fringe Benefits 6900 248558 (42772) 205786

165 49 Agency Staff 6900 0 0 0

165 40-99 Other - Nonlabor 6900 877263 99868 977131

166 Medical Records

166 20-39 Fringe Benefits 6900 36253 16254 52507

166 49 Agency Staff 6900 0 0 0

166 40-99 Other - Nonlabor 6900 0 0 0

170 20-39 Fringe Benefits 6800 13026 0 13026

170 49 Agency Staff 6800 0 0 0

170 40-99 Other - Nonlabor 6800 0 0 0

174 20-39 Fringe Benefits 6900 0 0 0

174 49 Agency Staff 6900 0 0 0

174 40-99 Other - Nonlabor 6900 0 0 0

Subtotal 155 - 174 $ 3110566 $ (94409) $ 3016157

200 Total $ 15672437 $ (469771) $ 15202666

(Sch 2)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

Provider Name

1396881033

TOTAL ADJ

(Pages 123amp4)

(16978)

(4493)

AUDIT ADJ

(16978)

AUDIT ADJ

(1358)

AUDIT ADJ

200 Total ($469771)

(To Sch 8)

0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

200 Total 0 0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Provider Name

1396881033

Fiscal Period

206390865

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8) Ratio

Inserv Ed

Accumulated

Medical

Records

166 Total

Capital

Property

Of Total

GENERAL SERVICES

010 Housekeeping

065 Dietary

155 Social Services

160 Activities

ANCILLARY SERVICES

085 Pharmacy 0 0 1350 302 1652 1585 67

090 Laboratory 0 0 304 68 372 357 15

ROUTINE SERVICES

125 Subacute Care 1130 166281 9778 2184 178243 171053 7190

NONREIMBURSABLE

TOTAL 771463$ 100 2743$ 729396$ $ 34387 7680$ $ 771463 740343$ 31120$

(To Schedule 1)

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8) Ratio

(From Sch 2)

(From Sch 3)

(From Sch 4)

(From Sch 5)

Allocated

of Total

Licensing Fees

of Total

Professional

Liability Ins

of Total

Quality Assur

of Total

Caregiver

Training

of Total

GENERAL SERVICES

Total 2626305 100 $ 2626305

ANCILLARY SERVICES

085 Pharmacy 0 0 482690 0 482690 103109 70496 1499 5469 25645 0

090 Laboratory 0 0 108582 0 108582 23195 15858 337 1230 5769 0

ROUTINE SERVICES

125 Subacute Care 2522195 185709 621943 166281 3496128 746819 510602 10861 39610 185746 0

NONREIMBURSABLE

SUBTOTAL 2626305 $ 6555073 $ 947179 $ 4063027 $ 729396 $ $ 12294675 $ 2626305

021361321

$ 1795611 38193 $ 139296 $ 653205 $ $ 0

(To Schedule 1)

Provider Name

1396881033

206390865

Fiscal Period

DESCRIPTION

Capital

(SQ FT)

VARIOUS

Plant Ops

(SQ FT)

Hskpng

(SQ FT)

Laundry

Dietary

(MEALS)

Soc Srvs

(DIRECT EXP)

Activities

(DIRECT EXP)

Inserv Ed

(DIRECT EXP)

(TOTAL

Med Records

(TOTAL

(ACCUM

GENERAL SERVICES

065 Dietary 3508 3508 3508

160 Activities 144 144 144

ANCILLARY SERVICES

085 Pharmacy 482690 482690

090 Laboratory 108582 108582

ROUTINE SERVICES

125 Subacute Care 4200 4200 4200 58414 11592 2935341 2935341 2935341 3496128 3496128

NONREIMBURSABLE

59123 $

0008296023

137462 $

0019288397

99682 $

442362652

232148 $

1031675211

151907 $

069379907

466338 $

439088421

2594 $

000036403

2123 $

000029784

73880 $

001036673

$ 14785

000120252

204890 $

001666493

305066 $

1353803142

61138 $

271701258

55273 $

025244548

340308 $

320422287

3203 $

000044942

14109 $

000197971

1300 $

000018247

$ 16304

000132609

3641 $

000029616

$ 771463

3268080149

35034 $

155470929

1096 $

004868618

13165 $

006012848

120269 $

113241213

6034 $

000084668

4937 $

000069274

2743 $

000038486

$ 34387

000279691

7680 $

000062463

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER REPORTED

ADJUSTMENTS

AUDITED

005 20-39 Fringe Benefits 6200 25355 0 25355

005 79 Agency Staff 6200 0 0 0

005 40-99 Other - Nonlabor 6200 277483 27583 305066

010 Housekeeping

010 20-39 Fringe Benefits 6300 0 0 0

010 79 Agency Staff 6300 275148 (43142) 232006

010 40-99 Other - Nonlabor 6300 17563 43142 60705

040 Property Taxes 7300 26550 4570 31120

055 Interest - Other 7600 90656 (6323) 84333

057 Subtotal 005 - 055 $ 1515304 $ 46750 $ 1562054

060 20-39 Fringe Benefits 6400 0 0 0

060 79 Agency Staff 6400 173797 (27550) 146247

060 40-99 Other - Nonlabor 6400 21481 27550 49031

065 Dietary

065 20-39 Fringe Benefits 6500 121973 0 121973

065 79 Agency Staff 6500 0 0 0

065 40-99 Other - Nonlabor 6500 268049 15236 283285

065 Dietary - Total 6500 $ 682678 $ 15236 $ 697914

Ancillary Services

075 20-39 Fringe Benefits 8100 0 0 0

075 79 Agency Staff 8100 0 0 0

075 40-99 Other - Nonlabor 8100 209288 (133296) 75992

077 20-39 Fringe Benefits 8150 0 0 0

077 79 Agency Staff 8150 0 0 0

077 40-99 Other - Nonlabor 8150 0 133296 133296

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 5)

(Sch 6)

(Sch 5)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

080 20-39 Fringe Benefits 8200 0 0 0

080 79 Agency Staff 8200 0 0 0

080 40-99 Other - Nonlabor 8200 648743 0 648743

081 20-39 Fringe Benefits 8220 0 0 0

081 79 Agency Staff 8220 0 0 0

081 40-99 Other - Nonlabor 8220 0 0 0

082 20-39 Fringe Benefits 8250 0 0 0

082 79 Agency Staff 8250 0 0 0

082 40-99 Other - Nonlabor 8250 622924 0 622924

083 20-39 Fringe Benefits 8280 0 0 0

083 79 Agency Staff 8280 0 0 0

083 40-99 Other - Nonlabor 8280 340620 0 340620

085 Pharmacy

085 20-39 Fringe Benefits 8300 0 0 0

085 79 Agency Staff 8300 0 0 0

085 40-99 Other - Nonlabor 8300 482690 0 482690

085 Pharmacy - Total 8300 $ 482690 $ 0 $ 482690

090 Laboratory

090 20-39 Fringe Benefits 8400 0 0 0

090 79 Agency Staff 8400 0 0 0

090 40-99 Other - Nonlabor 8400 108582 0 108582

095 20-39 Fringe Benefits 8800 0 0 0

095 79 Agency Staff 8800 0 0 0

095 40-99 Other - Nonlabor 8800 0 0 0

100 20-39 Fringe Benefits 8900 0 0 0

100 79 Agency Staff 8900 0 0 0

100 40-99 Other - Nonlabor 8900 189504 2244 191748

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

101 20-39 Fringe Benefits 8100-8900 0 0 0

101 79 Agency Staff 8100-8900 0 0 0

101 40-99 Other - Nonlabor 8100-8900 0 0 0

102 20-39 Fringe Benefits 8100-8900 0 0 0

102 79 Agency Staff 8100-8900 0 0 0

102 40-99 Other - Nonlabor 8100-8900 0 0 0

104 Subtotal 075 - 102 $ 2602351 $ 2244 $ 2604595

Routine Services

105 20-39 Fringe Benefits 6110 957187 (4396) 952791

105 49 Agency Staff 6110 0 0 0

105 40-99 Other - Nonlabor 6110 406243 (132179) 274064

110 20-39 Fringe Benefits 6120 0 0 0

110 49 Agency Staff 6120 0 0 0

110 40-99 Other - Nonlabor 6120 0 0 0

115 20-39 Fringe Benefits 6130 0 0 0

115 49 Agency Staff 6130 0 0 0

115 40-99 Other - Nonlabor 6130 0 0 0

120 20-39 Fringe Benefits 6140 0 0 0

120 49 Agency Staff 6140 0 0 0

120 40-99 Other - Nonlabor 6140 0 0 0

125 Subacute Care

125 20-39 Fringe Benefits 6150 581593 0 581593

125 49 Agency Staff 6150 0 0 0

125 40-99 Other - Nonlabor 6150 763239 (269123) 494116

126 20-39 Fringe Benefits 6160 0 0 0

126 49 Agency Staff 6160 0 0 0

126 40-99 Other - Nonlabor 6160 0 0 0

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

128 20-39 Fringe Benefits 6170 0 0 0

128 49 Agency Staff 6170 0 0 0

128 40-99 Other - Nonlabor 6170 0 0 0

130 20-39 Fringe Benefits 6180 0 0 0

130 49 Agency Staff 6180 0 0 0

130 40-99 Other - Nonlabor 6180 0 0 0

135 20-39 Fringe Benefits 6190 0 0 0

135 49 Agency Staff 6190 0 0 0

135 40-99 Other - Nonlabor 6190 0 0 0

139 20-39 Fringe Benefits 9100 0 0 0

139 49 Agency Staff 9100 0 0 0

139 40-99 Other - Nonlabor 9100 0 0 0

140 20-39 Fringe Benefits 8900 0 0 0

140 49 Agency Staff 8900 0 0 0

140 40-99 Other - Nonlabor 8900 0 0 0

145 20-39 Fringe Benefits 9100 0 0 0

145 49 Agency Staff 9100 0 0 0

145 40-99 Other - Nonlabor 9100 0 0 0

146 Subtotal 105 - 145 $ 7566260 $ (439592) $ 7126668

155 Social Services

155 20-39 Fringe Benefits 6600 15845 0 15845

155 49 Agency Staff 6600 342 (342) 0

155 40-99 Other - Nonlabor 6600 0 342 342

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

160 Activities

160 20-39 Fringe Benefits 6700 40781 0 40781

160 49 Agency Staff 6700 11768 (11768) 0

160 40-99 Other - Nonlabor 6700 0 11768 11768

165 Administration

165 20-39 Fringe Benefits 6900 248558 (42772) 205786

165 49 Agency Staff 6900 0 0 0

165 40-99 Other - Nonlabor 6900 877263 99868 977131

166 Medical Records

166 20-39 Fringe Benefits 6900 36253 16254 52507

166 49 Agency Staff 6900 0 0 0

166 40-99 Other - Nonlabor 6900 0 0 0

170 20-39 Fringe Benefits 6800 13026 0 13026

170 49 Agency Staff 6800 0 0 0

170 40-99 Other - Nonlabor 6800 0 0 0

174 20-39 Fringe Benefits 6900 0 0 0

174 49 Agency Staff 6900 0 0 0

174 40-99 Other - Nonlabor 6900 0 0 0

Subtotal 155 - 174 $ 3110566 $ (94409) $ 3016157

200 Total $ 15672437 $ (469771) $ 15202666

(Sch 2)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

Provider Name

1396881033

TOTAL ADJ

(Pages 123amp4)

(16978)

(4493)

AUDIT ADJ

(16978)

AUDIT ADJ

(1358)

AUDIT ADJ

200 Total ($469771)

(To Sch 8)

0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

200 Total 0 0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

DESCRIPTION

Net Exp For

Cost Alloc

(From Sch 8) Ratio

(From Sch 2)

(From Sch 3)

(From Sch 4)

(From Sch 5)

Allocated

of Total

Licensing Fees

of Total

Professional

Liability Ins

of Total

Quality Assur

of Total

Caregiver

Training

of Total

GENERAL SERVICES

Total 2626305 100 $ 2626305

ANCILLARY SERVICES

085 Pharmacy 0 0 482690 0 482690 103109 70496 1499 5469 25645 0

090 Laboratory 0 0 108582 0 108582 23195 15858 337 1230 5769 0

ROUTINE SERVICES

125 Subacute Care 2522195 185709 621943 166281 3496128 746819 510602 10861 39610 185746 0

NONREIMBURSABLE

SUBTOTAL 2626305 $ 6555073 $ 947179 $ 4063027 $ 729396 $ $ 12294675 $ 2626305

021361321

$ 1795611 38193 $ 139296 $ 653205 $ $ 0

(To Schedule 1)

Provider Name

1396881033

206390865

Fiscal Period

DESCRIPTION

Capital

(SQ FT)

VARIOUS

Plant Ops

(SQ FT)

Hskpng

(SQ FT)

Laundry

Dietary

(MEALS)

Soc Srvs

(DIRECT EXP)

Activities

(DIRECT EXP)

Inserv Ed

(DIRECT EXP)

(TOTAL

Med Records

(TOTAL

(ACCUM

GENERAL SERVICES

065 Dietary 3508 3508 3508

160 Activities 144 144 144

ANCILLARY SERVICES

085 Pharmacy 482690 482690

090 Laboratory 108582 108582

ROUTINE SERVICES

125 Subacute Care 4200 4200 4200 58414 11592 2935341 2935341 2935341 3496128 3496128

NONREIMBURSABLE

59123 $

0008296023

137462 $

0019288397

99682 $

442362652

232148 $

1031675211

151907 $

069379907

466338 $

439088421

2594 $

000036403

2123 $

000029784

73880 $

001036673

$ 14785

000120252

204890 $

001666493

305066 $

1353803142

61138 $

271701258

55273 $

025244548

340308 $

320422287

3203 $

000044942

14109 $

000197971

1300 $

000018247

$ 16304

000132609

3641 $

000029616

$ 771463

3268080149

35034 $

155470929

1096 $

004868618

13165 $

006012848

120269 $

113241213

6034 $

000084668

4937 $

000069274

2743 $

000038486

$ 34387

000279691

7680 $

000062463

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER REPORTED

ADJUSTMENTS

AUDITED

005 20-39 Fringe Benefits 6200 25355 0 25355

005 79 Agency Staff 6200 0 0 0

005 40-99 Other - Nonlabor 6200 277483 27583 305066

010 Housekeeping

010 20-39 Fringe Benefits 6300 0 0 0

010 79 Agency Staff 6300 275148 (43142) 232006

010 40-99 Other - Nonlabor 6300 17563 43142 60705

040 Property Taxes 7300 26550 4570 31120

055 Interest - Other 7600 90656 (6323) 84333

057 Subtotal 005 - 055 $ 1515304 $ 46750 $ 1562054

060 20-39 Fringe Benefits 6400 0 0 0

060 79 Agency Staff 6400 173797 (27550) 146247

060 40-99 Other - Nonlabor 6400 21481 27550 49031

065 Dietary

065 20-39 Fringe Benefits 6500 121973 0 121973

065 79 Agency Staff 6500 0 0 0

065 40-99 Other - Nonlabor 6500 268049 15236 283285

065 Dietary - Total 6500 $ 682678 $ 15236 $ 697914

Ancillary Services

075 20-39 Fringe Benefits 8100 0 0 0

075 79 Agency Staff 8100 0 0 0

075 40-99 Other - Nonlabor 8100 209288 (133296) 75992

077 20-39 Fringe Benefits 8150 0 0 0

077 79 Agency Staff 8150 0 0 0

077 40-99 Other - Nonlabor 8150 0 133296 133296

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 5)

(Sch 6)

(Sch 5)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

080 20-39 Fringe Benefits 8200 0 0 0

080 79 Agency Staff 8200 0 0 0

080 40-99 Other - Nonlabor 8200 648743 0 648743

081 20-39 Fringe Benefits 8220 0 0 0

081 79 Agency Staff 8220 0 0 0

081 40-99 Other - Nonlabor 8220 0 0 0

082 20-39 Fringe Benefits 8250 0 0 0

082 79 Agency Staff 8250 0 0 0

082 40-99 Other - Nonlabor 8250 622924 0 622924

083 20-39 Fringe Benefits 8280 0 0 0

083 79 Agency Staff 8280 0 0 0

083 40-99 Other - Nonlabor 8280 340620 0 340620

085 Pharmacy

085 20-39 Fringe Benefits 8300 0 0 0

085 79 Agency Staff 8300 0 0 0

085 40-99 Other - Nonlabor 8300 482690 0 482690

085 Pharmacy - Total 8300 $ 482690 $ 0 $ 482690

090 Laboratory

090 20-39 Fringe Benefits 8400 0 0 0

090 79 Agency Staff 8400 0 0 0

090 40-99 Other - Nonlabor 8400 108582 0 108582

095 20-39 Fringe Benefits 8800 0 0 0

095 79 Agency Staff 8800 0 0 0

095 40-99 Other - Nonlabor 8800 0 0 0

100 20-39 Fringe Benefits 8900 0 0 0

100 79 Agency Staff 8900 0 0 0

100 40-99 Other - Nonlabor 8900 189504 2244 191748

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

101 20-39 Fringe Benefits 8100-8900 0 0 0

101 79 Agency Staff 8100-8900 0 0 0

101 40-99 Other - Nonlabor 8100-8900 0 0 0

102 20-39 Fringe Benefits 8100-8900 0 0 0

102 79 Agency Staff 8100-8900 0 0 0

102 40-99 Other - Nonlabor 8100-8900 0 0 0

104 Subtotal 075 - 102 $ 2602351 $ 2244 $ 2604595

Routine Services

105 20-39 Fringe Benefits 6110 957187 (4396) 952791

105 49 Agency Staff 6110 0 0 0

105 40-99 Other - Nonlabor 6110 406243 (132179) 274064

110 20-39 Fringe Benefits 6120 0 0 0

110 49 Agency Staff 6120 0 0 0

110 40-99 Other - Nonlabor 6120 0 0 0

115 20-39 Fringe Benefits 6130 0 0 0

115 49 Agency Staff 6130 0 0 0

115 40-99 Other - Nonlabor 6130 0 0 0

120 20-39 Fringe Benefits 6140 0 0 0

120 49 Agency Staff 6140 0 0 0

120 40-99 Other - Nonlabor 6140 0 0 0

125 Subacute Care

125 20-39 Fringe Benefits 6150 581593 0 581593

125 49 Agency Staff 6150 0 0 0

125 40-99 Other - Nonlabor 6150 763239 (269123) 494116

126 20-39 Fringe Benefits 6160 0 0 0

126 49 Agency Staff 6160 0 0 0

126 40-99 Other - Nonlabor 6160 0 0 0

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

128 20-39 Fringe Benefits 6170 0 0 0

128 49 Agency Staff 6170 0 0 0

128 40-99 Other - Nonlabor 6170 0 0 0

130 20-39 Fringe Benefits 6180 0 0 0

130 49 Agency Staff 6180 0 0 0

130 40-99 Other - Nonlabor 6180 0 0 0

135 20-39 Fringe Benefits 6190 0 0 0

135 49 Agency Staff 6190 0 0 0

135 40-99 Other - Nonlabor 6190 0 0 0

139 20-39 Fringe Benefits 9100 0 0 0

139 49 Agency Staff 9100 0 0 0

139 40-99 Other - Nonlabor 9100 0 0 0

140 20-39 Fringe Benefits 8900 0 0 0

140 49 Agency Staff 8900 0 0 0

140 40-99 Other - Nonlabor 8900 0 0 0

145 20-39 Fringe Benefits 9100 0 0 0

145 49 Agency Staff 9100 0 0 0

145 40-99 Other - Nonlabor 9100 0 0 0

146 Subtotal 105 - 145 $ 7566260 $ (439592) $ 7126668

155 Social Services

155 20-39 Fringe Benefits 6600 15845 0 15845

155 49 Agency Staff 6600 342 (342) 0

155 40-99 Other - Nonlabor 6600 0 342 342

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

160 Activities

160 20-39 Fringe Benefits 6700 40781 0 40781

160 49 Agency Staff 6700 11768 (11768) 0

160 40-99 Other - Nonlabor 6700 0 11768 11768

165 Administration

165 20-39 Fringe Benefits 6900 248558 (42772) 205786

165 49 Agency Staff 6900 0 0 0

165 40-99 Other - Nonlabor 6900 877263 99868 977131

166 Medical Records

166 20-39 Fringe Benefits 6900 36253 16254 52507

166 49 Agency Staff 6900 0 0 0

166 40-99 Other - Nonlabor 6900 0 0 0

170 20-39 Fringe Benefits 6800 13026 0 13026

170 49 Agency Staff 6800 0 0 0

170 40-99 Other - Nonlabor 6800 0 0 0

174 20-39 Fringe Benefits 6900 0 0 0

174 49 Agency Staff 6900 0 0 0

174 40-99 Other - Nonlabor 6900 0 0 0

Subtotal 155 - 174 $ 3110566 $ (94409) $ 3016157

200 Total $ 15672437 $ (469771) $ 15202666

(Sch 2)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

Provider Name

1396881033

TOTAL ADJ

(Pages 123amp4)

(16978)

(4493)

AUDIT ADJ

(16978)

AUDIT ADJ

(1358)

AUDIT ADJ

200 Total ($469771)

(To Sch 8)

0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

200 Total 0 0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Provider Name

1396881033

206390865

Fiscal Period

DESCRIPTION

Capital

(SQ FT)

VARIOUS

Plant Ops

(SQ FT)

Hskpng

(SQ FT)

Laundry

Dietary

(MEALS)

Soc Srvs

(DIRECT EXP)

Activities

(DIRECT EXP)

Inserv Ed

(DIRECT EXP)

(TOTAL

Med Records

(TOTAL

(ACCUM

GENERAL SERVICES

065 Dietary 3508 3508 3508

160 Activities 144 144 144

ANCILLARY SERVICES

085 Pharmacy 482690 482690

090 Laboratory 108582 108582

ROUTINE SERVICES

125 Subacute Care 4200 4200 4200 58414 11592 2935341 2935341 2935341 3496128 3496128

NONREIMBURSABLE

59123 $

0008296023

137462 $

0019288397

99682 $

442362652

232148 $

1031675211

151907 $

069379907

466338 $

439088421

2594 $

000036403

2123 $

000029784

73880 $

001036673

$ 14785

000120252

204890 $

001666493

305066 $

1353803142

61138 $

271701258

55273 $

025244548

340308 $

320422287

3203 $

000044942

14109 $

000197971

1300 $

000018247

$ 16304

000132609

3641 $

000029616

$ 771463

3268080149

35034 $

155470929

1096 $

004868618

13165 $

006012848

120269 $

113241213

6034 $

000084668

4937 $

000069274

2743 $

000038486

$ 34387

000279691

7680 $

000062463

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER REPORTED

ADJUSTMENTS

AUDITED

005 20-39 Fringe Benefits 6200 25355 0 25355

005 79 Agency Staff 6200 0 0 0

005 40-99 Other - Nonlabor 6200 277483 27583 305066

010 Housekeeping

010 20-39 Fringe Benefits 6300 0 0 0

010 79 Agency Staff 6300 275148 (43142) 232006

010 40-99 Other - Nonlabor 6300 17563 43142 60705

040 Property Taxes 7300 26550 4570 31120

055 Interest - Other 7600 90656 (6323) 84333

057 Subtotal 005 - 055 $ 1515304 $ 46750 $ 1562054

060 20-39 Fringe Benefits 6400 0 0 0

060 79 Agency Staff 6400 173797 (27550) 146247

060 40-99 Other - Nonlabor 6400 21481 27550 49031

065 Dietary

065 20-39 Fringe Benefits 6500 121973 0 121973

065 79 Agency Staff 6500 0 0 0

065 40-99 Other - Nonlabor 6500 268049 15236 283285

065 Dietary - Total 6500 $ 682678 $ 15236 $ 697914

Ancillary Services

075 20-39 Fringe Benefits 8100 0 0 0

075 79 Agency Staff 8100 0 0 0

075 40-99 Other - Nonlabor 8100 209288 (133296) 75992

077 20-39 Fringe Benefits 8150 0 0 0

077 79 Agency Staff 8150 0 0 0

077 40-99 Other - Nonlabor 8150 0 133296 133296

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 5)

(Sch 6)

(Sch 5)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

080 20-39 Fringe Benefits 8200 0 0 0

080 79 Agency Staff 8200 0 0 0

080 40-99 Other - Nonlabor 8200 648743 0 648743

081 20-39 Fringe Benefits 8220 0 0 0

081 79 Agency Staff 8220 0 0 0

081 40-99 Other - Nonlabor 8220 0 0 0

082 20-39 Fringe Benefits 8250 0 0 0

082 79 Agency Staff 8250 0 0 0

082 40-99 Other - Nonlabor 8250 622924 0 622924

083 20-39 Fringe Benefits 8280 0 0 0

083 79 Agency Staff 8280 0 0 0

083 40-99 Other - Nonlabor 8280 340620 0 340620

085 Pharmacy

085 20-39 Fringe Benefits 8300 0 0 0

085 79 Agency Staff 8300 0 0 0

085 40-99 Other - Nonlabor 8300 482690 0 482690

085 Pharmacy - Total 8300 $ 482690 $ 0 $ 482690

090 Laboratory

090 20-39 Fringe Benefits 8400 0 0 0

090 79 Agency Staff 8400 0 0 0

090 40-99 Other - Nonlabor 8400 108582 0 108582

095 20-39 Fringe Benefits 8800 0 0 0

095 79 Agency Staff 8800 0 0 0

095 40-99 Other - Nonlabor 8800 0 0 0

100 20-39 Fringe Benefits 8900 0 0 0

100 79 Agency Staff 8900 0 0 0

100 40-99 Other - Nonlabor 8900 189504 2244 191748

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

101 20-39 Fringe Benefits 8100-8900 0 0 0

101 79 Agency Staff 8100-8900 0 0 0

101 40-99 Other - Nonlabor 8100-8900 0 0 0

102 20-39 Fringe Benefits 8100-8900 0 0 0

102 79 Agency Staff 8100-8900 0 0 0

102 40-99 Other - Nonlabor 8100-8900 0 0 0

104 Subtotal 075 - 102 $ 2602351 $ 2244 $ 2604595

Routine Services

105 20-39 Fringe Benefits 6110 957187 (4396) 952791

105 49 Agency Staff 6110 0 0 0

105 40-99 Other - Nonlabor 6110 406243 (132179) 274064

110 20-39 Fringe Benefits 6120 0 0 0

110 49 Agency Staff 6120 0 0 0

110 40-99 Other - Nonlabor 6120 0 0 0

115 20-39 Fringe Benefits 6130 0 0 0

115 49 Agency Staff 6130 0 0 0

115 40-99 Other - Nonlabor 6130 0 0 0

120 20-39 Fringe Benefits 6140 0 0 0

120 49 Agency Staff 6140 0 0 0

120 40-99 Other - Nonlabor 6140 0 0 0

125 Subacute Care

125 20-39 Fringe Benefits 6150 581593 0 581593

125 49 Agency Staff 6150 0 0 0

125 40-99 Other - Nonlabor 6150 763239 (269123) 494116

126 20-39 Fringe Benefits 6160 0 0 0

126 49 Agency Staff 6160 0 0 0

126 40-99 Other - Nonlabor 6160 0 0 0

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

128 20-39 Fringe Benefits 6170 0 0 0

128 49 Agency Staff 6170 0 0 0

128 40-99 Other - Nonlabor 6170 0 0 0

130 20-39 Fringe Benefits 6180 0 0 0

130 49 Agency Staff 6180 0 0 0

130 40-99 Other - Nonlabor 6180 0 0 0

135 20-39 Fringe Benefits 6190 0 0 0

135 49 Agency Staff 6190 0 0 0

135 40-99 Other - Nonlabor 6190 0 0 0

139 20-39 Fringe Benefits 9100 0 0 0

139 49 Agency Staff 9100 0 0 0

139 40-99 Other - Nonlabor 9100 0 0 0

140 20-39 Fringe Benefits 8900 0 0 0

140 49 Agency Staff 8900 0 0 0

140 40-99 Other - Nonlabor 8900 0 0 0

145 20-39 Fringe Benefits 9100 0 0 0

145 49 Agency Staff 9100 0 0 0

145 40-99 Other - Nonlabor 9100 0 0 0

146 Subtotal 105 - 145 $ 7566260 $ (439592) $ 7126668

155 Social Services

155 20-39 Fringe Benefits 6600 15845 0 15845

155 49 Agency Staff 6600 342 (342) 0

155 40-99 Other - Nonlabor 6600 0 342 342

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

160 Activities

160 20-39 Fringe Benefits 6700 40781 0 40781

160 49 Agency Staff 6700 11768 (11768) 0

160 40-99 Other - Nonlabor 6700 0 11768 11768

165 Administration

165 20-39 Fringe Benefits 6900 248558 (42772) 205786

165 49 Agency Staff 6900 0 0 0

165 40-99 Other - Nonlabor 6900 877263 99868 977131

166 Medical Records

166 20-39 Fringe Benefits 6900 36253 16254 52507

166 49 Agency Staff 6900 0 0 0

166 40-99 Other - Nonlabor 6900 0 0 0

170 20-39 Fringe Benefits 6800 13026 0 13026

170 49 Agency Staff 6800 0 0 0

170 40-99 Other - Nonlabor 6800 0 0 0

174 20-39 Fringe Benefits 6900 0 0 0

174 49 Agency Staff 6900 0 0 0

174 40-99 Other - Nonlabor 6900 0 0 0

Subtotal 155 - 174 $ 3110566 $ (94409) $ 3016157

200 Total $ 15672437 $ (469771) $ 15202666

(Sch 2)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

Provider Name

1396881033

TOTAL ADJ

(Pages 123amp4)

(16978)

(4493)

AUDIT ADJ

(16978)

AUDIT ADJ

(1358)

AUDIT ADJ

200 Total ($469771)

(To Sch 8)

0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

200 Total 0 0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER REPORTED

ADJUSTMENTS

AUDITED

005 20-39 Fringe Benefits 6200 25355 0 25355

005 79 Agency Staff 6200 0 0 0

005 40-99 Other - Nonlabor 6200 277483 27583 305066

010 Housekeeping

010 20-39 Fringe Benefits 6300 0 0 0

010 79 Agency Staff 6300 275148 (43142) 232006

010 40-99 Other - Nonlabor 6300 17563 43142 60705

040 Property Taxes 7300 26550 4570 31120

055 Interest - Other 7600 90656 (6323) 84333

057 Subtotal 005 - 055 $ 1515304 $ 46750 $ 1562054

060 20-39 Fringe Benefits 6400 0 0 0

060 79 Agency Staff 6400 173797 (27550) 146247

060 40-99 Other - Nonlabor 6400 21481 27550 49031

065 Dietary

065 20-39 Fringe Benefits 6500 121973 0 121973

065 79 Agency Staff 6500 0 0 0

065 40-99 Other - Nonlabor 6500 268049 15236 283285

065 Dietary - Total 6500 $ 682678 $ 15236 $ 697914

Ancillary Services

075 20-39 Fringe Benefits 8100 0 0 0

075 79 Agency Staff 8100 0 0 0

075 40-99 Other - Nonlabor 8100 209288 (133296) 75992

077 20-39 Fringe Benefits 8150 0 0 0

077 79 Agency Staff 8150 0 0 0

077 40-99 Other - Nonlabor 8150 0 133296 133296

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 5)

(Sch 6)

(Sch 5)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 3)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

080 20-39 Fringe Benefits 8200 0 0 0

080 79 Agency Staff 8200 0 0 0

080 40-99 Other - Nonlabor 8200 648743 0 648743

081 20-39 Fringe Benefits 8220 0 0 0

081 79 Agency Staff 8220 0 0 0

081 40-99 Other - Nonlabor 8220 0 0 0

082 20-39 Fringe Benefits 8250 0 0 0

082 79 Agency Staff 8250 0 0 0

082 40-99 Other - Nonlabor 8250 622924 0 622924

083 20-39 Fringe Benefits 8280 0 0 0

083 79 Agency Staff 8280 0 0 0

083 40-99 Other - Nonlabor 8280 340620 0 340620

085 Pharmacy

085 20-39 Fringe Benefits 8300 0 0 0

085 79 Agency Staff 8300 0 0 0

085 40-99 Other - Nonlabor 8300 482690 0 482690

085 Pharmacy - Total 8300 $ 482690 $ 0 $ 482690

090 Laboratory

090 20-39 Fringe Benefits 8400 0 0 0

090 79 Agency Staff 8400 0 0 0

090 40-99 Other - Nonlabor 8400 108582 0 108582

095 20-39 Fringe Benefits 8800 0 0 0

095 79 Agency Staff 8800 0 0 0

095 40-99 Other - Nonlabor 8800 0 0 0

100 20-39 Fringe Benefits 8900 0 0 0

100 79 Agency Staff 8900 0 0 0

100 40-99 Other - Nonlabor 8900 189504 2244 191748

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

101 20-39 Fringe Benefits 8100-8900 0 0 0

101 79 Agency Staff 8100-8900 0 0 0

101 40-99 Other - Nonlabor 8100-8900 0 0 0

102 20-39 Fringe Benefits 8100-8900 0 0 0

102 79 Agency Staff 8100-8900 0 0 0

102 40-99 Other - Nonlabor 8100-8900 0 0 0

104 Subtotal 075 - 102 $ 2602351 $ 2244 $ 2604595

Routine Services

105 20-39 Fringe Benefits 6110 957187 (4396) 952791

105 49 Agency Staff 6110 0 0 0

105 40-99 Other - Nonlabor 6110 406243 (132179) 274064

110 20-39 Fringe Benefits 6120 0 0 0

110 49 Agency Staff 6120 0 0 0

110 40-99 Other - Nonlabor 6120 0 0 0

115 20-39 Fringe Benefits 6130 0 0 0

115 49 Agency Staff 6130 0 0 0

115 40-99 Other - Nonlabor 6130 0 0 0

120 20-39 Fringe Benefits 6140 0 0 0

120 49 Agency Staff 6140 0 0 0

120 40-99 Other - Nonlabor 6140 0 0 0

125 Subacute Care

125 20-39 Fringe Benefits 6150 581593 0 581593

125 49 Agency Staff 6150 0 0 0

125 40-99 Other - Nonlabor 6150 763239 (269123) 494116

126 20-39 Fringe Benefits 6160 0 0 0

126 49 Agency Staff 6160 0 0 0

126 40-99 Other - Nonlabor 6160 0 0 0

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

128 20-39 Fringe Benefits 6170 0 0 0

128 49 Agency Staff 6170 0 0 0

128 40-99 Other - Nonlabor 6170 0 0 0

130 20-39 Fringe Benefits 6180 0 0 0

130 49 Agency Staff 6180 0 0 0

130 40-99 Other - Nonlabor 6180 0 0 0

135 20-39 Fringe Benefits 6190 0 0 0

135 49 Agency Staff 6190 0 0 0

135 40-99 Other - Nonlabor 6190 0 0 0

139 20-39 Fringe Benefits 9100 0 0 0

139 49 Agency Staff 9100 0 0 0

139 40-99 Other - Nonlabor 9100 0 0 0

140 20-39 Fringe Benefits 8900 0 0 0

140 49 Agency Staff 8900 0 0 0

140 40-99 Other - Nonlabor 8900 0 0 0

145 20-39 Fringe Benefits 9100 0 0 0

145 49 Agency Staff 9100 0 0 0

145 40-99 Other - Nonlabor 9100 0 0 0

146 Subtotal 105 - 145 $ 7566260 $ (439592) $ 7126668

155 Social Services

155 20-39 Fringe Benefits 6600 15845 0 15845

155 49 Agency Staff 6600 342 (342) 0

155 40-99 Other - Nonlabor 6600 0 342 342

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

160 Activities

160 20-39 Fringe Benefits 6700 40781 0 40781

160 49 Agency Staff 6700 11768 (11768) 0

160 40-99 Other - Nonlabor 6700 0 11768 11768

165 Administration

165 20-39 Fringe Benefits 6900 248558 (42772) 205786

165 49 Agency Staff 6900 0 0 0

165 40-99 Other - Nonlabor 6900 877263 99868 977131

166 Medical Records

166 20-39 Fringe Benefits 6900 36253 16254 52507

166 49 Agency Staff 6900 0 0 0

166 40-99 Other - Nonlabor 6900 0 0 0

170 20-39 Fringe Benefits 6800 13026 0 13026

170 49 Agency Staff 6800 0 0 0

170 40-99 Other - Nonlabor 6800 0 0 0

174 20-39 Fringe Benefits 6900 0 0 0

174 49 Agency Staff 6900 0 0 0

174 40-99 Other - Nonlabor 6900 0 0 0

Subtotal 155 - 174 $ 3110566 $ (94409) $ 3016157

200 Total $ 15672437 $ (469771) $ 15202666

(Sch 2)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

Provider Name

1396881033

TOTAL ADJ

(Pages 123amp4)

(16978)

(4493)

AUDIT ADJ

(16978)

AUDIT ADJ

(1358)

AUDIT ADJ

200 Total ($469771)

(To Sch 8)

0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

200 Total 0 0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

080 20-39 Fringe Benefits 8200 0 0 0

080 79 Agency Staff 8200 0 0 0

080 40-99 Other - Nonlabor 8200 648743 0 648743

081 20-39 Fringe Benefits 8220 0 0 0

081 79 Agency Staff 8220 0 0 0

081 40-99 Other - Nonlabor 8220 0 0 0

082 20-39 Fringe Benefits 8250 0 0 0

082 79 Agency Staff 8250 0 0 0

082 40-99 Other - Nonlabor 8250 622924 0 622924

083 20-39 Fringe Benefits 8280 0 0 0

083 79 Agency Staff 8280 0 0 0

083 40-99 Other - Nonlabor 8280 340620 0 340620

085 Pharmacy

085 20-39 Fringe Benefits 8300 0 0 0

085 79 Agency Staff 8300 0 0 0

085 40-99 Other - Nonlabor 8300 482690 0 482690

085 Pharmacy - Total 8300 $ 482690 $ 0 $ 482690

090 Laboratory

090 20-39 Fringe Benefits 8400 0 0 0

090 79 Agency Staff 8400 0 0 0

090 40-99 Other - Nonlabor 8400 108582 0 108582

095 20-39 Fringe Benefits 8800 0 0 0

095 79 Agency Staff 8800 0 0 0

095 40-99 Other - Nonlabor 8800 0 0 0

100 20-39 Fringe Benefits 8900 0 0 0

100 79 Agency Staff 8900 0 0 0

100 40-99 Other - Nonlabor 8900 189504 2244 191748

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

101 20-39 Fringe Benefits 8100-8900 0 0 0

101 79 Agency Staff 8100-8900 0 0 0

101 40-99 Other - Nonlabor 8100-8900 0 0 0

102 20-39 Fringe Benefits 8100-8900 0 0 0

102 79 Agency Staff 8100-8900 0 0 0

102 40-99 Other - Nonlabor 8100-8900 0 0 0

104 Subtotal 075 - 102 $ 2602351 $ 2244 $ 2604595

Routine Services

105 20-39 Fringe Benefits 6110 957187 (4396) 952791

105 49 Agency Staff 6110 0 0 0

105 40-99 Other - Nonlabor 6110 406243 (132179) 274064

110 20-39 Fringe Benefits 6120 0 0 0

110 49 Agency Staff 6120 0 0 0

110 40-99 Other - Nonlabor 6120 0 0 0

115 20-39 Fringe Benefits 6130 0 0 0

115 49 Agency Staff 6130 0 0 0

115 40-99 Other - Nonlabor 6130 0 0 0

120 20-39 Fringe Benefits 6140 0 0 0

120 49 Agency Staff 6140 0 0 0

120 40-99 Other - Nonlabor 6140 0 0 0

125 Subacute Care

125 20-39 Fringe Benefits 6150 581593 0 581593

125 49 Agency Staff 6150 0 0 0

125 40-99 Other - Nonlabor 6150 763239 (269123) 494116

126 20-39 Fringe Benefits 6160 0 0 0

126 49 Agency Staff 6160 0 0 0

126 40-99 Other - Nonlabor 6160 0 0 0

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

128 20-39 Fringe Benefits 6170 0 0 0

128 49 Agency Staff 6170 0 0 0

128 40-99 Other - Nonlabor 6170 0 0 0

130 20-39 Fringe Benefits 6180 0 0 0

130 49 Agency Staff 6180 0 0 0

130 40-99 Other - Nonlabor 6180 0 0 0

135 20-39 Fringe Benefits 6190 0 0 0

135 49 Agency Staff 6190 0 0 0

135 40-99 Other - Nonlabor 6190 0 0 0

139 20-39 Fringe Benefits 9100 0 0 0

139 49 Agency Staff 9100 0 0 0

139 40-99 Other - Nonlabor 9100 0 0 0

140 20-39 Fringe Benefits 8900 0 0 0

140 49 Agency Staff 8900 0 0 0

140 40-99 Other - Nonlabor 8900 0 0 0

145 20-39 Fringe Benefits 9100 0 0 0

145 49 Agency Staff 9100 0 0 0

145 40-99 Other - Nonlabor 9100 0 0 0

146 Subtotal 105 - 145 $ 7566260 $ (439592) $ 7126668

155 Social Services

155 20-39 Fringe Benefits 6600 15845 0 15845

155 49 Agency Staff 6600 342 (342) 0

155 40-99 Other - Nonlabor 6600 0 342 342

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

160 Activities

160 20-39 Fringe Benefits 6700 40781 0 40781

160 49 Agency Staff 6700 11768 (11768) 0

160 40-99 Other - Nonlabor 6700 0 11768 11768

165 Administration

165 20-39 Fringe Benefits 6900 248558 (42772) 205786

165 49 Agency Staff 6900 0 0 0

165 40-99 Other - Nonlabor 6900 877263 99868 977131

166 Medical Records

166 20-39 Fringe Benefits 6900 36253 16254 52507

166 49 Agency Staff 6900 0 0 0

166 40-99 Other - Nonlabor 6900 0 0 0

170 20-39 Fringe Benefits 6800 13026 0 13026

170 49 Agency Staff 6800 0 0 0

170 40-99 Other - Nonlabor 6800 0 0 0

174 20-39 Fringe Benefits 6900 0 0 0

174 49 Agency Staff 6900 0 0 0

174 40-99 Other - Nonlabor 6900 0 0 0

Subtotal 155 - 174 $ 3110566 $ (94409) $ 3016157

200 Total $ 15672437 $ (469771) $ 15202666

(Sch 2)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

Provider Name

1396881033

TOTAL ADJ

(Pages 123amp4)

(16978)

(4493)

AUDIT ADJ

(16978)

AUDIT ADJ

(1358)

AUDIT ADJ

200 Total ($469771)

(To Sch 8)

0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

200 Total 0 0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

101 20-39 Fringe Benefits 8100-8900 0 0 0

101 79 Agency Staff 8100-8900 0 0 0

101 40-99 Other - Nonlabor 8100-8900 0 0 0

102 20-39 Fringe Benefits 8100-8900 0 0 0

102 79 Agency Staff 8100-8900 0 0 0

102 40-99 Other - Nonlabor 8100-8900 0 0 0

104 Subtotal 075 - 102 $ 2602351 $ 2244 $ 2604595

Routine Services

105 20-39 Fringe Benefits 6110 957187 (4396) 952791

105 49 Agency Staff 6110 0 0 0

105 40-99 Other - Nonlabor 6110 406243 (132179) 274064

110 20-39 Fringe Benefits 6120 0 0 0

110 49 Agency Staff 6120 0 0 0

110 40-99 Other - Nonlabor 6120 0 0 0

115 20-39 Fringe Benefits 6130 0 0 0

115 49 Agency Staff 6130 0 0 0

115 40-99 Other - Nonlabor 6130 0 0 0

120 20-39 Fringe Benefits 6140 0 0 0

120 49 Agency Staff 6140 0 0 0

120 40-99 Other - Nonlabor 6140 0 0 0

125 Subacute Care

125 20-39 Fringe Benefits 6150 581593 0 581593

125 49 Agency Staff 6150 0 0 0

125 40-99 Other - Nonlabor 6150 763239 (269123) 494116

126 20-39 Fringe Benefits 6160 0 0 0

126 49 Agency Staff 6160 0 0 0

126 40-99 Other - Nonlabor 6160 0 0 0

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

128 20-39 Fringe Benefits 6170 0 0 0

128 49 Agency Staff 6170 0 0 0

128 40-99 Other - Nonlabor 6170 0 0 0

130 20-39 Fringe Benefits 6180 0 0 0

130 49 Agency Staff 6180 0 0 0

130 40-99 Other - Nonlabor 6180 0 0 0

135 20-39 Fringe Benefits 6190 0 0 0

135 49 Agency Staff 6190 0 0 0

135 40-99 Other - Nonlabor 6190 0 0 0

139 20-39 Fringe Benefits 9100 0 0 0

139 49 Agency Staff 9100 0 0 0

139 40-99 Other - Nonlabor 9100 0 0 0

140 20-39 Fringe Benefits 8900 0 0 0

140 49 Agency Staff 8900 0 0 0

140 40-99 Other - Nonlabor 8900 0 0 0

145 20-39 Fringe Benefits 9100 0 0 0

145 49 Agency Staff 9100 0 0 0

145 40-99 Other - Nonlabor 9100 0 0 0

146 Subtotal 105 - 145 $ 7566260 $ (439592) $ 7126668

155 Social Services

155 20-39 Fringe Benefits 6600 15845 0 15845

155 49 Agency Staff 6600 342 (342) 0

155 40-99 Other - Nonlabor 6600 0 342 342

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

160 Activities

160 20-39 Fringe Benefits 6700 40781 0 40781

160 49 Agency Staff 6700 11768 (11768) 0

160 40-99 Other - Nonlabor 6700 0 11768 11768

165 Administration

165 20-39 Fringe Benefits 6900 248558 (42772) 205786

165 49 Agency Staff 6900 0 0 0

165 40-99 Other - Nonlabor 6900 877263 99868 977131

166 Medical Records

166 20-39 Fringe Benefits 6900 36253 16254 52507

166 49 Agency Staff 6900 0 0 0

166 40-99 Other - Nonlabor 6900 0 0 0

170 20-39 Fringe Benefits 6800 13026 0 13026

170 49 Agency Staff 6800 0 0 0

170 40-99 Other - Nonlabor 6800 0 0 0

174 20-39 Fringe Benefits 6900 0 0 0

174 49 Agency Staff 6900 0 0 0

174 40-99 Other - Nonlabor 6900 0 0 0

Subtotal 155 - 174 $ 3110566 $ (94409) $ 3016157

200 Total $ 15672437 $ (469771) $ 15202666

(Sch 2)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

Provider Name

1396881033

TOTAL ADJ

(Pages 123amp4)

(16978)

(4493)

AUDIT ADJ

(16978)

AUDIT ADJ

(1358)

AUDIT ADJ

200 Total ($469771)

(To Sch 8)

0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

200 Total 0 0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

128 20-39 Fringe Benefits 6170 0 0 0

128 49 Agency Staff 6170 0 0 0

128 40-99 Other - Nonlabor 6170 0 0 0

130 20-39 Fringe Benefits 6180 0 0 0

130 49 Agency Staff 6180 0 0 0

130 40-99 Other - Nonlabor 6180 0 0 0

135 20-39 Fringe Benefits 6190 0 0 0

135 49 Agency Staff 6190 0 0 0

135 40-99 Other - Nonlabor 6190 0 0 0

139 20-39 Fringe Benefits 9100 0 0 0

139 49 Agency Staff 9100 0 0 0

139 40-99 Other - Nonlabor 9100 0 0 0

140 20-39 Fringe Benefits 8900 0 0 0

140 49 Agency Staff 8900 0 0 0

140 40-99 Other - Nonlabor 8900 0 0 0

145 20-39 Fringe Benefits 9100 0 0 0

145 49 Agency Staff 9100 0 0 0

145 40-99 Other - Nonlabor 9100 0 0 0

146 Subtotal 105 - 145 $ 7566260 $ (439592) $ 7126668

155 Social Services

155 20-39 Fringe Benefits 6600 15845 0 15845

155 49 Agency Staff 6600 342 (342) 0

155 40-99 Other - Nonlabor 6600 0 342 342

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

(Sch 2)

(Sch 4)

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

160 Activities

160 20-39 Fringe Benefits 6700 40781 0 40781

160 49 Agency Staff 6700 11768 (11768) 0

160 40-99 Other - Nonlabor 6700 0 11768 11768

165 Administration

165 20-39 Fringe Benefits 6900 248558 (42772) 205786

165 49 Agency Staff 6900 0 0 0

165 40-99 Other - Nonlabor 6900 877263 99868 977131

166 Medical Records

166 20-39 Fringe Benefits 6900 36253 16254 52507

166 49 Agency Staff 6900 0 0 0

166 40-99 Other - Nonlabor 6900 0 0 0

170 20-39 Fringe Benefits 6800 13026 0 13026

170 49 Agency Staff 6800 0 0 0

170 40-99 Other - Nonlabor 6800 0 0 0

174 20-39 Fringe Benefits 6900 0 0 0

174 49 Agency Staff 6900 0 0 0

174 40-99 Other - Nonlabor 6900 0 0 0

Subtotal 155 - 174 $ 3110566 $ (94409) $ 3016157

200 Total $ 15672437 $ (469771) $ 15202666

(Sch 2)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

Provider Name

1396881033

TOTAL ADJ

(Pages 123amp4)

(16978)

(4493)

AUDIT ADJ

(16978)

AUDIT ADJ

(1358)

AUDIT ADJ

200 Total ($469771)

(To Sch 8)

0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

200 Total 0 0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

1396881033 206390865

Natural

Class ACCOUNT TITLE

ACCOUNT

NUMBER

REPORTED

ADJUSTMENTS

AUDITED

160 Activities

160 20-39 Fringe Benefits 6700 40781 0 40781

160 49 Agency Staff 6700 11768 (11768) 0

160 40-99 Other - Nonlabor 6700 0 11768 11768

165 Administration

165 20-39 Fringe Benefits 6900 248558 (42772) 205786

165 49 Agency Staff 6900 0 0 0

165 40-99 Other - Nonlabor 6900 877263 99868 977131

166 Medical Records

166 20-39 Fringe Benefits 6900 36253 16254 52507

166 49 Agency Staff 6900 0 0 0

166 40-99 Other - Nonlabor 6900 0 0 0

170 20-39 Fringe Benefits 6800 13026 0 13026

170 49 Agency Staff 6800 0 0 0

170 40-99 Other - Nonlabor 6800 0 0 0

174 20-39 Fringe Benefits 6900 0 0 0

174 49 Agency Staff 6900 0 0 0

174 40-99 Other - Nonlabor 6900 0 0 0

Subtotal 155 - 174 $ 3110566 $ (94409) $ 3016157

200 Total $ 15672437 $ (469771) $ 15202666

(Sch 2)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

(Sch 3)

(Sch 4)

(Sch 6)

Provider Name

1396881033

TOTAL ADJ

(Pages 123amp4)

(16978)

(4493)

AUDIT ADJ

(16978)

AUDIT ADJ

(1358)

AUDIT ADJ

200 Total ($469771)

(To Sch 8)

0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

200 Total 0 0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Provider Name

1396881033

TOTAL ADJ

(Pages 123amp4)

(16978)

(4493)

AUDIT ADJ

(16978)

AUDIT ADJ

(1358)

AUDIT ADJ

200 Total ($469771)

(To Sch 8)

0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

200 Total 0 0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Provider Name

1396881033

TOTAL ADJ

(Pages 123amp4)

(16978)

(4493)

AUDIT ADJ

(16978)

AUDIT ADJ

(1358)

AUDIT ADJ

200 Total ($469771)

(To Sch 8)

0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

200 Total 0 0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Provider Name

1396881033

TOTAL ADJ

(Pages 123amp4)

(16978)

(4493)

AUDIT ADJ

(16978)

AUDIT ADJ

(1358)

AUDIT ADJ

200 Total ($469771)

(To Sch 8)

0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

200 Total 0 0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Provider Name

1396881033

TOTAL ADJ

(Pages 123amp4)

(16978)

(4493)

AUDIT ADJ

(16978)

AUDIT ADJ

(1358)

AUDIT ADJ

200 Total ($469771)

(To Sch 8)

0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

200 Total 0 0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

200 Total 0 0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

200 Total 0 0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

200 Total 0 0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 10 11 12 13 14 15 16 17 18

200 Total 0 0 0 0 0 0 0 0 0

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 19 20 21 22 23 24 25 26 27

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

(2268)

AUDIT ADJ

200 Total (11530) (211096) (867) (2268) (48878) (1149) (4943) (750) (9000)

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Provider Name

1396881033

206390865

Fiscal Period

Line Sub 28 29 30

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

(To Sch 8)

Provider Name

1396881033

206390865

Fiscal Period

AUDIT ADJ

200 Total (1792) (1967) (175531) 0 0 0 0 0 0

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

1396881033 206390865

DESCRIPTION

SUBACUTE CARE COST

AUDITED

SUBACUTE CARE TOTAL

GENERAL INFORMATION

AUDITED

(Adj 35)

AUDITED

TOTAL DAYS

(Adj 38)

AUDITED

MEDI-CAL DAYS

50 TOTAL $ NA 11683 9121

(To Schedule 1)

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

1396881033 206390865

COSTS (Adj 40)

ANCILLARY

CHARGES

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42) COST

SUBACUTE CARE

ANCILLARY

PATIENT SUPPLIES

PHYSICAL THERAPY

RESPIRATORY THERAPY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

SPEECH PATHOLOGY

PHARMACY

LABORATORY

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

1396881033 206390865

ANCILLARY

CHARGES

(Adj 40)

COSTCHG

SUBACUTE CARE

ANCILLARY CHARGES

(Adj 39 41 42)

SUBACUTE CARE

ANCILLARY

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$0 $494098 $494098

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

010 060 010 060

010 010

167 165

168 165

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

010 060 010 060

010 010

167 165

168 165

3 3 4 4

$275148 173797 17563 21481

$234671 58040

$55171 877263

$143789 894241

($40477) (27550) 40477 27550

($2665) 2665

($16978) 16978

($1358) 1358

$234671 146247 58040 49031

$232006 60705

$38193 894241

$142431 895599

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

165 040

065 035

075 077

105 100

105 035

8A-1 8A-1

165 040

065 035

075 077

105 100

105 035

$895599 26550

$268049 587111

$209288 0

$406243 189504

$403999 588963

($4570) 4570

($1852) 1852

($133296) 133296

($2244) 2244

($19706) 19706

$891029 31120

$266197 588963

$75992 133296

$403999 191748

$384293 608669

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105

125 035

105 165

125 065

105 165

125 165

8A-1 8A-1

125 035

105 165

125 065

105 165

125 165

$763239 608669

$384293 891029

$758735 266197

$375043 900279

$741647 954009

($4504) 4504

($9250) 9250

($17088) 17088

($53730) 53730

($72000) 72000

$758735 613173

$375043 900279

$741647 283285

$321313 954009

$669647 1026009

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105 105

105 105

155 160 155 160

165 166

105 005

3 3 4 4

8A-1 8A-1 8A-1 8A-1

8A-1 8A-1

155 160 155 160

165 166

105 005

3 3 4 4

$342 11768

$248558 36253

$321313 277483

($342) (11768)

342 11768

($16254) 16254

($34425) 34425

342 11768

$232304 52507

$286888 311908

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

105 105 105

105 105 105 105

045 055 105

105 105 165 165

1 2 1 2

8A-1 8A-1 8A-1

8A-1 8A-1 8A-1 8A-1

045 055 105

105 105 165 165

1 2 1 2

$13941 90656

286888

$2998366 957187 665850 232304

$142431

$1026009

($5142) (6323)

($33894) (4396)

(146288) (26518)

($867)

(2268) ($3135)

($48878)

$8799 84333

286823

$2964472 952791 519562 205786

$139296

$977131

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$311908

$286823

($1149)

(4943)

(750) ($6842)

($9000)

(1792)

(1967) ($12759)

$305066

$274064

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

$669647 ($175531) $494116

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107 107

107 107 107

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 175 175 175

105 125 175

1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3

7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7

005 010 060 065 080 082 083 105 125 140 155 160 165 166 170 NA NA NA

105 125 NA

NA NA NA

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

1072 32

384 3508

444 427 233

11511 4200

168 176 144

1003 224 80

23606 22534 22502

160536 58414

218950

94614 11592

106206

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

100 115

1 Subacute 1

32029 11761

7868 3893

79 (78)

(128) 50

32108 11683

7740 3943

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

38 43 43 43

100 115 120

48 49 44

NA NA NA

6248 3248 9496

(167) (208) (375)

6081 3040 9121

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Subacute 2

$83080

$278693 0

$139719

$182678

$56639

($184589) 184589

($60381)

($121396)

$139719

$94104 184589

$79338

$61282

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Adjustments 46

Report References

Reported Increase

(Decrease) As

Adjusted Adj No

Not Reported

Subacute 1

Overpayments

$27053

32300 $60217

$60217

Title Page

Documents

Windsor Elmhaven Care Center - California Department of ... · PDF filereport on the rate setting audit windsor elmhaven care center stockton, california national provider identifier: