SANTA CRUZ SKILLED NURSING CENTER SANTA filereport on the rate setting audit santa cruz skilled...
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REPORT ON THE RATE SETTING AUDIT SANTA CRUZ SKILLED NURSING CENTER SANTA CRUZ, CALIFORNIA PROVIDER NUMBER: ZZR05017N AND NPI NUMBER: 1629256953 FISCAL PERIOD ENDED DECEMBER 31, 2008 Audits Section - Richmond Financial Audits Branch Audits and Investigations Department of Health Care Services Section Chief: Louise Wong Audit Supervisor: Sandra Garcia Auditor: Dan Matterson
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Transcript of SANTA CRUZ SKILLED NURSING CENTER SANTA filereport on the rate setting audit santa cruz skilled...
REPORT ON THE
RATE SETTING AUDIT
SANTA CRUZ SKILLED NURSING CENTER SANTA CRUZ, CALIFORNIA
PROVIDER NUMBER: ZZR05017N AND NPI NUMBER: 1629256953
FISCAL PERIOD ENDED
DECEMBER 31, 2008
Audits Section - Richmond Financial Audits Branch
Audits and Investigations Department of Health Care Services
Section Chief: Louise Wong Audit Supervisor: Sandra Garcia Auditor: Dan Matterson
State of California—Health and Human Services Agency
Department of Health Care Services
DAVID MAXWELL-JOLLY ARNOLD SCHWARZENEGGER Director Governor
850 Marina Bay Parkway, Building P, 2nd Floor, MS 2104, Richmond, CA 94804-6403
Telephone: (510) 620-3100 FAX: (510) 620-3111 Internet Address: www.dhcs.ca.gov
March 29, 2010 Ralph Unterbrink, Administrator Santa Cruz Skilled Nursing Center 2990 Soquel Avenue Santa Cruz, California 95062 PROVIDER: SANTA CRUZ SKILLED NURSING CENTER PROVIDER NO. ZZR05017N AND NPI NO. 1629256953 FISCAL PERIOD ENDED DECEMBER 31, 2008 We have examined the facility's Integrated Disclosure and Medi-Cal Cost Report for the above-referenced fiscal period. 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. 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 and patient days for the above fiscal period in accordance with Medi-Cal reimbursement principles. This audit report includes the: 1. Summary of Audited Facility Cost per Patient Day and supporting schedules 2. Audit Adjustments Schedule 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 Department's Rate Development Branch. Notwithstanding this audit report, overpayments to the provider are subject to recovery pursuant to Section 51458.1, Article 6 of Division 3, Title 22, California Code of Regulations.
Ralph Unterbrink Page 2
If you disagree with the decision of the Department, you may appeal by writing to: John Melton, Chief Office of Administrative Appeals and Hearings 1029 J Street, Suite 200 Sacramento, CA 95814-2825 (916) 322-5603 The written notice of disagreement must be received by the Department within 60 calendar days from the day you receive this letter. A copy of this notice should be sent to: United States Postal Service (USPS) Courier (UPS, FedEx, etc.) Assistant Chief Counsel Assistant Chief Counsel Department of Health Care Services Department of Health Care Services Office of Legal Services Office of Legal Services MS 0010 MS 0010 P.O. Box 997413 1501 Capitol Avenue, Suite 71.5001 Sacramento, CA 95899-7413 Sacramento, CA 95814-5005 (916) 440-7745 The procedures that govern an appeal are contained in Welfare and Institutions Code, Section 14171, and California Code of Regulations, Title 22, Section 51016, et seq. If you have questions regarding this report, you may call the Audits Section—Richmond at (510) 620-3100. Original Signed by Louise Wong, Chief Audits Section—Richmond Financial Audits Branch Certified
STATE OF CALIFORNIA SCHEDULE 1
Provider Name: Fiscal Period:SANTA CRUZ SKILLED NURSING CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008
Provider Number: Provider NPI: OSHPD Facility No.:ZZR05017N 1629256953 206440727
LineNo.
SKILLED NURSING CARE1 Cost of Direct Care - Labor (Sch. 2, Ln. 105) $ N/A $ 3,791,366 $ 103.75
2 Cost of Indirect Care - Labor (Sch. 3, Ln. 105) $ N/A $ 1,074,147 $ 29.39
3 Cost of Direct and Indirect NonLabor - Other (Sch. 4, Ln. 105) $ N/A $ 1,118,964 $ 30.62
4 Cost of Capital Related (Sch. 5, Ln. 105) $ N/A $ 525,568 $ 14.38
5 Property Taxes (Sch. 5, Ln. 105) $ N/A $ 52,168 $ 1.43
6 Facility License Fees (Sch. 6, Ln. 105) $ N/A $ 32,281 $ 0.88
7 Liability Insurance (Sch. 6, Ln. 105) $ N/A $ 136,580 $ 3.74
8 Caregiver Training (Sch. 6, Ln. 105) $ N/A $ 0 $ 0.00
9 Quality Assurance Fees (Sch. 6, Ln. 105) $ N/A $ 316,857 $ 8.67
10 Cost of Administration (Sch. 6, Ln. 105) $ N/A $ 656,402 $ 17.96
11 Cost of Routine Service/Audited Total Costs $ 7,711,709 $ 7,704,333 $ 210.83
12 Total Patient Days (Adj ) 36,543 36,543
13 Cost Per Patient Day (Cost Divided by Days) $ 211.03 $ 210.83
14 Overpayments (Adj ) $ $ 0
INTERMEDIATE CARE15 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 0
16 Total Patient Days (Adj ) 0
17 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
18 Overpayments (Adj ) $ $ 0
MENTALLY DISORDERED19 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 0
20 Total Patient Days (Adj ) 0
21 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
22 Overpayments (Adj ) $ $ 0
DEVELOPMENTALLY DISABLED23 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 0
24 Total Patient Days (Adj ) 0
25 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
26 Overpayments (Adj ) $ $ 0
ADULT SUBACUTE27 Cost of Direct Care - Labor (Adult Subacute Sch. 1, Ln. 25) $ N/A $ 0 $ 0.00
28 Cost of Indirect Care - Labor (Adult Subacute Sch. 1, Ln. 26) $ N/A $ 0 $ 0.00
29 Cost of Direct and Indirect NonLabor - Other (Adult SA Sch. 1, Ln. 27) $ N/A $ 0 $ 0.00
30 Cost of Capital Related (Adult Subacute Sch. 1, Ln. 28) $ N/A $ 0 $ 0.00
31 Property Taxes (Adult Subacute Sch. 1, Ln. 29) $ N/A $ 0 $ 0.00
32 Facility License Fees (Adult Subacute Sch. 1, Ln. 30) $ N/A $ 0 $ 0.00
33 Liability Insurance (Adult Subacute Sch. 1, Ln. 31) $ N/A $ 0 $ 0.00
34 Caregiver Training (Adult Subacute Sch. 1, Ln. 32) $ N/A $ 0 $ 0.00
35 Quality Assurance Fees (Adult Subacute Sch. 1, Ln. 33) $ N/A $ 0 $ 0.00
36 Cost of Administration (Adult Subacute Sch., Ln. 34) $ N/A $ 0 $ 0.00
37 Total Cost of Subacute Service (Adult Subacute Sch. 1, Ln. 35) $ 0 $ 0 $ 0.00
38 Total Patient Days (Adult Subacute Sch. 1, Ln. 36) 0 0
39 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
40 Overpayments (Adult Subacute Sch. 1, Ln. 38 + Ln. 39) $ 0 $ 0
SUMMARY OF AUDITED FACILITY COST PER PATIENT DAY
COST PERAUDITED
AS REPORTED AS AUDITED PATIENT DAYPROGRAM DESCRIPTION
STATE OF CALIFORNIA SCHEDULE 1
Provider Name: Fiscal Period:SANTA CRUZ SKILLED NURSING CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008
Provider Number: Provider NPI: OSHPD Facility No.:ZZR05017N 1629256953 206440727
LineNo.
SUMMARY OF AUDITED FACILITY COST PER PATIENT DAY
COST PERAUDITED
AS REPORTED AS AUDITED PATIENT DAYPROGRAM DESCRIPTION
PEDIATRIC SUBACUTE41 Cost of Routine Service (Ped-SA, Sch. 1, Ln 3) $ 0 $ 0
42 Cost of Ancillary Service (Ped-SA, Sch. 1, Ln. 1 + Ln. 2) $ 0 $ 0
43 Total Cost of Pediatric Subacute Service (Ln. 42 + Ln. 43) $ 0 $ 0
44 Total Patient Days (Ped-SA, Sch. 1, Ln. 5) 0 0
45 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
46 Overpayments (Ped-SA, Sch. 1, Ln. 7 + Ln. 8) $ 0 $ 0
HOSPICE INPATIENT CARE47 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 0
48 Total Patient Days (Adj ) 0
49 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
50 Overpayments (Adj ) $ $ 0
OTHER ROUTINE SERVICES51 Cost of Routine Service (Sch. 2, 3, 4, 5, 6) $ $ 0
52 Total Patient Days (Adj ) 0
53 Cost Per Patient Day (Cost Divided by Days) $ 0.00 $ 0.00
54 Overpayments (Adj ) $ $ 0
STATE OF CALIFORNIA SCHEDULE 2
Provider Name: Fiscal Period:SANTA CRUZ SKILLED NURSING CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008
Provider Number: Provider NPI: OSHPD Facility No.:ZZR05017N 1629256953 206440727
Soc Srvs ActivitiesNet Exp For
Line DESCRIPTION Cost AllocNo. (From Sch 8) 155 160 Total
GENERAL SERVICES5.00 Plant Operations and Maintenance
10.00 Housekeeping60.00 Laundry and Linen65.00 Dietary
155.00 Social Services (Salaries, Fringe Benefits, & Agency Labor) 172,195$ 172,195$ 160.00 Activities (Salaries, Fringe Benefits, & Agency Labor) 108,077 108,077$ 165.00 Administration165.00 Medical Records170.00 Inservice Education - Nursing
ANCILLARY SERVICES75.00 Patient Supplies 26,302 0 0 26,302$ 77.00 Specialized Support Surfaces N/A 0 0 080.00 Physical Therapy 185,265 0 0 185,26581.00 Respiratory Therapy 0 0 0 082.00 Occupational Therapy 111,159 0 0 111,15983.00 Speech Pathology 74,106 0 0 74,10685.00 Pharmacy 171,072 0 0 171,07290.00 Laboratory 12,625 0 0 12,62595.00 Home Health Services 0 0 0 0
100.00 Other Ancillary Services 3,095 0 0 3,095100.06 Subacute Ancillary Services 0 0 0 0100.12 Subacute Pediatrics Ancillary Services 0 0 0 0
ROUTINE SERVICES105.00 Skilled Nursing Care 3,511,094 172,195 108,077 3,791,366 *110.00 Intermediate Care 0 0 0 0 *115.00 Mentally Disordered 0 0 0 0 *120.00 Developmentally Disabled 0 0 0 0 *125.00 Subacute Care 0 0 0 0 *126.00 Subacute Care - Pediatrics 0 0 0 0 *130.00 Hospice Inpatient Care 0 0 0 0 *135.00 Other Routine Services 0 0 0 0 *
NONREIMBURSABLE 136.00 Residential Care 0 0 0 0140.00 Beauty and Barber 0 0 0 0145.00 Other Nonreimbursable 135,193 0 0 135,193
TOTAL 4,510,183$ 172,195$ 108,077$ 4,510,183$
* (To Schedule 1)
ALLOCATION OF GENERAL SERVICES - LABOR (DIRECT CARE)
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STATE OF CALIFORNIA SCHEDULE 5
ALLOCATION OF CAPITAL COSTS
Provider Name: Fiscal Period:SANTA CRUZ SKILLED NURSING CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008
Provider Number: Provider NPI: OSHPD Facility Number:ZZR05017N 1629256953 206440727
Capital Plant Ops Hskpng Laundry Dietary Soc Srvs ActivitiesNet Exp For
Line DESCRIPTION Cost AllocNo. (From Sch 8) Ratio Various 5 10 60 65 155 160
GENERAL SERVICESCapital Related (excluding lines 40 & 45) 559,041$ 91%
Property Tax (line 40) 55,491 9% 614,532$
5.00 Plant Operations and Maintenance 13,118 13,118$
10.00 Housekeeping 6,110 133 6,244$
60.00 Laundry and Linen 9,751 213 102 10,065$
65.00 Dietary 55,318 1,207 580 0 57,105$
155.00 Social Services 58,763 1,282 616 0 0 60,661$
160.00 Activities 0 0 0 0 0 0 -$
165.00 Administration 34,608 755 363 0 0 0 0
165.00 Medical Records 5,668 124 59 0 0 0 0
170.00 Inservice Education - Nursing 29,122 635 305 0 0 0 0
ANCILLARY SERVICES75.00 Patient Supplies 6,695 146 70 0 0 0 0
77.00 Specialized Support Surfaces 0 0 0 0 0 0 0
80.00 Physical Therapy 12,546 274 132 0 0 0 0
81.00 Respiratory Therapy 0 0 0 0 0 0 0
82.00 Occupational Therapy 3,848 84 40 0 0 0 0
83.00 Speech Pathology 2,262 49 24 0 0 0 0
85.00 Pharmacy 2,535 55 27 0 0 0 0
90.00 Laboratory 0 0 0 0 0 0 0
95.00 Home Health Services 0 0 0 0 0 0 0
100.00 Other Ancillary Services 0 0 0 0 0 0 0
100.06 Subacute Ancillary Services 0 0 0 0 0 0 0
100.12 Subacute Pediatrics Ancillary Services 0 0 0 0 0 0 0
ROUTINE SERVICES105.00 Skilled Nursing Care 370,911 8,090 3,890 10,065 57,105 60,661 0
110.00 Intermediate Care 0 0 0 0 0 0 0
115.00 Mentally Disordered 0 0 0 0 0 0 0
120.00 Developmentally Disabled 0 0 0 0 0 0 0
125.00 Subacute Care 0 0 0 0 0 0 0
126.00 Subacute Care - Pediatrics 0 0 0 0 0 0 0
130.00 Hospice Inpatient Care 0 0 0 0 0 0 0
135.00 Other Routine Services 0 0 0 0 0 0 0
NONREIMBURSABLE 136.00 Residential Care 0 0 0 0 0 0 0
140.00 Beauty and Barber 3,276 71 34 0 0 0 0
145.00 Other Nonreimbursable 0 0 0 0 0 0 0
TOTAL 614,532$ 100% 614,532$ 13,118$ 6,244$ 10,065$ 57,105$ 60,661$ -$
* (To Schedule 1)
STATE OF CALIFORNIA
Provider Name:SANTA CRUZ SKILLED NURSING CENTER
Provider Number: Provider NPI:ZZR05017N 1629256953
Net Exp ForLine DESCRIPTION Cost AllocNo. (From Sch 8) Ratio
GENERAL SERVICESCapital Related (excluding lines 40 & 45) 559,041$ 91%Property Tax (line 40) 55,491 9%
5.00 Plant Operations and Maintenance10.00 Housekeeping60.00 Laundry and Linen65.00 Dietary
155.00 Social Services160.00 Activities165.00 Administration165.00 Medical Records170.00 Inservice Education - Nursing
ANCILLARY SERVICES75.00 Patient Supplies77.00 Specialized Support Surfaces80.00 Physical Therapy81.00 Respiratory Therapy82.00 Occupational Therapy83.00 Speech Pathology85.00 Pharmacy90.00 Laboratory95.00 Home Health Services
100.00 Other Ancillary Services100.06 Subacute Ancillary Services100.12 Subacute Pediatrics Ancillary Services
ROUTINE SERVICES105.00 Skilled Nursing Care110.00 Intermediate Care115.00 Mentally Disordered120.00 Developmentally Disabled125.00 Subacute Care126.00 Subacute Care - Pediatrics130.00 Hospice Inpatient Care135.00 Other Routine Services
NONREIMBURSABLE 136.00 Residential Care140.00 Beauty and Barber145.00 Other Nonreimbursable
TOTAL 614,532$ 100%
* (To Schedule 1)
SCHEDULE 5
ALLOCATION OF CAPITAL COSTS
Fiscal Period:JANUARY 1, 2008 THROUGH DECEMBER 31, 2008
OSHPD Facility Number:206440727
In-serv. Ed Admin Medical Capital PropertyRecords Related Tax
Accumulated 91% 9%170 Costs 165 165 Total Of Total Of Total
35,726$ 35,726$ 5,851 5,851$
30,062$
0 6,912 209 34 7,155$ 6,509$ 646$ 0 0 0 0 0 0 00 12,951 1,076 176 14,204 12,921 1,2830 0 0 0 0 0 00 3,973 604 99 4,675 4,253 4220 2,335 399 65 2,799 2,547 2530 2,617 890 146 3,653 3,323 3300 0 64 10 74 67 70 0 0 0 0 0 00 0 16 3 18 16 20 0 0 0 0 0 00 0 0 0 0 0 0
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0 0 0 0 0 0 00 3,382 38 6 3,426 3,116 3090 0 680 111 792 720 71
30,062$ 572,955$ 35,726$ 5,851$ 614,532$ 559,041$ 55,491$
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STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:SANTA CRUZ SKILLED NURSING CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008
Provider Number: Provider NPI: OSHPD Facility Number:ZZR05017N 1629256953 206440727
Line Natural ACCOUNT TITLE AccountNo. Class Number
5.00 Plant Operations and Maintenance 6200 $ 492,590 $ (492,590) $ 0 $ 0 $ 05.01 .01-.19 Salaries and Wages 6200 123,344 123,344 0 123,344 (Sch 3)5.02 .20-.39 Fringe Benefits 6200 23,216 23,216 0 23,216 (Sch 3)5.03 .79 Agency Staff 6200 0 0 0 0 (Sch 3)5.04 .40-.99 Other - Nonlabor 6200 346,030 346,030 0 346,030 (Sch 4)5.05 Plant Operations and Maintenance - Total 6200 $ 492,590 $ 0 $ 492,590 $ 0 $ 492,590
10.00 Housekeeping 6300 $ 250,827 $ (250,827) $ 0 $ 0 $ 010.01 .01-.19 Salaries and Wages 6300 192,023 192,023 0 192,023 (Sch 3)10.02 .20-.39 Fringe Benefits 6300 36,441 36,441 0 36,441 (Sch 3)10.03 .79 Agency Staff 6300 0 0 0 0 (Sch 3)10.04 .40-.99 Other - Nonlabor 6300 22,363 22,363 0 22,363 (Sch 4)10.05 Housekeeping - Total 6300 $ 250,827 $ 0 $ 250,827 $ 0 $ 250,827
15.00 Depreciation: Bldgs and Improvements 7110 - 7120 $ $ 0 $ 0 $ 0 (Sch 5)20.00 Depreciation: Leasehold Improvements 7130 21,271 21,271 0 21,271 (Sch 5)25.00 Depreciation: Equipment 7140 11,118 11,118 0 11,118 (Sch 5)30.00 Depreciation and Amortization - Other 7150 - 7160 0 0 0 (Sch 5)35.00 Leases and Rentals 7200 526,652 526,652 0 526,652 (Sch 5)40.00 Property Taxes 7300 55,491 55,491 0 55,491 (Sch 5)45.00 Property Insurance 7400 13,672 13,672 (3,555) 10,117 (Sch 6)50.00 Interest-Property, Plant, and Equipment 7500 0 0 0 (Sch 5)55.00 Interest-Other 7600 0 0 0 (Sch 6)
57.00 Subtotal 005 - 055 $ 1,371,621 $ 0 $ 1,371,621 $ (3,555) $ 1,368,066
60.00 Laundry and Linen 6400 $ 190,504 $ (190,504) $ 0 $ 0 $ 060.01 .01-.19 Salaries and Wages 6400 140,643 140,643 0 140,643 (Sch 3)60.02 .20-.39 Fringe Benefits 6400 26,582 26,582 0 26,582 (Sch 3)60.03 .79 Agency Staff 6400 0 0 0 0 (Sch 3)60.04 .40-.99 Other - Nonlabor 6400 23,279 23,279 0 23,279 (Sch 4)60.05 Laundry and Linen - Total 6400 $ 190,504 $ 0 $ 190,504 $ 0 $ 190,504
65.00 Dietary 6500 $ 700,990 $ (700,990) $ 0 $ 0 $ 065.01 .01-.19 Salaries and Wages 6500 300,168 300,168 0 300,168 (Sch 3)65.02 .20-.39 Fringe Benefits 6500 56,519 56,519 0 56,519 (Sch 3)65.03 .79 Agency Staff 6500 0 0 0 0 (Sch 3)65.04 .40-.99 Other - Nonlabor 6500 344,303 344,303 0 344,303 (Sch 4)65.05 Dietary - Total 6500 $ 700,990 $ 0 $ 700,990 $ 0 $ 700,990
70.00 Provision for Bad Debts 7700 $ $ 0 $ 0 $ 0
Ancillary Services (Note 1)75.00 Patient Supplies 8100 $ 26,302 $ 0 $ 26,302 $ 0 $ 26,302 (Sch 2)75.01 .01-.19 Salaries and Wages 8100 0 0 0 0 (Sch 2)75.02 .20-.39 Fringe Benefits 8100 0 0 0 0 (Sch 2)75.03 .79 Agency Staff 8100 0 0 0 0 (Sch 2)75.04 .40-.99 Other - Nonlabor 8100 0 0 0 0 (Sch 4)75.05 Patient Supplies - Total 8100 $ 26,302 $ 0 $ 26,302 $ 0 $ 26,302
77.00 Specialized Support Surfaces 8150 $ 0 $ 0 $ 0 (Sch 4)
80.00 Physical Therapy 8200 $ 185,265 $ 0 $ 185,265 $ 0 $ 185,265 (Sch 2)80.01 .01-.19 Salaries and Wages 8200 0 0 0 0 (Sch 2)80.02 .20-.39 Fringe Benefits 8200 0 0 0 0 (Sch 2)80.03 .79 Agency Staff 8200 0 0 0 0 (Sch 2)80.04 .40-.99 Other - Nonlabor 8200 0 0 0 0 (Sch 4)80.05 Physical Therapy - Total 8200 $ 185,265 $ 0 $ 185,265 $ 0 $ 185,265
81.00 Respiratory Therapy 8220 $ $ 0 $ 0 $ 0 $ 0 (Sch 2)81.01 .01-.19 Salaries and Wages 8220 0 0 0 0 (Sch 2)81.02 .20-.39 Fringe Benefits 8220 0 0 0 0 (Sch 2)81.03 .79 Agency Staff 8220 0 0 0 0 (Sch 2)81.04 .40-.99 Other - Nonlabor 8220 0 0 0 0 (Sch 4)81.05 Respiratory Therapy - Total 8220 $ 0 $ 0 $ 0 $ 0 $ 0
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT ADJUSTMENTSREPORTED AUDITED(SCHEDULE 8A-1)
AS ASSUBTOTAL (SCHEDULE 8A-2)
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:SANTA CRUZ SKILLED NURSING CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008
Provider Number: Provider NPI: OSHPD Facility Number:ZZR05017N 1629256953 206440727
Line Natural ACCOUNT TITLE AccountNo. Class Number
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT ADJUSTMENTSREPORTED AUDITED(SCHEDULE 8A-1)
AS ASSUBTOTAL (SCHEDULE 8A-2)
82.00 Occupational Therapy 8250 $ 111,159 $ 0 $ 111,159 $ 0 $ 111,159 (Sch 2)82.01 .01-.19 Salaries and Wages 8250 0 0 0 0 (Sch 2)82.02 .20-.39 Fringe Benefits 8250 0 0 0 0 (Sch 2)82.03 .79 Agency Staff 8250 0 0 0 0 (Sch 2)82.04 .40-.99 Other - Nonlabor 8250 0 0 0 0 (Sch 4)82.05 Occupational Therapy - Total 8250 $ 111,159 $ 0 $ 111,159 $ 0 $ 111,159
83.00 Speech Pathology 8280 $ 74,106 $ 0 $ 74,106 $ 0 $ 74,106 (Sch 2)83.01 .01-.19 Salaries and Wages 8280 0 0 0 0 (Sch 2)83.02 .20-.39 Fringe Benefits 8280 0 0 0 0 (Sch 2)83.03 .79 Agency Staff 8280 0 0 0 0 (Sch 2)83.04 .40-.99 Other - Nonlabor 8280 0 0 0 0 (Sch 4)83.05 Speech Pathology - Total 8280 $ 74,106 $ 0 $ 74,106 $ 0 $ 74,106
85.00 Pharmacy 8300 $ 171,072 $ 0 $ 171,072 $ 0 $ 171,072 (Sch 2)85.01 .01-.19 Salaries and Wages 8300 0 0 0 0 (Sch 2)85.02 .20-.39 Fringe Benefits 8300 0 0 0 0 (Sch 2)85.03 .79 Agency Staff 8300 0 0 0 0 (Sch 2)85.04 .40-.99 Other - Nonlabor 8300 0 0 0 0 (Sch 4)85.05 Pharmacy - Total 8300 $ 171,072 $ 0 $ 171,072 $ 0 $ 171,072
90.00 Laboratory 8400 $ 12,625 $ 0 $ 12,625 $ 0 $ 12,625 (Sch 2)90.01 .01-.19 Salaries and Wages 8400 0 0 0 0 (Sch 2)90.02 .20-.39 Fringe Benefits 8400 0 0 0 0 (Sch 2)90.03 .79 Agency Staff 8400 0 0 0 0 (Sch 2)90.04 .40-.99 Other - Nonlabor 8400 0 0 0 0 (Sch 4)90.05 Laboratory - Total 8400 $ 12,625 $ 0 $ 12,625 $ 0 $ 12,625
95.00 Home Health Services 8800 $ $ 0 $ 0 $ 0 $ 0 (Sch 2)95.01 .01-.19 Salaries and Wages 8800 0 0 0 0 (Sch 2)95.02 .20-.39 Fringe Benefits 8800 0 0 0 0 (Sch 2)95.03 .79 Agency Staff 8800 0 0 0 0 (Sch 2)95.04 .40-.99 Other - Nonlabor 8800 0 0 0 0 (Sch 4)95.05 Home Health Services - Total 8800 $ 0 $ 0 $ 0 $ 0 $ 0
100.00 Other Ancillary Services 8900 $ 3,095 $ 0 $ 3,095 $ 0 $ 3,095 (Sch 2)100.01 .01-.19 Salaries and Wages 8900 0 0 0 0 (Sch 2)100.02 .20-.39 Fringe Benefits 8900 0 0 0 0 (Sch 2)100.03 .79 Agency Staff 8900 0 0 0 0 (Sch 2)100.04 .40-.99 Other - Nonlabor 8900 0 0 0 0 (Sch 4)100.05 Other Ancillary Services - Total 8900 $ 3,095 $ 0 $ 3,095 $ 0 $ 3,095
100.06 Subacute Ancillary Services $ $ 0 $ 0 $ 0 $ 0 (Sch 2)100.07 .01-.19 Salaries and Wages 0 0 0 0 (Sch 2)100.08 .20-.39 Fringe Benefits 0 0 0 0 (Sch 2)100.09 .79 Agency Staff 0 0 0 0 (Sch 2)100.10 .40-.99 Other - Nonlabor 0 0 0 0 (Sch 4)100.11 Subacute Ancillary Services - Total $ 0 $ 0 $ 0 $ 0 $ 0
100.12 Subacute Pediatrics Ancillary Services $ $ 0 $ 0 $ 0 (Sch 2)
101.00 Subtotal 075 - 100.12 $ 583,624 $ 0 $ 583,624 $ 0 $ 583,624
Routine Services105.00 Skilled Nursing Care 6110 $ 3,814,066 $ (3,814,066) $ 0 $ 0 $ 0105.01 .01-.19 Salaries and Wages 6110 2,986,602 2,986,602 0 2,986,602 (Sch 2)105.02 .20-.39 Fringe Benefits 6110 524,492 524,492 0 524,492 (Sch 2)105.03 .49 Agency Staff 6110 0 0 0 0 (Sch 2)105.04 .40-.99 Other - Nonlabor 6110 302,972 302,972 0 302,972 (Sch 4)105.05 Skilled Nursing Care - Total 6110 $ 3,814,066 $ 0 $ 3,814,066 $ 0 $ 3,814,066
110.00 Intermediate Care 6120 $ $ 0 $ 0 $ 0 (Sch 2)115.00 Mentally Disordered 6130 0 0 0 (Sch 2)120.00 Developmentally Disabled 6140 0 0 0 (Sch 2)
STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period:SANTA CRUZ SKILLED NURSING CENTER JANUARY 1, 2008 THROUGH DECEMBER 31, 2008
Provider Number: Provider NPI: OSHPD Facility Number:ZZR05017N 1629256953 206440727
Line Natural ACCOUNT TITLE AccountNo. Class Number
SUMMARY OF AUDITED PROGRAM EXPENSES
AUDIT ADJUSTMENTSREPORTED AUDITED(SCHEDULE 8A-1)
AS ASSUBTOTAL (SCHEDULE 8A-2)
125.00 Subacute Care 6150 $ $ 0 $ 0 $ 0 $ 0125.01 .01-.19 Salaries and Wages 6150 0 0 0 0 (Sch 2)125.02 .20-.39 Fringe Benefits 6150 0 0 0 0 (Sch 2)125.03 .49 Agency Staff 6150 0 0 0 0 (Sch 2)125.04 .40-.99 Other - Nonlabor 6150 0 0 0 0 (Sch 4)125.05 Subacute Care - Total 6150 $ 0 $ 0 $ 0 $ 0 $ 0
126.00 Subacute Care - Pediatrics 6160 $ $ 0 $ 0 $ 0 (Sch 2)130.00 Hospice Inpatient Care 6180 0 0 0 (Sch 2)135.00 Other Routine Services 6190 0 0 0 (Sch 2)
Other Nonreimbursable136.00 Residential Care 9100 $ $ 0 $ 0 $ 0 (Sch 2)140.00 Beauty and Barber 8900 0 0 0 (Sch 2)145.00 Other Nonreimbursable 9100 135,193 135,193 0 135,193 (Sch 2)
146.00 Subtotal 105 - 145 $ 3,949,259 $ 0 $ 3,949,259 $ 0 $ 3,949,259
155.00 Social Services 6600 $ 206,378 $ (206,378) $ 0 $ 0 $ 0155.01 .01-.19 Salaries and Wages 6600 150,401 150,401 0 150,401 (Sch 2)155.02 .20-.39 Fringe Benefits 6600 21,794 21,794 0 21,794 (Sch 2)155.03 .79 Agency Staff 6600 0 0 0 0 (Sch 2)155.04 .40-.99 Other - Nonlabor 6600 34,183 34,183 0 34,183 (Sch 4)155.05 Social Services - Total 6600 $ 206,378 $ 0 $ 206,378 $ 0 $ 206,378
160.00 Activities 6700 $ 109,971 $ (109,971) $ 0 $ 0 $ 0160.01 .01-.19 Salaries and Wages 6700 90,343 90,343 0 90,343 (Sch 2)160.02 .20-.39 Fringe Benefits 6700 17,734 17,734 0 17,734 (Sch 2)160.03 .79 Agency Staff 6700 0 0 0 0 (Sch 2)160.04 .40-.99 Other - Nonlabor 6700 1,894 1,894 0 1,894 (Sch 4)160.05 Activities - Total 6700 $ 109,971 $ 0 $ 109,971 $ 0 $ 109,971
165.00 Administration 6900 $ 1,487,759 $ (1,487,759) $ 0 $ 0 $ 0165.01 .01-.19 Salaries and Wages 6900 432,562 432,562 (116,780) 315,782 (Sch 6)165.02 .20-.39 Fringe Benefits 6900 107,128 107,128 (4,552) 102,576 (Sch 6)165.03 .01-.19 Medical Records - Salaries and Wages 6900 0 0 116,780 116,780 (Sch 3)165.04 .20-.39 Medical Records - Fringe Benefits 6900 0 0 4,552 4,552 (Sch 3)165.05 .79 Medical Records - Agency Staff 6900 0 0 0 0 (Sch 3)165.06 .40-.99 Medical Records - Other - Nonlabor 6900 0 0 71,490 71,490 (Sch 4)165.07 Facility License Fees 6900 0 0 36,322 36,322 (Sch 6)165.08 Liability Insurance 6900 0 0 153,680 153,680 (Sch 6)165.09 Caregiver Training 6900 0 0 0 0 (Sch 6)165.10 Quality Assurance Fees 6900 0 0 356,527 356,527 (Sch 6)165.11 .40-.99 Other - Nonlabor 6900 948,069 948,069 (637,961) 310,108 (Sch 6)165.12 Administration - Total 6900 $ 1,487,759 $ 0 $ 1,487,759 $ (19,942) $ 1,467,817
170.00 Inservice Education - Nursing 6800 $ 92,296 $ (92,296) $ 0 $ 0 $ 0170.01 .01-.19 Salaries and Wages 6800 74,446 74,446 0 74,446 (Sch 3)170.02 .20-.39 Fringe Benefits 6800 15,388 15,388 0 15,388 (Sch 3)170.03 .79 Agency Staff 6800 0 0 0 0 (Sch 3)170.04 .40-.99 Other - Nonlabor 6800 2,462 2,462 0 2,462 (Sch 4)170.05 Inservice Education - Nursing - Total 6800 $ 92,296 $ 0 $ 92,296 $ 0 $ 92,296
171.00 Subtotal 155 - 170.05 $ 1,896,404 $ 0 $ 1,896,404 $ (19,942) $ 1,876,462
175.00 Total $ 8,692,402 $ 0 $ 8,692,402 $ (23,497) $ 8,668,905
NOTE 1: Ancillary service costs are reclassified only if the facility has an Adult Subacute unit.
ST
AT
E O
F C
ALI
FOR
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Sch
edul
e 8A
-1
Pag
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Pro
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r N
ame:
Pro
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NP
I:O
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Fac
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SA
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5320
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3,34
412
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23,2
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26,5
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300,
168
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168
65.0
2D
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Sch
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Pag
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Pro
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Fac
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ST
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F C
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FOR
NIA
Sch
edul
e 8A
-1
Pag
e 1
Pro
vide
r N
ame:
Pro
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r N
umbe
r:P
rovi
der
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I:O
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PD
Fac
ility
Num
ber:
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NT
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1, 2
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L A
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17,7
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948,
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15,3
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175.
00
To
tal
$00
00
00
00
00
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Sch
8)
ST
AT
E O
F C
ALI
FOR
NIA
Pro
vide
r N
ame:
SA
NT
A C
RU
Z S
KIL
LED
NU
RS
ING
CE
NT
ER
5.00
Pla
nt O
pera
tions
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Mai
nten
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5.01
Pla
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and
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nten
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alar
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Wag
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5.02
Pla
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Mai
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Ben
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5.03
Pla
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Mai
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5.04
Pla
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10.0
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undr
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60.0
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nen
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alar
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and
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60.0
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y an
d Li
nen
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ringe
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efits
60.0
3La
undr
y an
d Li
nen
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genc
y S
taff
60.0
4La
undr
y an
d Li
nen
- O
ther
- N
onl
abo
r
65.0
0D
ieta
ry
65.0
1D
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ry -
Sal
arie
s an
d W
ages
65.0
2D
ieta
ry -
Frin
ge B
enef
its
65.0
3D
ieta
ry -
Age
ncy
Sta
ff
65.0
4D
ieta
ry -
Oth
er -
No
nlab
or
75.0
0P
atie
nt S
uppl
ies
75.0
1P
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uppl
ies
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alar
ies
and
Wag
es
75.0
2P
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nt S
uppl
ies
- F
ringe
Ben
efits
75.0
3P
atie
nt S
uppl
ies
- A
genc
y S
taff
75.0
4P
atie
nt S
uppl
ies
- O
ther
- N
onl
abo
r
80.0
0P
hysi
cal T
hera
py
80.0
1P
hysi
cal T
hera
py -
Sal
arie
s an
d W
ages
80.0
2P
hysi
cal T
hera
py -
Frin
ge B
enef
its
80.0
3P
hysi
cal T
hera
py -
Age
ncy
Sta
ff
80.0
4P
hysi
cal T
hera
py -
Oth
er -
No
nlab
or
81.0
0R
espi
rato
ry T
hera
py
81.0
1R
espi
rato
ry T
hera
py -
Sal
arie
s an
d W
ages
81.0
2R
espi
rato
ry T
hera
py -
Frin
ge B
enef
its
81.0
3R
espi
rato
ry T
hera
py -
Age
ncy
Sta
ff
81.0
4R
espi
rato
ry T
hera
py -
Oth
er -
No
nlab
or
82.0
0O
ccup
atio
nal T
hera
py
82.0
1O
ccup
atio
nal T
hera
py -
Sal
arie
s an
d W
ages
82.0
2O
ccup
atio
nal T
hera
py -
Frin
ge B
enef
its
82.0
3O
ccup
atio
nal T
hera
py -
Age
ncy
Sta
ff
82.0
4O
ccup
atio
nal T
hera
py -
Oth
er -
No
nlab
or
83.0
0S
peec
h P
atho
logy
Sch
edul
e 8A
-1
Pag
e 2
Pro
vide
r N
umbe
r:P
rovi
der
NP
I:O
SH
PD
Fac
ility
Num
ber:
Fisc
al P
erio
d:
ZZ
R05
017N
1629
2569
5320
6440
727
JAN
UA
RY
1, 2
008
TH
RO
UG
H D
EC
EM
BE
R 3
1, 2
008
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
J
1011
12
RE
CO
NC
ILIA
TIO
N O
F T
HE
PR
OV
IDE
R'S
AD
JUS
TM
EN
TS
TO
TH
E A
UD
IT R
EP
OR
T
ST
AT
E O
F C
ALI
FOR
NIA
Pro
vide
r N
ame:
SA
NT
A C
RU
Z S
KIL
LED
NU
RS
ING
CE
NT
ER
83.0
1S
peec
h P
atho
logy
- S
alar
ies
and
Wag
es
83.0
2S
peec
h P
atho
logy
- F
ringe
Ben
efits
83.0
3S
peec
h P
atho
logy
- A
genc
y S
taff
83.0
4S
peec
h P
atho
logy
- O
ther
- N
onl
abo
r
85.0
0P
harm
acy
85.0
1P
harm
acy
- S
alar
ies
and
Wag
es
85.0
2P
harm
acy
- F
ringe
Ben
efits
85.0
3P
harm
acy
- A
genc
y S
taff
85.0
4P
harm
acy
- O
ther
- N
onl
abo
r
90.0
0La
bora
tory
90.0
1La
bora
tory
- S
alar
ies
and
Wag
es
90.0
2La
bora
tory
- F
ringe
Ben
efits
90.0
3La
bora
tory
- A
genc
y S
taff
90.0
4La
bora
tory
- O
ther
- N
onl
abo
r
95.0
0H
om
e H
ealth
Ser
vice
s
95.0
1H
om
e H
ealth
Ser
vice
s -
Sal
arie
s an
d W
ages
95.0
2H
om
e H
ealth
Ser
vice
s -
Frin
ge B
enef
its
95.0
3H
om
e H
ealth
Ser
vice
s -
Age
ncy
Sta
ff
95.0
4H
om
e H
ealth
Ser
vice
s -
Oth
er -
No
nlab
or
100.
00O
ther
Anc
illar
y S
ervi
ces
100.
01O
ther
Anc
illar
y S
ervi
ces
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alar
ies
and
Wag
es
100.
02O
ther
Anc
illar
y S
ervi
ces
- F
ringe
Ben
efits
100.
03O
ther
Anc
illar
y S
ervi
ces
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genc
y S
taff
100.
04O
ther
Anc
illar
y S
ervi
ces
- O
ther
- N
onl
abo
r
100.
06S
ubac
ute
Anc
illar
y S
ervi
ces
100.
07S
ubac
ute
Anc
illar
y S
ervi
ces
- S
alar
ies
and
Wag
es
100.
08S
ubac
ute
Anc
illar
y S
ervi
ces
- F
ringe
Ben
efits
100.
09S
ubac
ute
Anc
illar
y S
ervi
ces
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genc
y S
taff
100.
10S
ubac
ute
Anc
illar
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ervi
ces
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ther
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onl
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r
105.
00S
kille
d N
ursi
ng C
are
105.
01S
kille
d N
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ng C
are
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alar
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and
Wag
es
105.
02S
kille
d N
ursi
ng C
are
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ringe
Ben
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105.
03S
kille
d N
ursi
ng C
are
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genc
y S
taff
105.
04S
kille
d N
ursi
ng C
are
- O
ther
- N
onl
abo
r
125.
00S
ubac
ute
Car
e
125.
01S
ubac
ute
Car
e -
Sal
arie
s an
d W
ages
125.
02S
ubac
ute
Car
e -
Frin
ge B
enef
its
125.
03S
ubac
ute
Car
e -
Age
ncy
Sta
ff
125.
04S
ubac
ute
Car
e -
Oth
er -
No
nlab
or
155.
00S
oci
al S
ervi
ces
155.
01S
oci
al S
ervi
ces
- S
alar
ies
and
Wag
es
Sch
edul
e 8A
-1
Pag
e 2
Pro
vide
r N
umbe
r:P
rovi
der
NP
I:O
SH
PD
Fac
ility
Num
ber:
Fisc
al P
erio
d:
ZZ
R05
017N
1629
2569
5320
6440
727
JAN
UA
RY
1, 2
008
TH
RO
UG
H D
EC
EM
BE
R 3
1, 2
008
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
J
1011
12
RE
CO
NC
ILIA
TIO
N O
F T
HE
PR
OV
IDE
R'S
AD
JUS
TM
EN
TS
TO
TH
E A
UD
IT R
EP
OR
T
ST
AT
E O
F C
ALI
FOR
NIA
Pro
vide
r N
ame:
SA
NT
A C
RU
Z S
KIL
LED
NU
RS
ING
CE
NT
ER
155.
02S
oci
al S
ervi
ces
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ringe
Ben
efits
155.
03S
oci
al S
ervi
ces
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genc
y S
taff
155.
04S
oci
al S
ervi
ces
- O
ther
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onl
abo
r
160.
00A
ctiv
ities
160.
01A
ctiv
ities
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alar
ies
and
Wag
es
160.
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ctiv
ities
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ringe
Ben
efits
160.
03A
ctiv
ities
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genc
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taff
160.
04A
ctiv
ities
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ther
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onl
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r
165.
00A
dmin
istr
atio
n
165.
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atio
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arie
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165.
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dmin
istr
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n -
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enef
its
165.
03A
dmin
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atio
n -
Med
ical
Rec
ord
s -
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d W
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165.
04A
dmin
istr
atio
n -
Med
ical
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s -
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ge B
enef
its
165.
05A
dmin
istr
atio
n -
Med
ical
Rec
ord
s -
Age
ncy
Sta
ff
165.
06A
dmin
istr
atio
n -
Med
ical
Rec
ord
s -
Oth
er -
No
nlab
or
165.
07A
dmin
istr
atio
n -
Fac
ility
Lic
ense
Fee
s
165.
08A
dmin
istr
atio
n -
Liab
ility
Insu
ranc
e
165.
09A
dmin
istr
atio
n -
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egiv
er T
rain
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165.
10A
dmin
istr
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n -
Qua
lity
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uran
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ees
165.
11A
dmin
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n -
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er -
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nlab
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170.
00In
serv
ice
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catio
n -
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sing
170.
01In
serv
ice
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sing
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alar
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170.
02In
serv
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ringe
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170.
03In
serv
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sing
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170.
04In
serv
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sing
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ther
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onl
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175.
00
To
tal
Sch
edul
e 8A
-1
Pag
e 2
Pro
vide
r N
umbe
r:P
rovi
der
NP
I:O
SH
PD
Fac
ility
Num
ber:
Fisc
al P
erio
d:
ZZ
R05
017N
1629
2569
5320
6440
727
JAN
UA
RY
1, 2
008
TH
RO
UG
H D
EC
EM
BE
R 3
1, 2
008
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
J
1011
12
RE
CO
NC
ILIA
TIO
N O
F T
HE
PR
OV
IDE
R'S
AD
JUS
TM
EN
TS
TO
TH
E A
UD
IT R
EP
OR
T
3,49
15,
785
8,62
1
(3,4
91)
(5,7
85)
(8,6
21)
00
00
00
00
00
00
ST
AT
E O
F C
AL
IFO
RN
IAS
ched
ule
8A
-2
Pag
e 1
Pro
vid
er N
ame:
Pro
vid
er N
um
ber
:P
rovi
der
NP
I:O
SH
PD
Fac
ilit
y N
um
ber
:F
isca
l Per
iod
:
SA
NT
A C
RU
Z S
KIL
LED
NU
RS
ING
CE
NT
ER
ZZ
R05
017N
1629
2569
5320
6440
727
JAN
UA
RY
1, 2
008
TH
RO
UG
H D
EC
EM
BE
R 3
1, 2
008
TO
TA
L A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
JA
UD
IT A
DJ
AU
DIT
AD
J
(Pag
e 1)
1314
1516
1718
19
5.00
Pla
nt O
pera
tions
and
Mai
nten
ance
0
5.01
Pla
nt O
pera
tions
and
Mai
nten
ance
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alar
ies
and
Wag
es0
5.02
Pla
nt O
pera
tions
and
Mai
nten
ance
- F
ringe
Ben
efits
0
5.03
Pla
nt O
pera
tions
and
Mai
nten
ance
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genc
y S
taff
0
5.04
Pla
nt O
pera
tions
and
Mai
nten
ance
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ther
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onla
bor
0
10.0
0H
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40.0
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45.0
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65.0
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ched
ule
8A
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Pag
e 1
Pro
vid
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ame:
Pro
vid
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:P
rovi
der
NP
I:O
SH
PD
Fac
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1629
2569
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JAN
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(Pag
e 1)
1314
1516
1718
19
RE
CL
AS
SIF
ICA
TIO
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AN
D/O
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ST
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82.0
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8A
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Pag
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Pro
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NP
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(Pag
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1314
1516
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19
RE
CL
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Pag
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