S TATE OF CA Provider Nam SAYLOR LAN Line Sub No. No. 167 4 168 4 169 4 170 1 170 2 170 3 170 4 174 1 174 2 174 3 174 4 180 4 200 Schedule 8A-2 Page 1 Provider Number: NPI: OSHPD Facility Number: Fiscal Period: ZZR05417K 1215928387 206341014 JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Pages 1, 2, & 3) 45678910 RECLASSIFICATIONS AND/OR ADJUSTMENTS TO REPORTED COSTS 0 (6,447) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ($164,664) 0000000 (To Sch 8) This is trial version www.adultpdf.com State of California Department of Health Care Serv Provider Name Fiscal Period Provider Number 30 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted MEMORANDUM ADJUSTMENTS 1 10.7 075 1,2,3 N/A N/A N/A Patient Supplies (Square Feet) 0 149 149 10.7 080 1,2,3 N/A N/A N/A Physical Therapy 0 184 184 10.7 082 1,2,3 N/A N/A N/A Occupational Therapy 0 106 106 10.7 083 1,2,3 N/A N/A N/A Speech Pathology 01616 10.7 085 1,2,3 N/A N/A N/A Pharmacy 05050 10.7 105 1,2,3 N/A N/A N/A Skilled Nursing Care 0 4,260 4,260 2 10.7 105 4 N/A N/A N/A Skilled Nursing Care (Pounds of Laundry) 0 63,390 63,390 3 10.7 105 5 N/A N/A N/A Skilled Nursing Care (Meals Served) 0 38,034 38,034 To reconcile the provider’s reported statistics on page 10.7 to the provider's reported statistics on page 11(1). 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 Page Adjustmen SAYLOR LANE HEALTHCARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05417K / 1215928387 Cost Report Explanation of Audit Adjustments Report References Audit Report This is trial version www.adultpdf.com State of California Department of Health Care Serv Provider Name Fiscal Period Provider Number 30 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustmen SAYLOR LANE HEALTHCARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05417K / 1215928387 Cost Report Explanation of Audit Adjustments Report References Audit Report RECLASSIFICATIONS OF REPORTED COSTS 4 10.5 005 2 8A-2 005 2 Plant Operations and Maintenance - Fringe Benefits $1,707 $1,403 $3,110 10.5 010 2 8A-2 010 2 Housekeeping - Fringe Benefits 25,507 5,955 31,462 10.5 060 2 8A-2 060 2 Laundry and Linen - Fringe Benefits 6,533 2,063 8,596 10.5 065 2 8A-2 065 2 Dietary - Fringe Benefits 43,852 11,175 55,027 10.5 080 2 8A-2 080 2 Physical Therapy - Fringe Benefits 19,287 6,522 25,809 10.5 082 2 8A-2 082 2 Occupational Therapy - Fringe Benefits 10,324 3,569 13,893 10.5 083 2 8A-2 083 2 Speech Pathology - Fringe Benefits 3,992 1,361 5,353 10.5 105 2 8A-2 105 2 Skilled Nursing Care - Fringe Benefits 346,396 63,760 410,156 10.5 155 2 8A-2 155 2 Social Services - Fringe Benefits 11,023 3,996 15,019 10.5 160 2 8A-2 160 2 Activities - Fringe Benefits 7,815 1,836 9,651 10.5 165 2 8A-2 165 2 Administration - Fringe Benefits 54,557 17,775 72,332 10.5 166 2 8A-2 166 2 Administration - Medical Records - Fringe Benefits 6,428 2,298 8,726 10.5 105 2 8A-2 105 2 Skilled Nursing Care - Fringe Benefits * 410,156 (121,713) 288,443 To reclassify workers' compensation paid claims expense for proper allocation of costs. 42 CFR 413.24 / CMS Pub. 15-1, Section 2302.8 5 10.5 035 4 8A-2 035 4 Leases and Rentals $129,740 $849 $130,589 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor 73,133 (849) 72,284 To reclassify Xerox copier lease expense for proper cost finding and to agree with AB1629 requirements. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 Welfare and Institutions Code Section 14126.023 6 10.5 085 4 8A-2 085 4 Pharmacy - Other - Nonlabor $83,946 $18,636 $102,582 10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor 83,665 (18,636) 65,029 To reclassify pharmacy costs to an ancillary cost center. 42 CFR 413.24 / CMS Pub. 15-1, Sections 2202.8 and 2203.2 CCR Title 22, Section 51511 *Balance carried forward from prior/to subsequent adjustments Page This is trial version www.adultpdf.com State of California Department of Health Care Serv Provider Name Fiscal Period Provider Number 30 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustmen SAYLOR LANE HEALTHCARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05417K / 1215928387 Cost Report Explanation of Audit Adjustments Report References Audit Report RECLASSIFICATIONS OF REPORTED COSTS 7 10.5 100 4 8A-2 100 4 Other Ancillary Services - Other - Nonlabor $1,348 $1,320 $2,668 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * 72,284 (1,320) 70,964 To reclassify dental services to the Other Ancillary Services cost center. 42 CFR 413.24 / CMS Pub. 15-1, Sections 2202.8 and 2203.2 CCR, Title 22, Sections 51511 and 51123 8 10.5 100 4 8A-2 100 4 Other Ancillary Services - Other - Nonlabor * $2,668 $8,193 $10,861 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * 70,964 (8,193) 62,771 To reclassify Community Mobile Diagnostic expenses from Administration to the Other Ancillary Services cost center. CCR, Title 22, Section 51511 9 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * $62,771 $4,814 $67,585 10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor * 65,029 (4,814) 60,215 To reclassify pharmacy consultant fees to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4, 2302.8, and 2304 10 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * $67,585 $163,030 $230,615 10.5 165 1 8A-2 165 1 Administration - Salaries and Wages 242,105 (163,030) 79,075 To reclassify Administrative Salary expense adjustment to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4, and 2302.8 *Balance carried forward from prior/to subsequent adjustments Page This is trial version www.adultpdf.com State of California Department of Health Care Serv Provider Name Fiscal Period Provider Number 30 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustmen SAYLOR LANE HEALTHCARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05417K / 1215928387 Cost Report Explanation of Audit Adjustments Report References Audit Report ADJUSTMENTS TO REPORTED COSTS 11 10.5 005 2 8A-2 005 2 Plant Operations and Maintenance - Fringe Benefits * $3,110 ($30) $3,080 10.5 010 2 8A-2 010 2 Housekeeping - Fringe Benefits * 31,462 (129) 31,333 10.5 060 2 8A-2 060 2 Laundry and Linen - Fringe Benefits * 8,596 (45) 8,551 10.5 065 2 8A-2 065 2 Dietary - Fringe Benefits * 55,027 (243) 54,784 10.5 080 2 8A-2 080 2 Physical Therapy - Fringe Benefits * 25,809 (142) 25,667 10.5 082 2 8A-2 082 2 Occupational Therapy - Fringe Benefits * 13,893 (78) 13,815 10.5 083 2 8A-2 083 2 Speech Pathology - Fringe Benefits * 5,353 (30) 5,323 10.5 105 2 8A-2 105 2 Skilled Nursing Care - Fringe Benefits * 288,443 (1,385) 287,058 10.5 155 2 8A-2 155 2 Social Services - Fringe Benefits * 15,019 (87) 14,932 10.5 160 2 8A-2 160 2 Activities - Fringe Benefits * 9,651 (40) 9,611 10.5 165 2 8A-2 165 2 Administration - Fringe Benefits * 72,332 (386) 71,946 10.5 166 2 8A-2 166 2 Administration - Medical Records - Fringe Benefits * 8,726 (50) 8,676 To adjust the reported workers' compensation premiums to agree with the provider's records. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 12 10.5 005 4 8A-2 005 4 Plant Operations and Maintenance - Other - Nonlabor $93,232 ($2,865) $90,367 To eliminate Plant Operations and Maintenance expenses due to lack of documentation. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 10.5 105 4 8A-2 105 4 Skilled Nursing Care - Other - Nonlabor * $60,215 13 To eliminate Skilled Nursing Care expenses due to lack of ($502) documentation. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 14 To eliminate health insurance expenses not related to patient care (780) at Saylor Lane. ($1,282) $58,933 42 CFR 413.9(c)(3) / CMS Pub. 15-1, Section 2102.3 15 10.5 165 1 8A-2 165 1 Administration - Salaries and Wages * $79,075 ($4,727) $74,348 To eliminate salary expense related to the home office. 42 CFR 413.17 / CMS Pub. 15-1, Section 1005 *Balance carried forward from prior/to subsequent adjustments Page This is trial version www.adultpdf.com State of California Department of Health Care Serv Provider Name Fiscal Period Provider Number 30 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustmen SAYLOR LANE HEALTHCARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05417K / 1215928387 Cost Report Explanation of Audit Adjustments Report References Audit Report ADJUSTMENTS TO REPORTED COSTS 10.5 165 2 8A-2 165 2 Administration - Fringe Benefits * $71,946 16 To eliminate retirement expense due to lack of documentation. ($714) 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 17 To eliminate tax penalty not related to patient care. (188) 42 CFR 413.9(c)(3) / CMS Pub. 15-1, Sections 2102.3 and 2122.1 ($902) $71,044 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * $230,615 18 To eliminate legal fees due to lack of documentation. ($139,844) 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 19 To eliminate dental costs for individual patients. (1,100) 42 CFR 413.9 / CMS Pub. 15-1, Section 2104.4 CCR, Title 22, Section 51123 20 To eliminate Administrative expenses due to lack of documentation. (2,420) 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 21 To eliminate legal and consultant fees in connection with a fair hearing (585) or other litigation against or involving any governmental agency or department. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 Welfare and Institutions Code Section 14126.023 22 To eliminate Kellogg and Andelson expenses due to lack of documentation. (7,592) 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 23 To eliminate tax preparation expense not related to patient care. (2,400) 42 CFR 413.9(c)(3) / CMS Pub. 15-1, Section 2102.3 ($153,941) $76,674 *Balance carried forward from prior/to subsequent adjustments Page This is trial version www.adultpdf.com State of California Department of Health Care Serv Provider Name Fiscal Period Provider Number 30 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustmen SAYLOR LANE HEALTHCARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05417K / 1215928387 Cost Report Explanation of Audit Adjustments Report References Audit Report ADJUSTMENTS TO REPORTED COSTS 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * $76,674 24 To adjust reported home office costs to agree with the Centurion, Inc. $8,982 Home Office Audit Report for fiscal period ended December 31, 2009. 42 CFR 413.17 / CMS Pub. 15-1, Sections 2150.2 and 2304 25 To eliminate Administrative expense due to insufficient documentation. (837) 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 $8,145 $84,819 26 10.5 168 4 8A-2 168 4 Liability Insurance $61,819 ($6,447) $55,372 To adjust the reported liability insurance expense to agree with the provider's records. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page This is trial version www.adultpdf.com State of California Department of Health Care Serv Provider Name Fiscal Period Provider Number 30 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustmen SAYLOR LANE HEALTHCARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05417K / 1215928387 Cost Report Explanation of Audit Adjustments Report References Audit Report ADJUSTMENT TO REPORTED STATISTICS 27 10.7 005 1 7 005 N/A Plant Operations and Maintenance (Square Feet) 0 144 144 10.7 010 1,2 7 010 N/A Housekeeping 03636 10.7 060 1,2,3 7 060 N/A Laundry and Linen 0 173 173 10.7 065 1,2,3 7 065 N/A Dietary 0 974 974 10.7 155 1,2,3 7 155 N/A Social Services 0 121 121 10.7 165 1,2,3 7 165 N/A Administration 0 284 284 10.7 175 1 7 N/A N/A Total - Square Feet Column 1 4,765 1,732 6,497 10.7 175 2 7 N/A N/A Total - Square Feet Column 2 4,765 1,588 6,353 10.7 175 3 7 N/A N/A Total - Square Feet Column 3 4,765 1,552 6,317 To adjust reported square feet statistics to agree with the provider's square footage worksheet. 42 CFR 413.24 and 413.50 / CMS Pub. 15-1, Sections 2300 and 2304 Page This is trial version www.adultpdf.com State of California Department of Health Care Serv Provider Name Fiscal Period Provider Number 30 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustmen SAYLOR LANE HEALTHCARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05417K / 1215928387 Cost Report Explanation of Audit Adjustments Report References Audit Report ADJUSTMENT TO REPORTED PATIENT DAYS 28 11(2) 105 1 1 12 Total Patient Days 12,682 (4) 12,678 To adjust total patient days to agree with the provider's patient census reports. 42 CFR 413.20 and 413.50 / CMS Pub. 15-1, Sections 2205 and 2304 Page This is trial version www.adultpdf.com State of California Department of Health Care Serv Provider Name Fiscal Period Provider Number 30 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch. Line Sub No Reported (Decrease) Adjusted Adjustmen SAYLOR LANE HEALTHCARE CENTER JANUARY 1, 2009 THROUGH DECEMBER 31, 2009 ZZR05417K / 1215928387 Cost Report Explanation of Audit Adjustments Report References Audit Report ADJUSTMENTS TO OTHER MATTERS 29 Not Reported 1 14 Overpayments $0 $2,359 $2,359 To recover outstanding Medi-Cal Credit balances. CCR, Title 22, Section 50761 and 51458.1 30 Not Reported 1 14 Overpayments * $2,359 $1,514 $3,873 To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed. 42 CFR 413.5 and 413.20 / CMS Pub. 15-1, Section 2409 *Balance carried forward from prior/to subsequent adjustments Page This is trial version www.adultpdf.com . Report Explanation of Audit Adjustments Report References Audit Report ADJUSTMENTS TO REPORTED COSTS 10.5 165 4 8A-2 165 4 Administration - Other - Nonlabor * $76,674 24 To adjust reported home office costs to. Report Explanation of Audit Adjustments Report References Audit Report ADJUSTMENTS TO REPORTED COSTS 10.5 165 2 8A-2 165 2 Administration - Fringe Benefits * $71,946 16 To eliminate retirement expense due to. Report Explanation of Audit Adjustments Report References Audit Report ADJUSTMENT TO REPORTED PATIENT DAYS 28 11(2) 105 1 1 12 Total Patient Days 12,682 (4) 12,678 To adjust total patient days to agree