STATE OF CALIFORNIA CONTRACT SCH ADJUSTMENTS TO MEDI-CAL CHARGES Provider Name: CENTINELA HOSPITAL MEDICAL CENTER Fiscal Period Ended: DECEMBER 31, 2008 Provider No: HSC30240H REPORTED 37.00 38.00 39.00 40.00 41.00 41.01 41.02 41.03 42.00 43.00 44.00 44.01 46.00 47.00 49.00 50.00 51.00 52.00 53.00 53.01 53.02 54.00 55.00 56.00 57.00 59.00 59.01 59.02 60.00 60.01 61.00 62.00 71.00 82.00 83.00 84.00 85.00 86.00 ANCILLARY CHARGES Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic CAT Scan Ultra Sound Magnetic Resonance Imaging (MRI) Radiology - Therapeutic Radioisotope Laboratory Pathological Lab Whole Blood Blood Storing and Processing Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Cardiology $ 6,870,523 5,495,246 4,265,489 7,081,545 2,747,636 1,892,411 2,232,044 (115,014) (6,193,970) (62,408) (83,824) 1,527 (2,697,042) 190,234 (1,135,682) 627,118 (2,295,534) (15,859,150) (362,016) 11,175,874 $ (5,417,790) (183,694) 615,525 13,272,773 653,702 264,573 59,524 6,603,600 1,808,185 1,135,682 290,744 36,458,083 61,362,782 4,321,788 Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis Lithotripsy Pain Management Rehab Nuero Clinic Other Clinic Services Emergency Observation Beds (4,061,823) (1,913,076) (66,140) (1,336,602) (1,252,158) (516,680) (829,163) 34,634,380 344,646 Cardiac Rehab TOTAL MEDI-CAL ANCILLARY CHARGES ADJUSTMENTS (Adj 9) 13,705,319 $ (2,835,092) $ (2,901,576) 217,292,074 $ (49,299,555) $ AUDITED 10,870,227 2,808,700 3,582,170 4,199,349 5,744,943 1,495,478 1,375,731 1,402,881 29,216,590 160,952 500,511 7,078,803 591,294 180,749 61,051 3,906,558 1,998,419 917,862 34,162,549 45,503,632 3,959,772 0 0 8,274,298 0 0 0 167,992,519 (To Contract Sch 5) This is trial version www.adultpdf.com STATE OF CALIFORNIA CONTRACT SCH COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED PHYSICIAN'S REMUNERATION Provider Name: CENTINELA HOSPITAL MEDICAL CENTER Fiscal Period Ended: DECEMBER 31, 2008 Provider No: HSC30240H PROFESSIONAL SERVICE COST CENTERS HBP REMUNERATION (Adj ) 40.00 41.00 43.00 44.00 53.00 54.00 61.00 Anesthesiology Radiology - Diagnostic Radioisotope Laboratory Electrocardiology Electroencephalography Emergency TOTAL $ $ 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 TOTAL CHARGES RATIO OF MEDI-CAL MEDI-CAL TO ALL PATIENTS REMUNERATION CHARGES COST TO CHARGES (Adj ) (Adj ) $ 0.000000 $ $ 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 0.000000 $ $ $ (To Contract Sch 3) This is trial version www.adultpdf.com 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 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 6.00 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 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8,936,596 4,845,922 0 0 0 0 874,680 0 0 0 0 28,104,432 6,773,264 2,968,824 1,160,013 4,097,116 1,334,732 0 1,506,128 380,762 4,936,559 4,091,346 1,975 0 0 0 0 NET EXP FOR OLD CAPITAL COST ALLOC BLDG & (From Sch 10) FIXTURES 0.00 1.00 Nursing School Intern & Res Service-Salary & Fringes Intern & Res Other Program Paramedical Ed Program INPATIENT ROUTINE COST CENTERS 25.00 Adults & Pediatrics (Gen Routine) 26.00 Intensive Care Unit 27.00 Coronary Care Unit 28.00 29.00 Surgical Intensive Care 30.00 Neonatal Intensive Care Unit 31.00 Subprovider II 32.00 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 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 Non-Patient Telephones Data Processing Purchasing/Receiving Patient Admitting Patient Business Office GENERAL SERVICE COST CENTER Old Cap Rel Costs-Bldg & Fixtures Old Cap Rel Costs-Movable Equipmen New Cap Rel Costs-Bldg & Fixtures New Cap Rel Costs-Movable Equipme TRIAL BALANCE EXPENSES Provider Name: CENTINELA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com 38,354,684 12,943,357 0 3,026,401 0 733,229 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2,645,004 339,852 0 20,011 0 60,969 0 0 0 0 0 0 0 65,816 0 0 0 0 603,286 280,130 1,242,485 61,168 40,391 169,104 33,645 24,263 0 229,024 43,339 0 0 0 0 OLD NEW CAPITAL MOVABLE BLDG & EQUIP FIXTURES 2.00 3.00 1,434,269 184,287 0 10,851 0 33,061 0 0 0 0 0 0 35,689 0 0 0 0 327,136 151,902 673,745 33,169 21,902 91,698 18,244 13,157 0 124,190 23,501 0 0 0 0 NEW MOVABLE EQUIP 4.00 ALLOC COST 4.01 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 4.02 COMPUTATION OF COST ALLOCATION (W/S B) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 4.03 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 4.04 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 4.05 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 4.06 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 4.07 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Fiscal Period Ended: DECEMBER 31, 2008 SCHEDULE 37.00 38.00 39.00 40.00 41.00 41.01 41.02 41.03 42.00 43.00 44.00 44.01 46.00 47.00 49.00 50.00 51.00 52.00 53.00 53.01 53.02 54.00 55.00 56.00 57.00 59.00 59.01 59.02 60.00 60.01 61.00 62.00 71.00 82.00 83.00 84.00 85.00 86.00 96.00 97.00 98.00 99.00 99.01 99.02 99.03 99.04 99.05 100.00 100.01 100.02 100.03 100.07 TOTAL Unoccupied Space Cent Transport Public Relations Mob I 198,237,822 0 0 0 0 54,179 1,286,455 1,040,893 0 12,146,523 3,271,283 224,325 4,260,722 949,832 925,117 755,004 839,017 7,785,099 460,375 2,212,743 5,880,235 1,488,686 515,585 228,361 1,420,107 6,623,053 125,289 210,505 322,242 7,479,233 1,817,433 14,000 53,622 51,012 0 10,726,872 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 NET EXP FOR OLD CAPITAL COST ALLOC BLDG & (From Sch 10) FIXTURES 0.00 1.00 NONREIMBURSABLE COST CENTERS Gift, Flower, Coffee Shop & Canteen Research Physicians' Private Office Nonpaid Workers ANCILLARY COST CENTERS Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic CAT Scan Ultra Sound Magnetic Resonance Imaging (MRI) Radiology - Therapeutic Radioisotope Laboratory Pathological Lab Whole Blood Blood Storing and Processing Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Cardiology Cardiac Rehab Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis Lithotripsy Pain Management Rehab Nuero Clinic Other Clinic Services Emergency Observation Beds TRIAL BALANCE EXPENSES Provider Name: CENTINELA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8,936,596 0 0 0 0 0 8,022 0 324,432 834,606 155,612 6,491 289,965 36,508 59,977 21,429 34,467 163,520 38,860 25,142 71,060 14,739 6,916 10,204 48,016 298,525 0 184,070 122,959 0 0 0 322,590 0 0 0 OLD NEW CAPITAL MOVABLE BLDG & EQUIP FIXTURES 2.00 3.00 4,845,922 0 0 0 0 0 4,350 0 175,925 452,570 84,381 3,520 157,235 19,797 32,523 11,620 18,690 88,670 21,072 13,633 38,533 7,992 3,750 5,533 26,037 161,877 0 99,813 66,675 0 0 0 174,926 0 0 0 NEW MOVABLE EQUIP 4.00 ALLOC COST 4.01 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 4.02 COMPUTATION OF COST ALLOCATION (W/S B) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 4.03 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 4.04 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 4.05 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 4.06 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 4.07 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Fiscal Period Ended: DECEMBER 31, 2008 SCHEDULE 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 6.00 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 Nursing School Intern & Res Service-Salary & Fringes Intern & Res Other Program Paramedical Ed Program INPATIENT ROUTINE COST CENTER 25.00 Adults & Pediatrics (Gen Routine) 26.00 Intensive Care Unit 27.00 Coronary Care Unit 28.00 29.00 Surgical Intensive Care 30.00 Neonatal Intensive Care Unit 31.00 Subprovider II 32.00 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 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 Non-Patient Telephones Data Processing Purchasing/Receiving Patient Admitting Patient Business Office GENERAL SERVICE COST CENTER Old Cap Rel Costs-Bldg & Fixtures Old Cap Rel Costs-Movable Equipmen New Cap Rel Costs-Bldg & Fixtures New Cap Rel Costs-Movable Equipme TRIAL BALANCE EXPENSES Provider Name: CENTINELA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com ALLOC COST 4.08 0 0 0 0 64,879 20,566 1,410 1,232 559 0 14,431 5,957 48,863 26,758 0 0 0 0 356,797 118,921 0 27,173 0 5,430 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 EMPLOYEE BENEFITS 5.00 0 0 0 0 0 0 0 ALLOC COST 6.01 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 6.02 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 6.03 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 6.04 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 COMPUTATION OF COST ALLOCATION (W/S B) ALLOC COST 6.05 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 6.06 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 6.07 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 6.08 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 42,790,753 13,586,416 0 3,084,437 0 832,689 0 0 29,099,733 7,225,862 4,885,054 1,255,759 4,160,641 1,596,092 51,889 1,557,979 386,719 4,985,422 4,471,318 68,815 0 0 0 0 ACCUMULATE COST 7,362,029 2,337,505 0 530,669 0 143,262 0 0 1,243,189 840,460 216,050 715,827 274,603 8,927 268,046 66,534 857,728 769,278 11,839 0 0 0 0 ADMINISTRATIVE & GENERAL 6.00 Fiscal Period Ended: DECEMBER 31, 2008 SCHEDULE 8.1 37.00 38.00 39.00 40.00 41.00 41.01 41.02 41.03 42.00 43.00 44.00 44.01 46.00 47.00 49.00 50.00 51.00 52.00 53.00 53.01 53.02 54.00 55.00 56.00 57.00 59.00 59.01 59.02 60.00 60.01 61.00 62.00 71.00 82.00 83.00 84.00 85.00 86.00 96.00 97.00 98.00 99.00 99.01 99.02 99.03 99.04 99.05 100.00 100.01 100.02 100.03 100.07 TOTAL Unoccupied Space Cent Transport Public Relations Mob I NONREIMBURSABLE COST CENTER Gift, Flower, Coffee Shop & Canteen Research Physicians' Private Office Nonpaid Workers ANCILLARY COST CENTERS Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic CAT Scan Ultra Sound Magnetic Resonance Imaging (MRI) Radiology - Therapeutic Radioisotope Laboratory Pathological Lab Whole Blood Blood Storing and Processing Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Cardiology Cardiac Rehab Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis Lithotripsy Pain Management Rehab Nuero Clinic Other Clinic Services Emergency Observation Beds TRIAL BALANCE EXPENSES Provider Name: CENTINELA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com ALLOC COST 4.08 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 976,185 0 0 0 0 422 0 0 48,943 25,346 594 29,265 8,275 8,040 4,232 4,543 51,982 2,118 0 50,109 16,921 6,355 2,508 9,941 9,558 1,296 1,561 0 0 602 599 0 0 0 0 0 EMPLOYEE BENEFITS 5.00 ALLOC COST 6.01 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 6.02 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 6.03 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 6.04 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 COMPUTATION OF COST ALLOCATION (W/S B) ALLOC COST 6.05 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 6.06 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 6.07 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 6.08 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 198,237,822 0 0 0 0 54,601 1,298,826 1,040,893 500,357 13,482,643 3,536,622 234,930 4,737,187 1,014,411 1,025,657 792,284 896,717 8,089,270 522,426 2,251,518 6,039,937 1,528,339 532,606 246,606 1,504,101 7,093,014 126,585 212,066 606,125 7,668,867 1,817,433 14,000 54,224 51,611 0 11,224,388 0 0 0 ACCUMULATE COST 29,099,733 0 0 0 0 9,394 223,459 179,083 86,085 2,319,651 608,466 40,419 815,020 174,527 176,461 136,310 154,278 1,391,736 89,882 387,367 1,039,154 262,946 91,633 42,428 258,776 1,220,333 21,779 36,485 104,282 1,319,407 312,684 2,409 9,329 8,879 0 1,931,124 0 0 0 ADMINISTRATIVE & GENERAL 6.00 Fiscal Period Ended: DECEMBER 31, 2008 SCHEDULE 8.1 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 6.00 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 Nursing School Intern & Res Service-Salary & Fringes Intern & Res Other Program Paramedical Ed Program INPATIENT ROUTINE COST CENTER 25.00 Adults & Pediatrics (Gen Routine) 26.00 Intensive Care Unit 27.00 Coronary Care Unit 28.00 29.00 Surgical Intensive Care 30.00 Neonatal Intensive Care Unit 31.00 Subprovider II 32.00 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 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 Non-Patient Telephones Data Processing Purchasing/Receiving Patient Admitting Patient Business Office GENERAL SERVICE COST CENTER Old Cap Rel Costs-Bldg & Fixtures Old Cap Rel Costs-Movable Equipmen New Cap Rel Costs-Bldg & Fixtures New Cap Rel Costs-Movable Equipme TRIAL BALANCE EXPENSES Provider Name: CENTINELA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com 63,871 42,176 176,576 35,132 25,335 0 239,145 45,254 0 0 0 0 OPER PLANT 8.00 2,761,884 354,869 0 20,896 0 63,663 0 0 1,317,415 64,856 42,827 179,302 35,674 25,726 0 242,836 45,952 0 0 0 0 MAINT & REPAIRS 7.00 2,804,514 360,347 0 21,218 0 64,646 0 0 913,222 149,424 0 0 0 20,330 0 0 0 0 0 14,696 0 0 0 0 0 1,975,384 253,813 0 14,945 0 45,534 0 0 126,293 25,127 18,120 0 171,044 32,367 0 0 0 0 LAUNDRY & LINEN HOUSEKEEP 9.00 10.00 0 0 0 0 0 0 0 2,142,825 139,634 0 0 0 0 0 0 DIETARY 11.00 59,110 15,471 0 3,795 0 876 0 0 0 1,751 1,605 7,152 0 0 0 0 CAFE 12.00 0 0 0 0 0 0 0 0 0 0 0 0 0 MAINT OF PERSONNEL 13.00 COMPUTATION OF COST ALLOCATION (W/S B) 1,086,116 281,957 0 75,733 0 18,802 0 0 1,983 779 0 0 0 0 NURSING ADMIN 14.00 22,980 9,305 0 2,973 0 41 0 0 1,075 12 0 0 0 0 CENTRAL SERVICE & SUPPLY 15.00 118,198 34,734 0 7,877 0 0 0 0 0 0 0 0 0 PHARMACY 16.00 1,149,285 259,197 0 82,520 0 30,139 0 0 0 0 0 0 0 MEDICAL RECORDS & LIBRARY 17.00 0 0 0 0 161,494 24,068 0 7,250 0 11,415 0 0 SOCIAL SERVICE 18.00 Fiscal Period Ended: DECEMBER 31, 2008 SCHEDULE 8.2 37.00 38.00 39.00 40.00 41.00 41.01 41.02 41.03 42.00 43.00 44.00 44.01 46.00 47.00 49.00 50.00 51.00 52.00 53.00 53.01 53.02 54.00 55.00 56.00 57.00 59.00 59.01 59.02 60.00 60.01 61.00 62.00 71.00 82.00 83.00 84.00 85.00 86.00 96.00 97.00 98.00 99.00 99.01 99.02 99.03 99.04 99.05 100.00 100.01 100.02 100.03 100.07 TOTAL Unoccupied Space Cent Transport Public Relations Mob I NONREIMBURSABLE COST CENTERS Gift, Flower, Coffee Shop & Canteen Research Physicians' Private Office Nonpaid Workers ANCILLARY COST CENTERS Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic CAT Scan Ultra Sound Magnetic Resonance Imaging (MRI) Radiology - Therapeutic Radioisotope Laboratory Pathological Lab Whole Blood Blood Storing and Processing Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Cardiology Cardiac Rehab Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis Lithotripsy Pain Management Rehab Nuero Clinic Other Clinic Services Emergency Observation Beds TRIAL BALANCE EXPENSES Provider Name: CENTINELA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com 0 0 0 0 0 0 0 90,607 46,591 68,667 0 0 0 0 1,035 1,394 0 22,902 0 0 0 0 0 271,660 0 0 0 LAUNDRY & LINEN 9.00 1,600,536 0 0 0 0 0 8,376 0 338,769 871,487 162,488 6,778 302,778 38,121 62,627 22,375 35,990 170,746 40,578 26,253 74,200 15,390 7,222 10,655 50,138 311,717 0 192,204 128,392 0 0 0 336,845 0 0 0 OPER PLANT 8.00 7,042,929 0 0 0 0 0 8,505 0 343,997 884,938 164,996 6,882 307,452 38,709 63,594 22,721 36,546 173,381 41,204 26,658 75,345 15,628 7,333 10,819 50,911 316,528 0 195,170 130,374 0 0 0 342,044 0 0 0 MAINT & REPAIRS 7.00 8,469,051 4,961,471 0 0 0 0 0 5,991 0 242,298 623,314 116,217 4,848 216,556 27,265 44,793 16,004 25,741 122,123 29,022 18,777 53,070 11,008 5,165 7,621 35,860 222,949 0 137,470 91,830 0 0 0 240,922 0 0 0 HOUSEKEEP 10.00 2,352,866 0 0 0 0 0 0 0 0 22,356 0 0 0 0 0 0 0 0 0 0 0 0 0 48,051 0 0 0 DIETARY 11.00 156,750 0 0 0 0 146 0 0 7,297 4,962 292 4,524 1,168 1,459 584 584 10,071 584 0 8,611 1,751 584 292 1,459 1,314 146 146 6,714 0 0 0 14,303 0 0 0 CAFE 12.00 COMPUTATION OF COST ALLOCATION (W/S B) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 MAINT OF PERSONNEL 13.00 1,896,958 0 0 0 0 0 0 0 84,417 68,503 1,735 11,960 326 76 134 40,209 0 0 3,982 324 9,709 8,442 151 76 0 0 0 0 201,544 0 0 0 NURSING ADMIN 14.00 471,538 0 0 0 0 0 55 0 145,027 6,207 2,975 28,153 397 1,046 124 3,479 59,454 5,093 59,291 11,407 21 37 7,394 87,800 240 5,476 16 22 0 11,439 0 0 0 CENTRAL SERVICE & SUPPLY 15.00 5,844,225 0 0 0 0 0 0 0 15,543 10,185 4,614 664 426 376 132,084 4,527 485 5,435 11,861 0 0 6,376 21 646 5,439,634 0 144 0 50,395 0 0 0 PHARMACY 16.00 5,901,562 0 0 0 0 0 0 0 409,267 34,178 85,030 123,961 219,121 62,382 50,248 43,591 621,062 4,618 9,774 205,523 17,697 6,081 1,549 154,275 75,824 35,796 6,023 893,762 921,581 68,009 728 2,065 0 328,275 0 0 0 MEDICAL RECORDS & LIBRARY 17.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 204,228 SOCIAL SERVICE 18.00 Fiscal Period Ended: DECEMBER 31, 2008 SCHEDULE 8.2 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 6.00 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 Nursing School Intern & Res Service-Salary & Fringes Intern & Res Other Program Paramedical Ed Program INPATIENT ROUTINE COST CENTER 25.00 Adults & Pediatrics (Gen Routine) 26.00 Intensive Care Unit 27.00 Coronary Care Unit 28.00 29.00 Surgical Intensive Care 30.00 Neonatal Intensive Care Unit 31.00 Subprovider II 32.00 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 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 Non-Patient Telephones Data Processing Purchasing/Receiving Patient Admitting Patient Business Office GENERAL SERVICE COST CENTER Old Cap Rel Costs-Bldg & Fixtures Old Cap Rel Costs-Movable Equipmen New Cap Rel Costs-Bldg & Fixtures New Cap Rel Costs-Movable Equipme TRIAL BALANCE EXPENSES Provider Name: CENTINELA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com ALLOC COST 19.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 19.02 ALLOC COST 19.03 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 NONPHYSICIAN ANESTH 20.00 NURSING SCHOOL 21.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 INT & RES SALARY & FRINGES 22.00 COMPUTATION OF COST ALLOCATION (W/S B) 0 0 0 0 0 0 0 INT & RES PROGRAM 23.00 0 0 0 0 0 0 0 PARAMED EDUCAT 24.00 63,347,793 17,806,741 0 3,852,313 0 1,231,396 0 0 POST STEP-DOWN SUBTOTAL ADJUSTMENT (Adj 1) 25.00 26.00 63,347,793 17,806,741 0 3,852,313 0 1,231,396 0 0 27.00 TOTAL COST Fiscal Period Ended: DECEMBER 31, 2008 SCHEDULE 8.3 37.00 38.00 39.00 40.00 41.00 41.01 41.02 41.03 42.00 43.00 44.00 44.01 46.00 47.00 49.00 50.00 51.00 52.00 53.00 53.01 53.02 54.00 55.00 56.00 57.00 59.00 59.01 59.02 60.00 60.01 61.00 62.00 71.00 82.00 83.00 84.00 85.00 86.00 96.00 97.00 98.00 99.00 99.01 99.02 99.03 99.04 99.05 100.00 100.01 100.02 100.03 100.07 TOTAL Unoccupied Space Cent Transport Public Relations Mob I NONREIMBURSABLE COST CENTERS Gift, Flower, Coffee Shop & Canteen Research Physicians' Private Office Nonpaid Workers ANCILLARY COST CENTERS Operating Room Recovery Room Delivery Room and Labor Room Anesthesiology Radiology - Diagnostic CAT Scan Ultra Sound Magnetic Resonance Imaging (MRI) Radiology - Therapeutic Radioisotope Laboratory Pathological Lab Whole Blood Blood Storing and Processing Respiratory Therapy Physical Therapy Occupational Therapy Speech Pathology Electrocardiology Cardiology Cardiac Rehab Electroencephalography Medical Supplies Charged to Patients Drugs Charged to Patients Renal Dialysis Lithotripsy Pain Management Rehab Nuero Clinic Other Clinic Services Emergency Observation Beds TRIAL BALANCE EXPENSES Provider Name: CENTINELA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com ALLOC COST 19.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 ALLOC COST 19.02 ALLOC COST 19.03 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 NONPHYSICIAN ANESTH 20.00 NURSING SCHOOL 21.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 INT & RES SALARY & FRINGES 22.00 COMPUTATION OF COST ALLOCATION (W/S B) INT & RES PROGRAM 23.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 PARAMED EDUCAT 24.00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 198,237,822 0 0 0 0 64,141 1,545,213 1,219,976 1,511,506 18,934,192 4,781,770 388,502 6,616,923 1,514,471 1,438,472 1,040,649 1,329,144 40,209 10,642,370 733,891 2,785,082 7,520,142 1,858,158 650,986 319,970 2,095,525 9,344,296 184,456 255,057 2,135,134 15,706,800 2,198,142 17,136 65,785 60,492 0 15,000,989 0 0 0 25.00 SUBTOTAL 184,456 (184,456) 40,209 (40,209) POST STEP-DOWN ADJUSTMENT (Adj 1) 26.00 198,237,822 0 0 0 0 64,141 1,545,213 1,219,976 1,511,506 18,934,192 4,781,770 388,502 6,616,923 1,514,471 1,438,472 1,040,649 1,369,353 10,642,370 733,891 2,785,082 7,520,142 1,858,158 650,986 319,970 2,095,525 9,528,752 255,057 2,135,134 15,706,800 2,198,142 17,136 65,785 60,492 0 15,000,989 0 0 0 27.00 TOTAL COST Fiscal Period Ended: DECEMBER 31, 2008 SCHEDULE 8.3 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 6.00 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 28.00 29.00 30.00 31.00 32.00 33.00 34.00 35.00 36.00 36.01 36.02 Nursery Medicare Certified Nursing Facility Distinct Part Nursing Facility Adult Subacute Care Unit Subacute Care Unit II Transitional Care Unit Surgical Intensive Care Neonatal Intensive Care Unit Subprovider II Nursing School Intern & Res Service-Salary & Fringes Intern & Res Other Program Paramedical Ed Program INPATIENT ROUTINE COST CENTERS Adults & Pediatrics (Gen Routine) Intensive Care Unit Coronary Care Unit 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 Non-Patient Telephones Data Processing Purchasing/Receiving Patient Admitting Patient Business Office GENERAL SERVICE COST CENTERS Old Cap Rel Costs-Bldg & Fixtures Old Cap Rel Costs-Movable Equipment New Cap Rel Costs-Bldg & Fixtures New Cap Rel Costs-Movable Equipment Provider Name: CENTINELA HOSPITAL MEDICAL CENTER STATE OF CALIFORNIA This is trial version www.adultpdf.com 8,080 1,529 8,080 1,529 2,151 706 2,151 706 93,316 11,990 856 856 93,316 11,990 21,284 9,883 43,835 2,158 1,425 5,966 1,187 2,322 21,284 9,883 43,835 2,158 1,425 5,966 1,187 2,322 OLD BLDG OLD MOVBLE NEW BLDG NEW MOVBLE & FIXTURES EQUIP & FIXTURES EQUIP (SQ FT) (SQ FT) (SQ FT) (SQ FT) 1.00 2.00 3.00 4.00 STAT 4.02 STAT STATISTICS FOR COST ALLOCATION (W/S B-1) 4.01 4.03 STAT 4.04 STAT 4.05 STAT 4.06 STAT 4.07 STAT 4.08 STAT Fiscal Period Ended: DECEMBER 31, 2008 SCHEDULE ... OF CALIFORNIA CONTRACT SCH COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED PHYSICIAN''S REMUNERATION Provider Name: CENTINELA HOSPITAL MEDICAL CENTER Fiscal Period Ended: DECEMBER 31, 2008. .. 1,0 39,154 262,946 91,6 33 42,428 258,776 1,2 20,333 21,7 79 36,485 104,282 1,3 19,407 312,684 2,409 9,329 8,879 0 1,9 31,1 24 0 0 0 ADMINISTRATIVE & GENERAL 6.00 Fiscal Period Ended: DECEMBER 31, 2008. .. ADJUSTMENT (Adj 1) 25.00 26.00 63,347,793 17,806,741 0 3,852,313 0 1,2 31,3 96 0 0 27.00 TOTAL COST Fiscal Period Ended: DECEMBER 31, 2008 SCHEDULE 8.3 37.00 38.00 39.00 40.00 41.00 41.01 41.02 41.03