STATE OF CALIFORNIA Provider Name: ANTELOPE VALLEY HOSPITAL GENERAL SERVICE COST CENTERS 1.00 Old Cap Rel Costs-Bldg & Fixtures 2.00 Old Cap Rel Costs-Movable Equipment 3.00 New Cap Rel Costs-Bldg & Fixtures 4.00 New Cap Rel Costs-Movable Equipment 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 Employee Benefits 6.01 Purchasing/Receiving 6.02 Patient Admitting 6.03 Cashiering/Accounts Receivable 6.04 6.05 6.06 6.07 6.08 6.04 Administrative and General 7.00 Maintenance and Repairs 8.00 Operation of Plant 9.00 Laundry and Linen Service 10.00 Housekeeping 11.00 Dietary 12.00 Cafeteria 13.00 Maintenance of Personnel 14.00 Nursing Administration 15.00 Central Services & Supply 16.00 Pharmacy 17.00 Medical Records and Library 18.00 Social Service 19.00 19.02 19.03 20.00 21.00 Nursing School 22.00 Intern & Res Service-Salary & Fringes 23.00 Intern & Res Other Program 24.00 Paramedical Ed Program INPATIENT ROUTINE COST CENTERS 25.00 Adults & Pediatrics (Gen Routine) 26.00 Intensive Care Unit 27.00 Coronary Care Unit 30.00 Neonatal Intensive Care Unit 31.00 Surgical Intensive Care 32.00 Subprovider I 32.01 Subprovider II 32.02 33.00 Nursery 34.00 Medicare Certified Nursing Facility 35.00 Distinct Part Nursing Facility 36.00 Adult Subacute Care Unit 36.01 Subacute Care Unit II 36.02 Transitional Care Unit SCHEDULE 9.1 Fiscal Period Ended: JUNE 30, 2008 EMP BENE Purchasing & Admitting Cashiering STAT STAT STAT STAT STAT ADM & GEN MAINT & (GROSS Receiving Acct Rec. (ACCUM REPAIRS SALARIES) (Purch Reqs) (Gross Rev) (Gross Rev) COST) (SQ FT) 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 7.00 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) 541,530 2,408,417 43,622 1,551,677 20,116 10,312,232 103,902 2,700,658 21,312 8,746,004 1,155,369 3,471 2,246,084 15,862 110,180 2,050 1,334,476 1,876 2,061,140 7,812 4,831,215 2,242 1,470,372 564,798 2,932,849 5,576 281,056 624,791 737,009 6,415 0 1,819,289 8,221 2,705,670 3,405 1,041,282 175,376 1,842,313 3,465 3,373,238 645,821 5,200,340 3,881 2,121,072 45,018 4,297,968 10,726 0 0 0 0 0 0 0 0 0 25,547,364 745,725 129,615,708 129,615,708 38,668,001 143,769 8,383,232 185,586 34,612,094 34,612,094 11,978,720 8,449 0 4,084,660 190,490 18,275,377 18,275,377 5,934,835 7,322 0 0 0 0 3,800,994 149,443 12,789,943 12,789,943 5,550,221 6,214 0 0 0 0 0 STATISTICS FOR COST ALLOCATION (W/S B-1) This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ANTELOPE VALLEY HOSPITAL ANCILLARY COST CENTERS 37.00 Operating Room 38.00 Recovery Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 41.01 41.02 42.00 Radiology - Therapeutic 43.00 Radioisotope 44.00 Laboratory 44.01 Pathological Lab 46.00 Whole Blood 47.00 Blood Storing and Processing 48.00 Intravenous Therapy 49.00 Respiratory Therapy 50.00 Physical Therapy 51.00 Occupational Therapy 52.00 Speech Pathology 53.00 Electrocardiology 54.00 Electroencephalography 55.00 Medical Supplies Charged to Patients 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 58.00 ASC (Non-Distinct Part) 59.00 Patient Education & Family Counseling 59.01 Ultrasound 59.02 Magnetic Resonance Imaging 59.03 60.00 Clinic 60.01 Other Clinic Services 61.00 Emergency 62.00 Observation Beds 71.00 Home Health Agency 82.00 83.00 84.00 85.00 86.00 NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop & Canteen 97.00 Research 98.00 Physicians' Private Office 99.00 Nonpaid Workers 99.01 Community Benefits 99.02 Marketing 99.03 Dialysis 99.04 99.05 100.00 100.01 100.02 100.03 100.04 TOTAL COST TO BE ALLOCATED UNIT COST MULTIPLIER - SCH 8 SCHEDULE 9.1 Fiscal Period Ended: JUNE 30, 2008 EMP BENE Purchasing & Admitting Cashiering STAT STAT STAT STAT STAT ADM & GEN MAINT & (GROSS Receiving Acct Rec. (ACCUM REPAIRS SALARIES) (Purch Reqs) (Gross Rev) (Gross Rev) COST) (SQ FT) 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 7.00 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) STATISTICS FOR COST ALLOCATION (W/S B-1) 8,831,834 488,832 64,678,604 64,678,604 14,618,136 23,061 0 5,416,880 676,186 50,935,422 50,935,422 9,450,264 52,562 0 3,914,542 1,058,122 103,024,136 103,024,136 7,249,602 11,590 0 0 0 394,922 308,865 4,391,070 4,391,070 1,108,506 2,128 5,522,969 371,496 80,129,005 80,129,005 12,687,587 12,165 0 0 0 0 3,842,798 740,382 71,377,030 71,377,030 6,272,541 2,363 781,166 7,742 4,003,812 4,003,812 1,119,419 2,370 49,330 1,145 306,981 306,981 86,018 970 245,375 245,375 64,041 143 458,168 10,927 8,650,091 8,650,091 759,499 1,013 146,255 6,248 1,447,672 1,447,672 262,556 4,347,963 91,497,374 91,497,374 21,114,189 66,037,141 66,037,141 9,898,311 4,756,348 4,756,348 1,064,588 0 71,698 102,595 102,595 32,273 750,247 32,340 12,939,156 12,939,156 1,187,246 246,012 6,732 7,659,264 7,659,264 698,475 5,000 0 0 0 11,643,308 13,996 79,933,736 79,933,736 16,836,115 11,600 0 1,350,591 2,045,589 0 0 0 0 0 0 0 6,313,299 0 2,213,001 79,499 3,918,148 175,912 6,877 788,395 1,470 21,955 0 0 0 0 0 0 0 118,573,395 11,694,906 847,407,934 847,407,93400000214,602,454 345,637 29,511,927 1,303,712 3,867,152 3,175,0380000028,314,658 9,899,952 0.248892 0.111477 0.004564 0.003747 0.000000 0.000000 0.000000 0.000000 0.000000 0.131940 28.642628 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ANTELOPE VALLEY HOSPITAL GENERAL SERVICE COST CENTERS 1.00 Old Cap Rel Costs-Bldg & Fixtures 2.00 Old Cap Rel Costs-Movable Equipment 3.00 New Cap Rel Costs-Bldg & Fixtures 4.00 New Cap Rel Costs-Movable Equipment 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 Employee Benefits 6.01 Purchasing/Receiving 6.02 Patient Admitting 6.03 Cashiering/Accounts Receivable 6.04 6.05 6.06 6.07 6.08 6.04 Administrative and General 7.00 Maintenance and Repairs 8.00 Operation of Plant 9.00 Laundry and Linen Service 10.00 Housekeeping 11.00 Dietary 12.00 Cafeteria 13.00 Maintenance of Personnel 14.00 Nursing Administration 15.00 Central Services & Supply 16.00 Pharmacy 17.00 Medical Records and Library 18.00 Social Service 19.00 19.02 19.03 20.00 21.00 Nursing School 22.00 Intern & Res Service-Salary & Fringes 23.00 Intern & Res Other Program 24.00 Paramedical Ed Program INPATIENT ROUTINE COST CENTERS 25.00 Adults & Pediatrics (Gen Routine) 26.00 Intensive Care Unit 27.00 Coronary Care Unit 30.00 Neonatal Intensive Care Unit 31.00 Surgical Intensive Care 32.00 Subprovider I 32.01 Subprovider II 32.02 33.00 Nursery 34.00 Medicare Certified Nursing Facility 35.00 Distinct Part Nursing Facility 36.00 Adult Subacute Care Unit 36.01 Subacute Care Unit II 36.02 Transitional Care Unit SCHEDULE 9.2 Fiscal Period Ended: JUNE 30, 2008 OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT & LINEN KEEPING (MEALS PERSONNEL ADMIN & SUPPLY (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) (FTE's) (# HOUSED) (FTE's) (PUR REQ) (PUR REQ) (Gross Rev) SPENT) 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) 1,876 2,242 5,576 5,576 6,415 6,418 3,405 3,405 2,299 3,465 7,578 3,465 2,758 2,758 3,881 3,881 3,418 3,418 645,821 10,726 10,726 3,790 3,790 45,018 45,018 143,769 933,210 143,769 198,189 39,698 39,698 745,725 745,725 129,615,708 8,449 185,303 8,449 18,035 8,942 8,942 185,586 185,586 34,612,094 7,322 1,362 7,322 3,956 3,956 190,490 190,490 18,275,377 6,214 6,214 149,443 149,443 12,789,943 STATISTICS FOR COST ALLOCATION (W/S B-1) This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ANTELOPE VALLEY HOSPITAL ANCILLARY COST CENTERS 37.00 Operating Room 38.00 Recovery Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 41.01 41.02 42.00 Radiology - Therapeutic 43.00 Radioisotope 44.00 Laboratory 44.01 Pathological Lab 46.00 Whole Blood 47.00 Blood Storing and Processing 48.00 Intravenous Therapy 49.00 Respiratory Therapy 50.00 Physical Therapy 51.00 Occupational Therapy 52.00 Speech Pathology 53.00 Electrocardiology 54.00 Electroencephalography 55.00 Medical Supplies Charged to Patients 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 58.00 ASC (Non-Distinct Part) 59.00 Patient Education & Family Counseling 59.01 Ultrasound 59.02 Magnetic Resonance Imaging 59.03 60.00 Clinic 60.01 Other Clinic Services 61.00 Emergency 62.00 Observation Beds 71.00 Home Health Agency 82.00 83.00 84.00 85.00 86.00 NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop & Canteen 97.00 Research 98.00 Physicians' Private Office 99.00 Nonpaid Workers 99.01 Community Benefits 99.02 Marketing 99.03 Dialysis 99.04 99.05 100.00 100.01 100.02 100.03 100.04 TOTAL COST TO BE ALLOCATED UNIT COST MULTIPLIER - SCH 8 SCHEDULE 9.2 Fiscal Period Ended: JUNE 30, 2008 OPER LAUNDRY HOUSE- DIETARY CAFETERIA MAINT OF NURSING CENT SERV PHARMACY MED REC SOC SERV STAT PLANT & LINEN KEEPING (MEALS PERSONNEL ADMIN & SUPPLY (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) (FTE's) (# HOUSED) (FTE's) (PUR REQ) (PUR REQ) (Gross Rev) SPENT) 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) STATISTICS FOR COST ALLOCATION (W/S B-1) 23,061 130,213 23,061 658 9,780 9,780 488,832 488,832 64,678,604 52,562 10,336 52,562 6,984 6,156 6,156 676,186 676,186 50,935,422 11,590 81,026 11,590 4,811 4,811 1,058,122 1,058,122 103,024,136 2,128 2,128 380 380 308,865 308,865 4,391,070 12,165 12,165 8,748 8,748 371,496 371,496 80,129,005 2,363 2,363 5,451 5,451 740,382 740,382 71,377,030 2,370 4,618 2,370 810 810 7,742 7,742 4,003,812 970 970 70 70 1,145 1,145 306,981 143 143 245,375 1,013 2,623 1,013 417 417 10,927 10,927 8,650,091 337 141 141 6,248 6,248 1,447,672 4,347,963 4,347,963 91,497,374 66,037,141 4,756,348 102,595 29,384 899 899 32,340 32,340 12,939,156 5,000 5,000 225 225 6,732 6,732 7,659,264 11,600 533,009 11,600 17,689 16,745 16,745 13,996 13,996 79,933,736 4,144 4,144 79,499 79,499 1,470 1,470 1,090 1,090 6,877 6,877 329,775 1,918,999 325,660 241,555 124,728 0 122,429 10,119,435 9,473,614 847,407,934 0 0 2,996,762 1,581,328 5,553,236 3,625,274 1,185,728 0 3,271,045 2,381,360 6,374,876 5,630,813 0 0 9.087292 0.824038 17.052252 15.008070 9.506512 0.000000 26.717893 0.235325 0.672909 0.006645 0.000000 0.000000 This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ANTELOPE VALLEY HOSPITAL GENERAL SERVICE COST CENTERS 1.00 Old Cap Rel Costs-Bldg & Fixtures 2.00 Old Cap Rel Costs-Movable Equipment 3.00 New Cap Rel Costs-Bldg & Fixtures 4.00 New Cap Rel Costs-Movable Equipment 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 5.00 Employee Benefits 6.01 Purchasing/Receiving 6.02 Patient Admitting 6.03 Cashiering/Accounts Receivable 6.04 6.05 6.06 6.07 6.08 6.04 Administrative and General 7.00 Maintenance and Repairs 8.00 Operation of Plant 9.00 Laundry and Linen Service 10.00 Housekeeping 11.00 Dietary 12.00 Cafeteria 13.00 Maintenance of Personnel 14.00 Nursing Administration 15.00 Central Services & Supply 16.00 Pharmacy 17.00 Medical Records and Library 18.00 Social Service 19.00 19.02 19.03 20.00 21.00 Nursing School 22.00 Intern & Res Service-Salary & Fringes 23.00 Intern & Res Other Program 24.00 Paramedical Ed Program INPATIENT ROUTINE COST CENTERS 25.00 Adults & Pediatrics (Gen Routine) 26.00 Intensive Care Unit 27.00 Coronary Care Unit 30.00 Neonatal Intensive Care Unit 31.00 Surgical Intensive Care 32.00 Subprovider I 32.01 Subprovider II 32.02 33.00 Nursery 34.00 Medicare Certified Nursing Facility 35.00 Distinct Part Nursing Facility 36.00 Adult Subacute Care Unit 36.01 Subacute Care Unit II 36.02 Transitional Care Unit SCHEDULE 9.3 Fiscal Period Ended: JUNE 30, 2008 STAT STAT NONPHY NURSE I&R-SAL I&R-PRG PARAMED ANESTH SCHOOL & FRINGES COST EDUCAT (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 19.02 19.03 20.00 21.00 22.00 23.00 24.00 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) STATISTICS FOR COST ALLOCATION (W/S B-1) This is trial version www.adultpdf.com STATE OF CALIFORNIA Provider Name: ANTELOPE VALLEY HOSPITAL ANCILLARY COST CENTERS 37.00 Operating Room 38.00 Recovery Room 39.00 Delivery Room and Labor Room 40.00 Anesthesiology 41.00 Radiology - Diagnostic 41.01 41.02 42.00 Radiology - Therapeutic 43.00 Radioisotope 44.00 Laboratory 44.01 Pathological Lab 46.00 Whole Blood 47.00 Blood Storing and Processing 48.00 Intravenous Therapy 49.00 Respiratory Therapy 50.00 Physical Therapy 51.00 Occupational Therapy 52.00 Speech Pathology 53.00 Electrocardiology 54.00 Electroencephalography 55.00 Medical Supplies Charged to Patients 56.00 Drugs Charged to Patients 57.00 Renal Dialysis 58.00 ASC (Non-Distinct Part) 59.00 Patient Education & Family Counseling 59.01 Ultrasound 59.02 Magnetic Resonance Imaging 59.03 60.00 Clinic 60.01 Other Clinic Services 61.00 Emergency 62.00 Observation Beds 71.00 Home Health Agency 82.00 83.00 84.00 85.00 86.00 NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop & Canteen 97.00 Research 98.00 Physicians' Private Office 99.00 Nonpaid Workers 99.01 Community Benefits 99.02 Marketing 99.03 Dialysis 99.04 99.05 100.00 100.01 100.02 100.03 100.04 TOTAL COST TO BE ALLOCATED UNIT COST MULTIPLIER - SCH 8 SCHEDULE 9.3 Fiscal Period Ended: JUNE 30, 2008 STAT STAT NONPHY NURSE I&R-SAL I&R-PRG PARAMED ANESTH SCHOOL & FRINGES COST EDUCAT (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) (ASG TIME) 19.02 19.03 20.00 21.00 22.00 23.00 24.00 (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) (Adj ) STATISTICS FOR COST ALLOCATION (W/S B-1) 0000000 0000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 10 Provider Name: Fiscal Period Ended: ANTELOPE VALLEY HOSPITAL JUNE 30, 2008 GENERAL SERVICE COST CENTERS 1.00 Old Cap Rel Costs-Bldg & Fixtures $ 7,298,703 $ (369,833) $ 6,928,870 2.00 Old Cap Rel Costs-Movable Equipment 3,661,734 (681,711) 2,980,023 3.00 New Cap Rel Costs-Bldg & Fixtures 821,239 0 821,239 4.00 New Cap Rel Costs-Movable Equipment 3,054,161 0 3,054,161 4.01 0 0 0 4.02 0 0 0 4.03 0 0 0 4.04 0 0 0 4.05 0 0 0 4.06 0 0 0 4.07 0 0 0 4.08 0 0 0 5.00 Employee Benefits 29,366,706 (1,972) 29,364,734 6.01 Purchasing/Receiving 988,264 (3,982) 984,282 6.02 Patient Admitting 3,233,020 (207) 3,232,813 6.03 Cashiering/Accounts Receivable 2,720,410 0 2,720,410 6.04 0 0 0 6.05 0 0 0 6.06 0 0 0 6.07 0 0 0 6.08 0 0 0 6.04 Administrative and General 22,863,818 43,665 22,907,483 7.00 Maintenance and Repairs 7,658,469 (119) 7,658,350 8.00 Operation of Plant 1,622,838 0 1,622,838 9.00 Laundry and Linen Service 1,270,296 0 1,270,296 10.00 Housekeeping 4,245,397 (4,677) 4,240,720 11.00 Dietary 2,374,193 0 2,374,193 12.00 Cafeteria 469,952 0 469,952 13.00 Maintenance of Personnel 0 0 0 14.00 Nursing Administration 2,131,843 (2,329) 2,129,514 15.00 Central Services & Supply 1,402,116 (24,526) 1,377,590 16.00 Pharmacy 3,902,773 241,132 4,143,905 17.00 Medical Records and Library 3,511,382 (29,340) 3,482,042 18.00 Social Service 0 0 0 19.00 0 0 0 19.02 0 0 0 19.03 0 0 0 20.00 0 0 0 21.00 Nursing School 0 0 0 22.00 Intern & Res Service-Salary & Fringes 0 0 0 23.00 Intern & Res Other Program 0 0 0 24.00 Paramedical Ed Program 0 0 0 INPATIENT ROUTINE COST CENTERS 25.00 Adults & Pediatrics (Gen Routine) 29,305,873 (1,114,313) 28,191,560 26.00 Intensive Care Unit 9,638,478 (357,156) 9,281,322 27.00 Coronary Care Unit 0 0 0 30.00 Neonatal Intensive Care Unit 4,715,057 (181,544) 4,533,513 31.00 Surgical Intensive Care 0 0 0 32.00 Subprovider I 0 0 0 32.01 Subprovider II 0 0 0 32.02 0 0 0 33.00 Nursery 4,365,555 0 4,365,555 34.00 Medicare Certified Nursing Facility 0 0 0 35.00 Distinct Part Nursing Facility 0 0 0 36.00 Adult Subacute Care Unit 0 0 0 36.01 Subacute Care Unit II 0 0 0 36.02 Transitional Care Unit 0 0 0 REPORTED ADJUSTMENTS TRIAL BALANCE OF EXPENSES (From Sch 10A) AUDITED This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 10 Provider Name: Fiscal Period Ended: ANTELOPE VALLEY HOSPITAL JUNE 30, 2008 REPORTED ADJUSTMENTS TRIAL BALANCE OF EXPENSES (From Sch 10A) AUDITED ANCILLARY COST CENTERS 37.00 Operating Room $ 10,868,446 $ (223,660) $ 10,644,786 38.00 Recovery Room 0 0 0 39.00 Delivery Room and Labor Room 7,077,366 (574,274) 6,503,092 40.00 Anesthesiology 0 0 0 41.00 Radiology - Diagnostic 6,370,702 (2,002,186) 4,368,516 41.01 0 0 0 41.02 0 0 0 42.00 Radiology - Therapeutic 0 0 0 43.00 Radioisotope 815,709 (3,814) 811,895 44.00 Laboratory 12,353,616 (2,249,665) 10,103,951 44.01 Pathological Lab 0 0 0 46.00 Whole Blood 0 0 0 47.00 Blood Storing and Processing 0 0 0 48.00 Intravenous Therapy 0 0 0 49.00 Respiratory Therapy 5,147,146 (680,214) 4,466,932 50.00 Physical Therapy 847,855 (4,880) 842,975 51.00 Occupational Therapy 53,370 (466) 52,904 52.00 Speech Pathology 59,340 0 59,340 53.00 Electrocardiology 535,260 (13,218) 522,042 54.00 Electroencephalography 199,059 (6,621) 192,438 55.00 Medical Supplies Charged to Patients 11,978,119 7,891,005 19,869,124 56.00 Drugs Charged to Patients 10,018,044 (668,520) 9,349,524 57.00 Renal Dialysis 1,025,061 0 1,025,061 58.00 ASC (Non-Distinct Part) 0 0 0 59.00 Patient Education & Family Counseling 20,481 (6,906) 13,575 59.01 Ultrasound 897,462 (30,498) 866,964 59.02 Magnetic Resonance Imaging 406,759 (4,329) 402,430 59.03 0 0 0 60.00 Clinic 0 0 0 60.01 Other Clinic Services 0 0 0 61.00 Emergency 12,967,029 (21,622) 12,945,407 62.00 Observation Beds 0 0 0 71.00 Home Health Agency 1,709,438 0 1,709,438 82.00 0 0 0 83.00 0 0 0 84.00 0 0 0 85.00 0 0 0 86.00 0 0 0 SUBTOTAL $ 233,972,539 $ (1,086,780) $ 232,885,759 NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop & Canteen 0 0 0 97.00 Research 0 0 0 98.00 Physicians' Private Office 5,258,056 679,531 5,937,587 99.00 Nonpaid Workers 0 0 0 99.01 Community Benefits 3,034,764 321,506 3,356,270 99.02 Marketing 692,343 23,198 715,541 99.03 Dialysis 26,097 (4,142) 21,955 99.04 0 0 0 99.05 0 0 0 100.00 0 0 0 100.01 0 0 0 100.02 0 0 0 100.03 0 0 0 100.04 0 0 0 100.99 SUBTOTAL $ 9,011,260 $ 1,020,093 $ 10,031,353 101 TOTAL $ 242,983,799 $ (66,687) $ 242,917,112 (To Schedule 8) This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 10A Page 1 Provider Name: Fiscal Period Ended: ANTELOPE VALLEY HOSPITAL JUNE 30, 2008 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 & 2)12345678 GENERAL SERVICE COST CENTER 1.00 Old Cap Rel Costs-Bldg & Fixtures ($369,833) (342,524) (27,309) 2.00 Old Cap Rel Costs-Movable Equipment (681,711) (681,711) 3.00 New Cap Rel Costs-Bldg & Fixtures 0 4.00 New Cap Rel Costs-Movable Equipment 0 4.01 0 4.02 0 4.03 0 4.04 0 4.05 0 4.06 0 4.07 0 4.08 0 5.00 Employee Benefits (1,972) (1,972) 6.01 Purchasing/Receiving (3,982) (3,982) 6.02 Patient Admitting (207) (207) 6.03 Cashiering/Accounts Receivable 0 6.04 0 6.05 0 6.06 0 6.07 0 6.08 0 6.04 Administrative and General 43,665 (18,630) (1,711) 103,384 (1,787) (37,591) 7.00 Maintenance and Repairs (119) (119) 8.00 Operation of Plant 0 9.00 Laundry and Linen Service 0 10.00 Housekeeping (4,677) (4,677) 11.00 Dietary 0 12.00 Cafeteria 0 13.00 Maintenance of Personnel 0 14.00 Nursing Administration (2,329) (2,329) 15.00 Central Services & Supply (24,526) (3,644) (20,882) 16.00 Pharmacy 241,132 831,244 (529,595) (60,517) 17.00 Medical Records and Library (29,340) (29,340) 18.00 Social Service 0 19.00 0 19.02 0 19.03 0 20.00 0 21.00 Nursing School 0 22.00 Intern & Res Service-Salary & Fringes 0 23.00 Intern & Res Other Program 0 24.00 Paramedical Ed Program 0 INPATIENT ROUTINE COST CENTERS 25.00 Adults & Pediatrics (Gen Routine) (1,114,313) (108,723) (1,005,590) 26.00 Intensive Care Unit (357,156) (357,156) 27.00 Coronary Care Unit 0 30.00 Neonatal Intensive Care Unit (181,544) (3,279) (174,456) (3,809) 31.00 Surgical Intensive Care 0 32.00 Subprovider I 0 32.01 Subprovider II 0 32.02 0 33.00 Nursery 0 34.00 Medicare Certified Nursing Facility 0 35.00 Distinct Part Nursing Facility 0 36.00 Adult Subacute Care Unit 0 36.01 Subacute Care Unit II 0 36.02 Transitional Care Unit 0 ADJUSTMENTS TO REPORTED COSTS This is trial version www.adultpdf.com STATE OF CALIFORNIA SCHEDULE 10A Page 1 Provider Name: Fiscal Period Ended: ANTELOPE VALLEY HOSPITAL JUNE 30, 2008 TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 & 2)12345678 ADJUSTMENTS TO REPORTED COSTS ANCILLARY COST CENTERS 37.00 Operating Room (223,660) (16,706) (206,954) 38.00 Recovery Room 0 39.00 Delivery Room and Labor Room (574,274) (574,274) 40.00 Anesthesiology 0 41.00 Radiology - Diagnostic (2,002,186) (9,492) (1,992,694) 41.01 0 41.02 0 42.00 Radiology - Therapeutic 0 43.00 Radioisotope (3,814) (3,814) 44.00 Laboratory (2,249,665) (2,249,665) 44.01 Pathological Lab 0 46.00 Whole Blood 0 47.00 Blood Storing and Processing 0 48.00 Intravenous Therapy 0 49.00 Respiratory Therapy (680,214) (1,478) (678,736) 50.00 Physical Therapy (4,880) (4,880) 51.00 Occupational Therapy (466) (466) 52.00 Speech Pathology 0 53.00 Electrocardiology (13,218) (13,218) 54.00 Electroencephalography (6,621) (6,621) 55.00 Medical Supplies Charged to Patients 7,891,005 7,891,005 56.00 Drugs Charged to Patients (668,520) (668,520) 57.00 Renal Dialysis 0 58.00 ASC (Non-Distinct Part) 0 59.00 Patient Education & Family Counseling (6,906) (3,302) (3,604) 59.01 Ultrasound (30,498) (353) (30,145) 59.02 Magnetic Resonance Imaging (4,329) (4,329) 59.03 0 60.00 Clinic 0 60.01 Other Clinic Services 0 61.00 Emergency (21,622) (419) (21,203) 62.00 Observation Beds 0 71.00 Home Health Agency 0 82.00 0 83.00 0 84.00 0 85.00 0 86.00 0 NONREIMBURSABLE COST CENTERS 96.00 Gift, Flower, Coffee Shop & Canteen 0 97.00 Research 0 98.00 Physicians' Private Office 679,531 679,531 99.00 Nonpaid Workers 0 99.01 Community Benefits 321,506 320,308 1,198 99.02 Marketing 23,198 22,216 982 99.03 Dialysis (4,142) (4,142) 99.04 0 99.05 0 100.00 0 100.01 0 100.02 0 100.03 0 100.04 0 101.00 TOTAL ($66,687) 0 0 0 0 0 (1,787) (37,591) (27,309) 0 0 0 0 (To Sch 10) This is trial version www.adultpdf.com [...]...1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4. 05 4.06 4.07 4.08 5. 00 6.01 6.02 6.03 6.04 6. 05 6.06 6.07 6.08 6.04 7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15. 00 16.00 17.00 18.00 19.00 19.02 19.03 20.00 21.00 22.00 23.00 24.00 25. 00 26.00 27.00 30.00 31.00 32.00 32.01 32.02 33.00 34.00 35. 00 36.00 36.01 36.02 Nursery Medicare Certified Nursing Facility Distinct Part... Costs-Bldg & Fixtures New Cap Rel Costs-Movable Equipment Provider Name: ANTELOPE VALLEY HOSPITAL STATE OF CALIFORNIA This is trial version www.adultpdf.com AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ ADJUSTMENTS TO REPORTED COSTS AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ SCHEDULE 10A Page 2 Fiscal Period Ended: JUNE 30, 2008 ... Coronary Care Unit Neonatal Intensive Care Unit Surgical Intensive Care Subprovider I Subprovider II Administrative and General Maintenance and Repairs Operation of Plant Laundry and Linen Service Housekeeping Dietary Cafeteria Maintenance of Personnel Nursing Administration Central Services & Supply Pharmacy Medical Records and Library Social Service Employee Benefits Purchasing/Receiving Patient Admitting . 23,061 0 5, 416,880 676,186 50 ,9 35, 422 50 ,9 35, 422 9, 450 ,264 52 ,56 2 0 3,914 ,54 2 1, 058 ,122 103,024,136 103,024,136 7,249,602 11 ,59 0 0 0 0 394,922 308,8 65 4,391,070 4,391,070 1,108 ,50 6 2,128 5, 522,969. (Adj ) (Adj ) 1,876 2,242 5, 576 5, 576 6,4 15 6,418 3,4 05 3,4 05 2,299 3,4 65 7 ,57 8 3,4 65 2, 758 2, 758 3,881 3,881 3,418 3,418 6 45, 821 10,726 10,726 3,790 3,790 45, 018 45, 018 143,769 933,210 143,769 198,189 39,698 39,698 7 45, 7 25 7 45, 7 25 129,6 15, 708 8,449. 3 25, 660 241 ,55 5 124,728 0 122,429 10,119,4 35 9,473,614 847,407,934 0 0 2,996,762 1 ,58 1,328 5, 553 ,236 3,6 25, 274 1,1 85, 728 0 3,271,0 45 2,381,360 6,374,876 5, 630,813 0 0 9.087292 0.824038 17. 052 252