State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 35 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Adjustments GRAND PARK CONVALESCENT HOSPITAL JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06244I Report References Cost Report Audit Report Explanation of Audit Adjustments RECLASSIFICATIONS OF REPORTED COSTS 15 10.1(4) 100 14 8A-2 100.00 Other Ancillary Services $28,605 $600 $29,205 * Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * 248,787 (600) 248,187 * To reclassify dental expense to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 CCR, Title 22, Section 51511(c) 16 10.1(4) 100 14 8A-2 100.00 Other Ancillary Services * $29,205 $279 $29,484 Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * 248,187 (279) 247,908 * To reclassify physician's services expense to the appropriate cost center. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8 CCR, Title 22, Section 51511(c) *Balance carried forward from prior/to subsequent adjustments Page 4 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 35 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Adjustments GRAND PARK CONVALESCENT HOSPITAL JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06244I Report References Cost Report Audit Report Explanation of Audit Adjustments ADJUSTMENTS TO REPORTED COSTS 17 Not Reported 8A-2 10.03 Housekeeping - Agency Staff * $196,755 ($121) $196,634 To adjust housekeeping agency cost to agree with the provider's invoices. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 18 Not Reported 8A-2 60.04 Laundry and Linen - Other - Nonlabor * $20,079 ($233) $19,846 To adjust laundry agency cost to agree with the provider's invoices. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300 and 2304 19 Not Reported 8A-2 105.03 Skilled Nursing Care - Agency Staff * $337,316 ($12,756) $324,560 To eliminate screening expense not applicable to the fiscal year. 42 CFR 413.20 and 413.24 CMS Pub. 15-1, Sections 2300, 2302.1 and 2304 20 Not Reported 8A-2 165.01 Administration - Salaries and Wages * $586,680 ($201,219) $385,461 Not Reported 8A-2 165.02 Administration - Fringe Benefits * 81,038 (16,380) 64,658 To adjust administrator's compensation based on the department survey. 42 CFR 413.102 CMS Pub. 15-1, Chapter 9 / Medi-Cal Bulletin 371 SPA 05-005, Section (III)(J) / W&I Code, Section 14126.023(f) 21 10.1(4) 45 14 8A-2 45.00 Property Insurance * $29,265 ($16,446) $12,819 To adjust property insurance expense to agree with the provider's invoices. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 22 10.1(4) 20 14 8A-2 20.00 Depreciation - Leasehold Improvements $4,250 ($4,250) $0 To eliminate depreciation expense due to insufficient documentation. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 5 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 35 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Adjustments GRAND PARK CONVALESCENT HOSPITAL JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06244I Report References Cost Report Audit Report Explanation of Audit Adjustments ADJUSTMENTS TO REPORTED COSTS 23 Not Reported 8A-2 165.08 Administration - Liability Insurance * $122,014 ($8,091) $113,923 To adjust 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 24 Not Reported 8A-2 165.10 Administration - Quality Assurance Fees * $521,737 ($65,127) $456,610 To adjust quality assurance fees to agree with the amount calculated using the published rate. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $189,903 25 To eliminate tax expenses not related to patient care and not applicable ($24,074) to the fiscal year. 42 CFR 413.5, 413.9(c)(3), 413.20 and 413.24 CMS Pub. 15-1, Sections 2102.3, 2300, 2302.1 and 2304 26 To eliminate administrative supplies expense due to insufficient (3,294) documentation. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 27 To eliminate promotional, personal automobile, and management meals (9,075) expenses not related to patient care. ($36,443) $153,460 * 42 CFR 413.5, 413.9 and 413.24 CMS Pub. 15-1, Sections 2102.3, 2105.5 and 2136.2 28 Not Reported 8A-2 5.04 Plant Operations and Maintenance - Other - Nonlabor * $252,184 ($2,806) $249,378 To eliminate maintenance supplies expense due to insufficient documentation. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 *Balance carried forward from prior/to subsequent adjustments Page 6 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 35 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Adjustments GRAND PARK CONVALESCENT HOSPITAL JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06244I Report References Cost Report Audit Report Explanation of Audit Adjustments ADJUSTMENTS TO REPORTED COSTS Not Reported 8A-2 160.04 Activities - Other - Nonlabor * $19,825 29 To eliminate activities supplies expense due to insufficient ($4,956) documentation. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 30 To eliminate marketing expense not related to patient care. (163) 42 CFR 413.20 and 413.24 ($5,119) $14,706 CMS Pub. 15-1, Sections 2102.3, 2105.5, 2300 and 2304 31 Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * $247,908 ($196) $247,712 To eliminate nursing supplies expense due to insufficient documentation. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $153,460 32 To eliminate franchise tax board expense due to insufficient ($800) documentation. 42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304 33 To abate interest revenue against related expense. (134) 42 CFR 413.153(b)(2)(iii) / CMS Pub. 15-1, Section 202.2 ($934) $152,526 *Balance carried forward from prior/to subsequent adjustments Page 7 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 35 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Adjustments GRAND PARK CONVALESCENT HOSPITAL JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06244I Report References Cost Report Audit Report Explanation of Audit Adjustments ADJUSTMENT TO REPORTED STATISTICS 34 Not Reported 7 5.00 Plant Operations and Maintenance (Square Feet) 0 231 231 Not Reported 7 10.00 Housekeeping 0 231 231 Not Reported 7 60.00 Laundry and Linen 0 536 536 Not Reported 7 65.00 Dietary 0 2,041 2,041 11.1 (1 of 3) 10 2 7 75.00 Patient Supplies 225 (19) 206 11.1 (1 of 3) 35 2 7 100.00 Other Ancillary Services 231 (181) 50 Not Reported 7 160.00 Activities 0 140 140 Not Reported 7 165.00 Administration 0 498 498 Not Reported 7 170.00 Inservice Education - Nursing 0 395 395 11.1 (1 of 3) 85 2 7 N/A Total Statistics - Square Feet 15,605 3,872 19,477 11.1 (1 of 3) 85 2 7 N/A Total Statistics - Square Feet 15,605 3,641 19,246 11.1 (1 of 3) 85 2 7 N/A Total Statistics - Square Feet 15,605 3,410 19,015 To adjust square footage to agree with the provider's square footage workpaper. 42 CFR 413.24 and 413.50 / CMS Pub. 15-1, Sections 2300, 2304 and 2306 Page 8 This is trial version www.adultpdf.com State of California Department of Health Care Services Provider Name Fiscal Period Provider Number 35 MC530 Adj. Page or As Increase As No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted Adjustments GRAND PARK CONVALESCENT HOSPITAL JANUARY 1, 2008 THROUGH DECEMBER 31, 2008 ZZT06244I Report References Cost Report Audit Report Explanation of Audit Adjustments ADJUSTMENT TO OTHER MATTERS 35 Not Reported 1 14.00 Overpayments $0 $3,884 $3,884 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 Page 9 This is trial version www.adultpdf.com . 536 Not Reported 7 65.00 Dietary 0 2,0 41 2,0 41 11. 1 (1 of 3) 10 2 7 75.00 Patient Supplies 225 (19 ) 206 11 .1 (1 of 3) 35 2 7 10 0.00 Other Ancillary Services 2 31 (18 1) 50 Not Reported 7 16 0.00. 19 ,477 11 .1 (1 of 3) 85 2 7 N/A Total Statistics - Square Feet 15 ,605 3,6 41 19,246 11 .1 (1 of 3) 85 2 7 N/A Total Statistics - Square Feet 15 ,605 3, 410 19 , 015 To adjust square footage to agree. dental expense to the appropriate cost center. 42 CFR 413 .20 and 413 .24 CMS Pub. 15 -1, Sections 2300, 2302.4 and 2302.8 CCR, Title 22, Section 515 11( c) 16 10 .1( 4) 10 0 14 8A-2 10 0.00 Other Ancillary