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LONG-TERM CARE FACILITY
INTEGRATED DISCLOSURE AND MEDI-CAL COST REPORT
1 GENERAL INFORMATION AND CERTIFICATION
1. Legal Name of Facility: 2. State License Number: 3. Medi-Cal Provider Number:
4. D. B. A. (Doing Business As): 5. Facility Business Phone:
6. Facility Street Address: 7. City: 8. Zip Code:
9. Mailing Address - Street or P.O. Box (if different): 10. City: 11. Zip Code:
12. Administrator:
13. Report Contact Person: 14. Phone Number:
Ext:
15. Mailing Address - Street or P. O. Box: 16. City: 17. State: 18. Zip Code:
19. Previous Name of Facility if Changed Since Previous Report: 20. Date of Change:
21. Previous State License Number: 22. Date of Change: 23. Previous Medi-Cal Provider No.: 24. Date of Change:
25. Reporting Period Began: 26. Reporting Period Ended:
CERTIFICATION
I, ________________________________________________ , certify under penalty of perjury as follows: That I am an
(Name of Individual)
official of ___________________________________________ and am duly authorized to sign this certification; that the
Name of Facility (D.B.A.)
Office of Statewide Health Planning and Development's accounting and reporting system as set forth in the Office's
"Accounting and Reporting Manual for California Long-Term Care Facilities" has been implemented by this institution;
that as applicable, the data in the accompanying reports are based on that system; and that to the best of my knowledge
and information I believe each statement and amount in the accompanying report to be true and correct, and in
compliance with Section 51511.2, Title 22, California Code of Regulations.
Name of Facility (D.B.A.)
Dated: ________________________ By:
(Signature)
Title:
Address:
NOTICE
Please be advised that submission of cost reports for items or services which were not provided; are not reimbursable
under the Medi-Cal program; or are claimed in violation of an agreement with the state, may subject your organization to
civil money penalty assessment in accordance with Welfare and Institution Code, Section 14123.2.
All Facilities, mail original and two copies to: DO NOT MAIL ANY REPORT
Office of Statewide Health Planning and Development TO DEPARTMENT OF HEALTH SERVICES
Accounting and Reporting Systems Section
400 R Street, Room 250
Sacramento, CA 95811
Telephone: (916) 326-3854
CHFC 7041 h-1 & MC530 (12-00)
1
2.1 FACILITY DESCRIPTION AND OTHER GENERAL INFORMATION
Facility D.B.A. Name Report Period End
(1) (2) (3)
Line License Category Third Party Payor Programs Date Line
No. (Check Only One) (X) (Complete All That Apply) Certified (X) No.
1 Skilled Nursing Facility Medicare 1
2 Intermediate Care Facility Medi-Cal/SNF 2
3 SNF/Residential Medi-Cal/ICF 3
4 ICF/Residential Medi-Cal/MD 4
5 Congregate Living Health Facility Medi-Cal/DD 5
6 Short-Doyle 6
7 VA 7
8 Champus 8
9 Other (Describe) 9
Type of Control Legal Organization
(Check Only One) (X) (Check Only One) (X)
10 Church Related Corporation 10
11 Not-for-Profit Division of a Corporation 11
12 Investor Owned Partnership 12
13 Government: Proprietorship 13
14 State Other (Describe) 14
15 County
16 City/County
17 City
18 District
Describe any items which management believes may have a significant effect on the data in this report:
25
26
27
28
29
30
CHFC 7040 h-2 & MC530 (12-00)
2.2 SERVICES INVENTORY
Line (1) Line
No. Health Services Code * No.
1 Pharmacy 1
2 Patient supplies 2
3 Laboratory 3
4 Radiology 4
5 Physical therapy 5
6 Inhalation therapy 6
7 Speech therapy 7
8 Occupational therapy 8
9 Audiology 9
10 Prosthetic devices 10
11 Social services 11
12 Physician care 12
13 Dental care 13
14 Podiatric care 14
15 Chiropractic care 15
16 Optometric care 16
17 Psychiatric care 17
18 Recreation/Activity 18
19 Alcoholism/Substance abuse treatment and recovery 19
20 Home health 20
21 Hospice 21
22 Long-term rehabilitation 22
23 Patient education 23
24 Adult day health care 24
25 Other (Describe) 25
26 26
27 27
CHFC 7041 h-3 (12-00)
* CODE EXPLANATION: Enter appropriate code in column 1 for every item.
1 - Service MAINTAINED in facility and staffed by facility personnel. Related 4 - Service NOT MAINTAINED in facility but available from an outside provider
expenses reported on Page 10.1, columns 1,2, and 3. under contract arrangement whereby patients or third party payors are
billed directly by the outside provider.
2 - Service MAINTAINED in facility and purchased by the facility under contract 5 - Service NOT MAINTAINED in facility and no formal referral agreement exists
arrangement with an outside provider. Related expenses reported on with an outside provider. Patients or responsible third party payors who
Page 10.1, column 3. independently purchase services are billed directly by the provider.
3 - Service NOT MAINTAINED in facility but available from an outside provider under 6 - Service MAINTAINED, but not used during reporting cycle.
contract arrangement whereby facility is billed directly by the provider.
Related expenses reported on Page 10.1, column 3.
2.1/2.2
0 (12-00)
3 (12-00)
ment exists
3.1 RELATED PERSONS AND ORGANIZATIONS AND OTHER INFORMATION
Facility D.B.A. Name Report Period End
The purpose of this schedule is to identify the facility's transactions during the current reporting period with related persons or organizations related by
common ownership or control as defined in Title 42, Code of Federal Regulations (CFR), Section 413.17. For an explanation of related party control
see the instructions for this form.
A. Are there any costs or revenues included in the Statement of Income for the current period which are a result of transactions with related
persons or organizations as defined in the instructions? (Exclude compensation of owners and their relatives reported in Item G).
5. Yes No (If "Yes", complete Item A1)
A1. List below those transactions referred to in A.
RELATED PARTY TRANSACTIONS - STATEMENT OF INCOME
(1) (2) (3) (4)
Related Transaction Amount
Account Title Party Service or Supply DR/(CR)
10. $
11.
12.
13.
14.
B. Are there any assets or liabilities which are included in the Balance Sheet for the current period which are a result of transactions
with related persons or ororganizations as defined in the instructions for this form?
Yes No (If "Yes", complete Item B1)
B1. List below those transactions referred to in B.
RELATED PARTY TRANSACTIONS - BALANCE SHEET
(1) (2) (3)
Related Transaction Amount
Account Title Party DR/(CR)
40. $
41.
42.
43.
44.
C. Is this facility part of an organization with two or more health facilities under common ownership or control, as defined in the
instructions for this form ?
60. Yes No (If "Yes", complete Items D and F, if "No" proceed to Item H)
D. Is this facility a:
65. Parent Subsidiary Division Other (If Subsidiary or Division, complete Item E)
1 2 3 4
E. Name and address of parent organization:
70. Name:
75. Address:
76. City: 77. State: 78. Zip:
F. NAME, ADDRESS AND PERCENT OF OWNERSHIP OF HEALTH FACILITIES UNDER COMMON OWNERSHIP OR CONTROL
(1) (2) (3)
Percent of
Name Address Ownership
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
CHFC 7041 h-4 & MC530 (12-00)
3.1
3.2 RELATED PERSONS AND ORGANIZATIONS AND OTHER INFORMATION
Facility D.B.A. Name Report Period End
G. STATEMENT OF COMPENSATION FOR OWNERS AND THEIR RELATIVES*
(1) (2) (3) (4) (5)
Average
Hours per Compensation
Percent Work Week Included in
of Devoted to Costs This
Name Title and Function Ownership Business Period**
100. $
101.
102.
103.
* Owner means any individual having a 5% or more equity interest, direct or indirect, in the entity licensed as a health facility as defined in 42 CFR 455.101
and 455.102. An owner's relatives are defined as: spouse, son, daughter, grandchild, great-grandchild, stepchild, brother, sister, half-brother, half-sister,
stepbrother, stepsister, parent, grandparent, great-grandparent, stepmother, stepfather, niece, nephew, aunt, uncle, son-in-law, daughter-in-law, mother-
in-law, father-in-law, brother-in-law, or sister-in law.
** Compensation as used in this schedule has the same definition as in 42 CFR 413.102 and refers to cash, personal benefits, cost of assets or services
used, deferred compensation, or other consideration, including non-monetary, given in exchange for services provided to the organization.
H. NAMES OF OWNERS HAVING A 5% OR MORE EQUITY INTEREST
140. 145.
141. 146.
142. 147.
143. 148.
144. 149.
I. GOVERNING BOARD OFFICERS AND MEMBERS
(1) (2) (3)
Name Occupation Compensation*
160. $
161.
162.
163.
164.
165.
* Amount received from all sources for services rendered as a board member.
J. STATEMENT OF COMPENSATION PAID TO ADMINISTRATORS AND/OR ASSISTANT ADMINISTRATORS (OTHER THAN OWNERS)
(1) (2) (3) (4) (5)
Average
hours per
Work Week
Devoted to Compensation Compensation
Name Title and Duties Performed Business This Period Prior Period
180. $ $
181.
182.
K. Does the facility use a Management Company?
185. Yes No (If "Yes" provide the following information. If "No", proceed to M)
195. Name of Management Company:
200. Address:
205. City: 215. State: 220. Zip:
221. Telephone Number:
NAMES OF MANAGEMENT COMPANY OWNERS HAVING MORE THAN 5% EQUITY INTEREST
222. 226.
223. 227.
224. 228.
225. 229.
CHFC 7041 h-4 & MC530 (12-00)
3.2
3.3 RELATED PERSONS AND ORGANIZATIONS AND OTHER INFORMATION
Facility D.B.A. Name Report Period End
FOR MEDI-CAL PROVIDERS, ONLY
M. Are Financial Statements available for the reporting period?
325. Yes (If "Yes", please enclose a copy) No (If "No", enclose a copy of your working trial balance)
N. Is this report being filed as a result of a change in ownership?
335. Yes No
(IF "YES" ATTACH A COPY OF THE SALES AGREEMENT SHOWING THE ALLOCATION OF THE SALES PRICE TO THE ASSETS)
O. STATEMENT OF HOME OFFICE (PARENT) COSTS
(1) (2) (3) (4)
Account Description Account Number Amount Explanation of Allocations
INTERIM PERIOD HOME OFFICE COST ALLOCATIONS :
340. $
341.
342.
343. Subtotal Interim Period (Sum of lines 340 through 342) $
YEAR END HOME OFFICE COST ALLOCATIONS :
344. $
347. Subtotal Year End (Sum of lines 344 through 346) $
348. TOTAL HOME OFFICE COST ALLOCATIONS (Sum of lines 343 and 347) $
HOME OFFICE EQUITY ALLOCATIONS :
ASSET
349. $
350.
LIABILITY
351. $
352.
353. TOTAL EQUITY ALLOCATIONS (Sum lines 349 through 352) $
P. Were any assets disposed of during the reporting period?
355. Yes No
If "Yes" attach a schedule showing: (a) description of asset, (b) date of sale, (c) date asset(s) acquired, (d) proceeds of disposition, (e) method of
depreciation, (f) how gain or loss was computed, (g) where gain or loss is reflected in the report, (h) if asset(s) was transferred to a related party,
give book value of asset(s) on transfer date and party to whom asset(s) was transferred.
Q. Does your facility handle patient monies either through a patient trust fund or a savings and loan association or other financial institution?
360. Yes No
(If "Yes" and through a savings and loan, include the name and address on lines 365 through 369 below.)
(If "Yes" and through a standard trust system, complete lines 370 through 375)
365. Name:
366. Address:
367. City: 368. State: 369. Zip:
PATIENT TRUST ACTIVITY ACCOUNT
370. Balance of Trust Account at beginning of the reporting period $
371. Total Deposits to the Trust Account during the reporting period, not including interest
372. Interest Added / Earned
373. Total Deposits and Interest (Sum of lines 371 and 372) $
374. Total Trust Account Expenditures
375. Balance of Trust Account at the end of the reporting period (Lines (370+373) - 374) $
CHFC 7041 h-4 & MC530 (12-00)
3.3
4.1 FACILITY PATIENT DAYS BY PAYER
Facility D.B.A. Name Report Period End
(1) (2) (3) (4) (5) (6)
Line Managed Other Total
No. PATIENT (Census) DAYS Medicare Medi-Cal Self -Pay Care Payers (Cols. 1 - 5)
Routine Services:
5 Skilled Nursing Care
10 Intermediate Care
15 Mentally Disordered Care
20 Developmentally Disabled Care
25 Sub-Acute Care
30 Sub-Acute Care - Pediatric
35 Transitional Inpatient Care
40 Hospice Inpatient Care
45 Other Routine Services
70 Subtotal (Lines 5 through 45)
CHFC 7041f-1 & MC530 (12-00)
4.1
4.2 FACILITY REVENUE INFORMATION
Facility D.B.A. Name Report Period End
Medicare Medi-Cal Self-Pay Managed Care Other Payers Total
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12)
Line GROSS REVENUE Account Inpatient Outpatient Inpatient Outpatient Inpatient Outpatient Inpatient Outpatient Inpatient Outpatient Inpatient Outpatient
No. Number .04 .44 .05 .45 .00 .40 .01 .41 .09 .49 (cs. 1,3,5,7,9) (cs. 2,4,6,8,10)
Routine Services:
5 Skilled Nursing Care 3100
10 Intermediate Care 3200
15 Mentally Disordered Care 3300
20 Developmentally Disabled Care 3400
25 Sub-Acute Care 3500
30 Sub-Acute Care - Pediatric 3600
35 Transitional Inpatient Care 3700
40 Hospice Inpatient Care 3800
45 Other Routine Services 3900
70 Subtotal (Lines 5 through 45)
Ancillary Services:
105 Patient Supplies 4100
110 Specialized Support Surfaces 4150
115 Physical Therapy 4200
4.2
120 Respiratory Therapy 4220
125 Occupational Therapy 4250
130 Speech Pathology 4280
135 Pharmacy 4300
140 Laboratory 4400
145 Home Health Services 4800
155 Other Ancillary Services 4900
170 Subtotal (Lines 105 through 155)
175 Total (Lines 70 and 170)
Line DEDUCTIONS FROM Account (1)
No. REVENUE Number Amount
205 Charity Adjustments 5100
210 Administrative Adjustments 5200
CHFC 7041f-1 & MC530 (12-00)
215 Contractual Adjustments -
Medicare 5310
220 Contractual Adjustments -
Medi-Cal 5320
222 Contractual Adjustments -
Managed Care 5330
225 Contractual Adjustments - Other 5340
230 Other Deductions from Revenue 5400
240 Total (Lines 205 through 230)
4.3 OTHER CENSUS AND REVENUE INFORMATION
Facility D.B.A. Name Report Period End
Line OTHER CENSUS INFORMATION (1) Line
No. Number No.
Licensed Beds:
005 End of Period 005
010 Average (Monthly average) 010
Available Beds:
020 End of Period 020
025 Average (Monthly average) 025
040 Admissions (Excluding transfers) 040
045 Discharges (Excluding transfers) 045
Occupancy Rate
060 (Page 4.1, line 70, column 6 / (Line 10 X days in reporting period) X 100) % 060
Line PATIENT (CENSUS) DAYS DETAIL FOR SPECIAL CARE PROGRAMS (1) (2) Line
No. Total Medi-Cal No.
100 Sub-Acute Care (Ventilator-Dependent) 100
115 Other Sub-Acute Care 115
Total Sub-Acute Care Patient (Census) Days
120 (Sum of lines 100 and 115) 120
130 Sub-Acute Care - Pediatric (Ventilator-Dependent) 130
145 Other Sub-Acute Care - Pediatric 145
150 Total Sub-Acute Care - Pediatric Patient (Census) Days
(Sum of lines 130 and 145) 150
165 Transitional Inpatient Care - Medical 165
170 Transitional Inpatient Care - Rehabilitation 170
175 (Sum of lines 160 and 165) 175
FOR MEDI-CAL PROVIDERS, ONLY
Line RECAP OF MEDI-CAL BENEFITS RECEIVED FROM FISCAL INTERMEDIARY (1) Line
No. Amount No.
200 Total Billed Charges - Medi-Cal (Net of contractual adjustments) $ 200
205 Less: Patient Liability ( ) 205
210 Third Party and Other Liability ( ) 210
215 Noncovered Charges ( ) 215
240 Other ( ) 240
250 Net Medi-Cal Received / Receivable from Fiscal Intermediary (Combine lines 200 through 240) 250
CHFC 7041h-5 & MC530 (12-00)
4.3
5.1 BALANCE SHEET - GENERAL FUND
Facility D.B.A. Name Report Period End
(1) (2)
Line ASSETS Account Current Reporting Prior Reporting Line
No. Numbers Period Period No.
CURRENT ASSETS
005 Cash 1000 $ $ 005
010 Marketable securities - at cost 1010 010
015 Assets whose use is limited - required for current liabilities (must agree with line 85) 015
020 Accounts and notes receivable 1020 020
025 Less estimated allowances for uncollectibles and contractual adjustments 1040 ( ) ( ) 025
030 Receivables from third party payors for contract settlement 1050 030
035 Pledges and other receivables 1060 035
040 Due from restricted funds 1070 040
045 Inventories - at lower of cost or market 1080 045
050 Receivables from related parties, current 1090 050
055 Prepaid expenses and other current assets 1100 055
060 TOTAL CURRENT ASSETS (Sum of lines 5 through 55) $ $ 060
ASSETS WHOSE USE IS LIMITED
065 Cash 1160 065
070 Marketable securities 1170 070
075 Other assets 1180 075
080 TOTAL ASSETS WHOSE USE IS LIMITED (Sum of lines 65 through 75) $ $ 080
085 Less assets whose use is limited and that are required for current liabilities ( ) ( ) 085
090 TOTAL NONCURRENT ASSETS WHOSE USE IS LIMITED (Line 80 less line 85) $ $ 090
PROPERTY, PLANT, AND EQUIPMENT
095 Land 1200 $ $ 095
100 Land improvements 1210 100
105 Buildings and improvements 1220 105
110 Less accumulated depreciation - buildings and improvements, land improvements 1270 ( ) ( ) 110
115 Leasehold improvements 1230 115
120 Less accumulated depreciation - leasehold improvements 1280 ( ) ( ) 120
125 Equipment 1240 125
130 Less accumulated depreciation - equipment 1290 ( ) ( ) 130
135 NET PROPERTY, PLANT, AND EQUIPMENT (Sum of lines 95 through 130) $ $ 135
140 Construction-in-progress 1250 $ $ 140
INVESTMENTS AND OTHER ASSETS
145 Investments in property, plant, and equipment 1310 $ 145
150 Less accumulated depreciation - investments in property, plant, and equipment 1320 ( ) ( ) 150
155 Other investments - at cost 1330 155
160 Receivables from related parties, noncurrent 1340 160
165 Deposits and other assets 1350 165
170 TOTAL INVESTMENTS AND OTHER ASSETS (Sum of lines 145 through 165) $ $ 170
INTANGIBLE ASSETS
175 Goodwill 1360 $ $ 175
180 Unamortized loan costs 1370 180
185 Organizational costs 1380 185
190 Other intangible assets 1390 190
195 TOTAL INTANGIBLE ASSETS (Sum of lines 175 through 190) $ $ 195
200 TOTAL ASSETS (Sum of lines 60, 90, 135, 140, 170, and 195) (must agree with Page 5.2, line 185) $ $ 200
(1) (2)
OTHER INFORMATION Current Reporting Prior Reporting
Period Period
205 Current market value - current asset marketable securities (Line 10) $ $ 205
210 Current market value - other investments (Line 155) 210
215 Cost to complete construction in progress (Line 140) 215
CHFC 7041a-1& MC530 (12-00)
5.1(1)
5.1 BALANCE SHEET - GENERAL FUND
Medi-Cal Adjustments and Reclassifications Worksheet
(Medi-Cal Proprietary Facilities, Only)
Facility D.B.A. Name Report Period End
(3) * (4) ** (5)
Line ASSETS Adjustments and Adjusted Balance Adjusted Balance Line
No. Reclassifications Current Period Prior Period No.
CURRENT ASSETS
005 Cash $ $ $ 005
010 Marketable securities - at cost 010
015 Assets whose use is limited - required for curr. liabilities (must agree with ln. 85) 015
020 Accounts and notes receivable 020
025 Less estimated allowances for uncollectibles and contractual adjustments ( ) ( ) 025
030 Receivables from third party payors for contract settlement 030
035 Pledges and other receivables 035
040 Due from restricted funds 040
045 Inventories - at lower of cost or market 045
050 Receivables from related parties, current ( ) 050
055 Prepaid expenses and other current assets 055
060 TOTAL CURRENT ASSETS (Sum of lines 5 through 55) $ $ $ 060
ASSETS WHOSE USE IS LIMITED
065 Cash 065
070 Marketable securities 070
075 Other assets 075
080 TOTAL ASSETS WHOSE USE IS LIMITED (Sum of lines 65 through 75) $ $ $ 080
085 Less assets whose use is limited and that are required for current liabilities ( ) ( ) 085
090 TOTAL NONCURR. ASSETS WHOSE USE IS LIMITED (Ln. 80 less ln. 85) $ $ $ 090
PROPERTY, PLANT, AND EQUIPMENT
095 Land $ $ $ 095
100 Land improvements 100
105 Buildings and improvements 105
110 Less accumulated deprec. - buildings and improvements, land improvements ( ) ( ) 110
115 Leasehold improvements 115
120 Less accumulated depreciation - leasehold improvements ( ) ( ) 120
125 Equipment 125
130 Less accumulated depreciation - equipment ( ) ( ) 130
135 NET PROPERTY, PLANT, AND EQUIPMENT (Sum of lines 95 through 130) $ $ $ 135
140 Construction-in-progress $ $ $ 140
INVESTMENTS AND OTHER ASSETS
145 Investments in property, plant, and equipment $ $ $ 145
150 Less accumulated depreciation - investments in property, plant, and equipment ( ) ( ) 150
155 Other investments - at cost 155
160 Receivables from related parties, noncurrent 160
165 Deposits and other assets 165
170 TOTAL INVESTMENTS AND OTHER ASSETS (Sum of lns. 145 thru 165) $ $ $ 170
INTANGIBLE ASSETS
175 Goodwill $ $ $ 175
180 Unamortized loan costs 180
185 Organizational costs 185
190 Other intangible assets 190
195 TOTAL INTANGIBLE ASSETS (Sum of lines 175 through 190) $ $ $ 195
200 TOTAL ASSETS (Sum of lns. 60, 90, 135, 140, 170, & 195)(must agree with P. 5.2, ln. 185) $ $ $ 200
* From Page 5.4 CHFC 7041a-1& MC530 (12-00)
** Combine Columns 1 and 3
5.1(2)
5.2 BALANCE SHEET - GENERAL FUND
Facility D.B.A. Name Report Period End
(1) (2)
Line LIABILITIES AND EQUITY Account Current Reporting Prior Reporting Line
No. Numbers Period Period No.
CURRENT LIABILITIES
005 Notes and loans payable 2000 $ $ 005
010 Accounts payable 2010 010
015 Accrued compensation and related liabilities 2020 015
020 Other accrued liabilities 2030 020
025 Advances from third party payors 2040 025
030 Payable to third party payors for contract settlement 2050 030
035 Due to restricted funds 2060 035
040 Income taxes payable 2070 040
045 Payables to related parties, current 2080 045
050 Current maturities of long term debt (Must agree with line 125) 050
055 Other current liabilities 2090 055
060 TOTAL CURRENT LIABILITIES (Sum of lines 5 through 55) $ $ 060
DEFERRED CREDITS
065 Deferred income taxes 2110 $ $ 065
070 Deferred third-party income 2120 070
075 Other deferred credits 2130 075
080 TOTAL DEFERRED CREDITS (Sum of lines 65 through 75) $ $ 080
LONG-TERM DEBT
085 Mortgages payable 2210 $ $ 085
090 Construction loans 2220 090
095 Notes under revolving credit 2230 095
100 Capitalized lease obligations 2240 100
105 Bonds payable 2250 105
110 Payable to related parties, noncurrent 2260 110
115 Other noncurrent liabilities 2270 115
TOTAL LONG-TERM DEBT
120 (Sum of ls. 85 thru 115)(Must include current maturities) $ $ 120
125 Less amount shown as current maturities (Must agree with line 50) ( ) ( ) 125
130 NET LONG-TERM DEBT (Line 120 minus 125) $ $ 130
135 TOTAL LIABILITIES (Sum of lines 60, 80, and 130) $ $ 135
FUND EQUITY (not-for-profit)
140 General fund balance 2410 & 2430 $ $ 140
145 Divisional fund balance 2460 145
EQUITY (investor-owned)
150 Preferred stock 2410 150
155 Common stock 2420 155
160 Additional paid-in capital 2430 160
165 Retained earnings / Capital account for partnership or sole proprietorship 2440 / 2410 165
170 Less treasury stock 2450 ( ) ( ) 170
175 Divisional equity 2460 175
180 TOTAL EQUITY 180
(Sum of lines 140 through 175)(Column 1 must agree with Page 7, col. 1, line 32) $ $
TOTAL LIABILITIES AND EQUITY
185 (Sum of lines 135 and 180) (Must agree with Page 5.1, line 200) $ $ 185
CHFC 7041a-1&MC530 (12-00)
5.2(1)
5.2 BALANCE SHEET - GENERAL FUND
Medi-Cal Adjustments and Reclassifications Worksheet
(Medi-Cal Proprietary Facilities, Only)
Facility D.B.A. Name Report Period End
(3) * (4) ** (5)
Line LIABILITIES AND EQUITY Adjustments and Adjusted Balance Adjusted Balance Line
No. Reclassifications Current Period Prior Period No.
CURRENT LIABILITIES
005 Notes and loans payable $ $ $ 005
010 Accounts payable 010
015 Accrued compensation and related liabilities 015
020 Other accrued liabilities 020
025 Advances from third party payors 025
030 Payable to third party payors for contract settlement 030
035 Due to restricted funds 035
040 Income taxes payable 040
045 Payables to related parties, current 045
050 Current maturities of long term debt (Must agree with line 125) 050
055 Other current liabilities 055
060 TOTAL CURRENT LIABILITIES (Sum of lines 5 through 55) $ $ $ 060
DEFERRED CREDITS
065 Deferred income taxes $ $ $ 065
070 Deferred third-party income 070
075 Other deferred credits 075
080 TOTAL DEFERRED CREDITS (Sum of lines 65 through 75) $ $ $ 080
LONG-TERM DEBT
085 Mortgages payable $ $ $ 085
090 Construction loans 090
095 Notes under revolving credit 095
100 Capital lease obligations 100
105 Bonds payable 105
110 Payable to related parties, noncurrent 110
115 Other noncurrent liabilities 115
TOTAL LONG-TERM DEBT
120 (Sum of ls. 85 thru 115)(Must include current maturities) $ $ $ 120
125 Less amounts shown as current maturities (Must agree with line 50) ( ) ( ) 125
130 NET LONG-TERM DEBT (Line 120 minus 125) $ $ $ 130
135 TOTAL LIABILITIES (Sum of lines 60, 80, and 130) $ $ $ 135
FUND EQUITY (not-for-profit)
140 General fund balance $ $ $ 140
145 Divisional fund balance 145
EQUITY (investor-owned)
150 Preferred stock 150
155 Common stock 155
160 Additional paid-in capital 160
165 Retained earnings / Capital account for partnership or sole proprietorship 165
170 Less treasury stock ( ) ( ) 170
175 Divisional equity 175
TOTAL EQUITY
180 (Sum of lines 140 through 175)(Column 1 must agree with Page 7, col. 5, line 32) $ $ $ 180
TOTAL LIABILITIES AND EQUITY
185 (Sum of lines 135 and 180) (Must agree with Page 5.1, line 200) $ $ $ 185
* From Page 5.4 CHFC 7041a-1(12-00)
** Combine Columns 1 and 3
5.2(2)
5.3 SUPPLEMENTAL LONG-TERM DEBT INFORMATION
Facility D.B.A. Name Report Period End
(1) (2) (3) (4) (5) (6)
Detail for Date Obligation
Line Page 5.2 Incurred Principal Amount at Due Date (*) Interest Line
No. Column 1, Line No. (Year Only) Date of Obligation (Year Only) Rate (*) Unpaid Principal (**) No.
1 $ . $ 1
2 . 2
3 . 3
4 . 4
5 . 5
6 . 6
7 . 7
8 . 8
9 . 9
10 . 10
11 . 11
12 . 12
13 . 13
14 . 14
15 . 15
16 . 16
17 . 17
18 . 18
19 . 19
20 . 20
(*) If more than one due date or interest rate, list each with unpaid principal amount.
Report interest rates to two decimal places. CHFC 7041a-2 & MC530 (12-00)
(**) Sum of all lines must agree with Page 5.2, column 1, line 120.
5.4 ADJUSTMENTS AND RECLASSIFICATIONS TO
BALANCE SHEET FOR COMPUTATION OF RETURN ON
EQUITY CAPITAL
MEDI-CAL PROVIDERS, ONLY
(1) (2) (3) (4)
Page 5.1 and AMOUNT
Line DESCRIPTION Page 5.2 Increase EXPLANATION OF ADJUSTMENT Line
No. Line No. (Decrease) No.
1 $ 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 25
26 26
27 27
28 28
29 29
30 30
50 Total (Combine lines 1 through 30) $ 0 50
MC530 (12-00)
5.3/5.4
6 BALANCE SHEET - RESTRICTED FUNDS
Facility D.B.A. Name Report Period End
(1) (2) (3) (4)
Line ASSETS Account Current Prior Line Line LIABILITIES AND FUND BALANCES Account Current Prior Line
No. Number Period Period No. No. Number Period Period No.
PLANT REPLACEMENT AND EXPANSION FUNDS PLANT REPLACEMENT AND EXPANSION FUNDS
005 Cash (Including CD's) 1710 $ $ 005 005 Due to other funds 2710-2730 $ $ 005
Investments, at cost:
010 Marketable securities ($_______________)* 1720 010
015 Other ($________________)* 1720 015
020 Pledges and receivables 1730 020
025 Due from other funds 1740 025 Fund balance
030 Other assets 1750 030 045 (Column 3 must agree with Page 7, column 2, line 32) 2770 045
TOTAL ASSETS TOTAL LIABILITIES AND FUND BALANCE
050 (Sum of lines 5 through 30) $ $ 050 050 (Sum of lines 5 and 45) $ $ 050
SPECIFIC PURPOSE FUNDS SPECIFIC PURPOSE FUNDS
105 Cash (Including CD's) 1810 $ $ 105 105 Due to other funds 2810-2830 $ $ 105
110 Marketable securities at cost ($______________)* 1820 110
115 Pledges and receivables 1830 115
6
120 Due from other funds 1840 120 Fund balance
125 Other assets 1850 125 145 (Column 3 must agree with Page 7, column 3, line 32) 2870 145
TOTAL ASSETS TOTAL LIABILITIES AND FUND BALANCE
150 (Sum of lines 105 through 125) $ $ 150 150 (Sum of lines 105 and 145) $ $ 150
ENDOWMENT FUNDS ENDOWMENT FUNDS
205 Cash (Including CD's) 1910 $ $ 205 205 Mortgages 2910 $ $ 205
Investments, at cost: 210 Other liabilities (Specify) 2920 210
210 Marketable securities ($_______________)* 1920 210 215 Due to other funds 2930-2950 215
215 Other ($_______________)* 1920 215
CHFC 7041b-1 & MC530 (12-00)
220 Pledges and receivables 1930 220
225 Due from other funds 1940 225 Fund balance
230 Other assets 1950 230 245 (Column 3 must agree with Page 7, column 4, line 32) 2970 245
TOTAL ASSETS TOTAL LIABILITIES AND FUND BALANCE
250 (Sum of lines 205 through 230) $ $ 250 250 (Sum of lines 205 through 245) $ $ 250
* Include Market Value at Current Year Balance Sheet Date in Parentheses.
7 STATEMENT OF CHANGES IN EQUITY
Facility D.B.A. Name Report Period End
GENERAL FUND EXTERNALLY RESTRICTED FUNDS
(1) (2) (3) (4)
Plant
Replacement
Line Total and Specific Line
No. Equity Expansion Purpose (A) Endowment No.
BALANCE AT BEGINNING OF YEAR,
1 AS PREVIOUSLY REPORTED $ $ $ $ 1
2 Prior period audit adjustments 2
3 Restatements (describe) 3
4 4
5 5
6 6
RESTATED BEGINNING BALANCE*
7 (Combine lines 1 through 6) $ $ $ $ 7
Additions (deductions):
8 Net income (loss) $ 8
9 Capital contributions 9
10 Proceeds from sale of stock 10
11 Owners' draw ( ) 11
12 Restricted contributions and grants $ $ $ 12
13 Restricted investment income 13
14 Expenditures for specific purposes ( ) ( ) ( ) 14
15 Dividends declared ( ) 15
16 Donated property, plant, and equipment 16
17 Acquisitions of pooled companies 17
18 Stock options exercised 18
19 Related party transfers 19
20 Unrealized losses on Marketable Equity Securities 20
21 Other (describe) 21
22 22
TOTAL ADDITIONS (DEDUCTIONS)
23 (Combine lines 8 through 22) $ $ $ $ 23
Transfers:
25 Property and equipment additions $ $( ) $( ) $( ) 25
26 Principal payments on long-term debt ( ) ( ) ( ) 26
27 Other (describe) 27
28 28
29 29
30 30
TOTAL TRANSFERS
31 (Combine lines 25 through 30) $ $ $ $ 31
BALANCE AT END OF YEAR**
32 (Combine lines 7, 23, and 31) $ $ $ $ 32
* Column 1, line 7 must agree with Page 5.2, column 2, line 180. CHFC 7041c-1 & MC530 (12-00)
Column 2, line 7 must be equal to Page 6, column 4, line 45.
Column 3, line 7 must agree with Page 6, column 4 line 145.
Column 4, line 7 must agree with Page 6, column 4, line 245.
** Column 1, line 32 must agree with Page 5.2, column 1 , line 180.
Column 2, line 32 must agree with Page 6, column 3, line 45.
Column 3, line 32 must agree with Page 6, column 3, line 145.
Column 4, line 32 must agree with Page 6, column 3, line 245.
(A) District Facilities - Include Bond Interest and Redemption.
7
8 STATEMENT OF INCOME - GENERAL FUND
Facility D.B.A. Name Report Period End
(1) (2)
Line DESCRIPTION Account Current Prior Line
No. No. Period Period No.
HEALTH CARE REVENUES :
005 Gross Routine Services Revenue P.4.2 Col.11 Ln.70 $ $ 005
007 Gross Ancillary Services Revenue P.4.2 Col.11 plus 12 Ln.170 007
010 Less: Deductions from Revenue P.4.2 Col.1 Ln.240 010
015 NET PATIENT SERVICE REVENUE Line 5 + Line 7 - Line 10 $ $ 015
020 Other Operating Revenue from Health Care Operations From P.10.2, Line 100 $ $ 020
025 NET OPERATING REVENUE FROM HEALTH CARE OPERATIONS Lines 15 + 20 $ $ 025
HEALTH CARE EXPENSES :
Routine Services:
030 Skilled Nursing Care 6110 $ $ 030
035 Intermediate Care 6120 035
040 Mentally Disordered Care 6130 040
045 Developmentally Disabled Care 6140 045
050 Sub-Acute Care 6150 050
051 Sub-Acute Care - Pediatric 6160 051
053 Transitional Inpatient Care 6170 053
055 Hospice Inpatient Care 6180 055
060 Other Routine Services 6190 060
065 Total Routine Services Lines 30 through 60 $ $ 065
Ancillary Services :
070 Patient Supplies 8100 $ 070
072 Specialized Support Surfaces 8150 072
075 Physical Therapy 8200 075
076 Respiratory Therapy 8220 076
077 Occupational Therapy 8250 077
078 Speech Pathology 8280 078
080 Pharmacy 8300 080
085 Laboratory 8400 085
090 Home Health Services 8800 090
095 Other Ancillary Services 8900 095
100 Total Ancillary Services Lines 70 through 95 $ $ 100
Support Services :
105 Plant Operations and Maintenance 6200 $ 105
110 Housekeeping 6300 110
115 Laundry and Linen 6400 115
120 Dietary 6500 120
125 Social Services 6600 125
130 Activities 6700 130
135 Inservice Education - Nursing 6800 135
140 Administration 6900 140
145 Total Support Services Lines 105 through 140 $ $ 145
Property Expenses :
155 Depreciation and Amortization 7110 through 7160 $ $ 155
160 Leases and Rentals 7200 160
165 Property Taxes 7300 165
170 Property Insurance 7400 170
175 Interest - Property, Plant, and Equipment 7500 175
180 Total Property Expenses Lines 155 through 175 $ $ 180
Other Expenses :
185 Interest - Other 7600 $ $ 185
190 Provision for Bad Debts 7700 190
195 Total Other Expenses Lines 185 + 190 $ $ 195
Sum of lines 65, 100,
200 TOTAL HEALTH CARE EXPENSES 145, 180, & 195 $ $ 200
205 INCOME (LOSS) FROM HEALTH CARE OPERATIONS Line 25 less line 200 $ $ 205
210 NONHEALTH CARE REVENUE AND EXPENSE+ NET * 9100 $ $ 210
INCOME (LOSS) BEFORE INCOME TAXES AND
215 EXTRAORDINARY ITEMS Lines 205 + 210 $ $ 215
PROVISION FOR INCOME TAXES:
220 Current 9200 $ $ 220
225 Deferred 9200 225
230 Total Income Taxes Lines 220 + 225 $ $ 230
235 INCOME (LOSS) BEFORE EXTRAORDINARY ITEMS Lines 215 - 230 $ $ 235
EXTRAORDINARY ITEMS: (Describe)
240 9300 $ $ 240
245 9300 245
250 Total Extraordinary Items Lines 240 + 245 $ $ 250
255 NET INCOME (LOSS) Lines 235 - 250 $ $ 255
CHARITY CARE FOOTNOTE
260 Forgone charges at Established Rates $ $ 260
265 Total Number of Charity Days 265
CHFC 7041d-1 & MC530 (12-00)
* Check this box if line 210 includes Residential Revenues and Expenses.
8
9 STATEMENT OF CASH FLOWS - GENERAL FUND
Facility D.B.A. Name Report Period End
(1) (2)
Line Current Period Prior Period Line
No. No.
Cash Flows from Operating Activities and Nonoperating Revenue :
005 Net Income (Loss) (Must agree with Page 8, line 255) $ $ 005
Adjustments to reconcile net income to net cash provided by (used for )
operating activities and nonoperating revenue :
010 Depreciation and amortization $ $ 010
015 Change in marketable securities 015
Change in accounts and notes receivable, net of allowances for
020 doubtful accounts and contractual adjustments 020
025 Change in receivables from third-party payors 025
030 Change in other receivables 030
035 Change in due from restricted funds 035
040 Change in inventory, prepaid expenses and other current assets 040
045 Change in accounts payable 045
050 Change in accrued compensation and related liabilities 050
055 Change in other accrued liabilities 055
060 Change in advances from third-party payors 060
065 Change in payables to third-party payors 065
070 Change in due to restricted funds 070
075 Change in income taxes payable and other current liabilities 075
080 Change in deferred credits 080
085 Change in related party receivables/payables (related to operating activities) 085
090 Other (describe) 090
095 Total adjustments (Sum of lines 10 through 90) 095
Net cash provided by (used for) operating activities
100 (Sum of lines 5 and 95) $ $ 100
Cash Flows from Investing Activities :
105 Change in assets whose use is limited 105
110 Purchase of property, plant, and equipment and increase in construction in progress 110
115 Other (describe) 115
120 120
125 125
130 130
135 135
Net cash provided by (used for) investing activities
140 (Sum of lines 105 through 135) $ $ 140
Cash Flows from Financing Activities :
145 Proceeds from issuance of long-term debt 145
150 Principal payments on long-term debt 150
155 Proceeds from issuance of notes and loans 155
160 Principal payments on notes and loans 160
165 Dividends paid 165
170 Proceeds from issuance of common stock 170
175 Other (describe) 175
180 180
185 185
190 190
195 195
Net cash provided by (used for) financing activities
200 (Sum of lines 145 through 195) $ $ 200
Net increase (decrease) in cash
205 (Lines 100 + 140 + 200) $ $ 205
Cash at beginning of period
210 (Column 1 must agree with column 2, line 215 and Page 5.1, column 2, line 5) $ $ 210
Cash at end of period
215 (Lines 205 + 210) (Column 1 must agree with Page 5.1, column 1, line 5) $ $ 215
CHFC 7041c-1 & MC530 (12-00)
9
10.1(1) EXPENSE TRIAL BALANCE WORKSHEET
Facility D.B.A. Name Report Period End
ALL FACILITIES
(1) (2) (3) (4)
Salaries Total
Line ACCOUNT Account and Employee Other Expenses
No. TITLE Number Wages* Benefits Expenses (Sum of Cs. 1, 2, 3)
005 Plant Operations and Maintenance 6200 $ $ $ $
010 Housekeeping 6300
015 Depreciation - Buildings and Improvements 7110-7120
020 Depreciation - Leasehold Improvements 7130
025 Depreciation - Equipment 7140
030 Depreciation and Amortization - Other 7150-7160
035 Leases and Rentals 7200
040 Property Taxes 7300
045 Property Insurance 7400
050 Interest - Property, Plant, and Equipment 7500
055 Interest - Other 7600
060 Laundry and Linen 6400
065 Dietary 6500
070 Provision for Bad Debts 7700
Ancillary Services:
075 Patient Supplies 8100
077 Specialized Support Surfaces 8150
080 Physical Therapy 8200
081 Respiratory Therapy 8220
082 Occupational Therapy 8250
083 Speech Pathology 8280
085 Pharmacy 8300
090 Laboratory 8400
095 Home Health Services 8800
100 Other Ancillary Services 8900
Routine Services:
105 Skilled Nursing Care 6110
110 Intermediate Care 6120
115 Mentally Disordered Care 6130
120 Developmentally Disabled Care 6140
125 Sub-Acute Care 6150
126 Sub-Acute Care - Pediatric 6160
128 Transitional Inpatient Care 6170
130 Hospice Inpatient Care 6180
135 Other Routine Services 6190
140 Beauty and Barber **
145 Other Non-reimbursable***
150 Subtotal (Lines 5 through 145) $
155 Social Services 6600
160 Activities 6700
165 Administration 6900
170 Inservice Education - Nursing 6800
175 Total (See Instructions) $ $ $ $
Line (2) (3)
No. SUPPLEMENTAL EXPENSE INFORMATION
180 Raw Food Costs (Included in column 3, line 65) $
185 Worker's Compensation Insurance (Included in column 2, line 175) $
190 State Unemployment Insurance (Included in column 2, line 175) $
CHFC 7041d-2 & MC530 (12-00)
* Column 1, lines 5 through 175 includes only Productive Salaries and Wages. Compensation for time off must be included in column 2, lines 5
through 175.
** Beauty and Barber must be included in Other Ancillary Services (line 100) through column 10 and then reclassified to line 140 in column 13.
*** All Other non-reimbursable expenses must be included in appropriate cost centers through column 10 and then reclassified to line 145 in column 13.
10.1(1)
10.1(2) EXPENSE TRIAL BALANCE WORKSHEET
Facility D.B.A. Name Report Period End
RESIDENTIAL CARE FACILITIES, ONLY
(5) (6) (7) (8) (9)
Apportionment Amounts
Amounts Directly Balanced To Be Factor Apportioned To
Line ACCOUNT Account Assignable Apportioned For Residential Residential Care
No. TITLE Number Residential Care Health Care [C4 - (C5 + C6)] Care Portion* (C7 X C8)
Based on Square Feet *
005 Plant Operations and Maintenance 6200 $ $ $ . $
010 Housekeeping 6300 .
015 Depreciation - Bldgs. & Improvements 7110-7120 .
020 Depreciation - Leasehold Improvements 7130 .
025 Depreciation - Equipment 7140 .
030 Depreciation & Amortization - Other 7150-7160 .
035 Leases and Rentals 7200 .
040 Property Taxes 7300 .
045 Property Insurance 7400 .
050 Interest - Property, Plant & Equipment 7500 .
055 Interest - Other 7600 .
Based on Lbs. of Linen*
060 Laundry and Linen 6400 .
Based on Meals Served*
065 Dietary 6500 .
Based on Revenue*
070 Provision for Bad Debts 7700 .
Ancillary Services:
075 Patient Supplies 8100
077 Specialized Support Surfaces 8150
080 Physical Therapy 8200
081 Respiratory Therapy 8220
082 Occupational Therapy 8250
083 Speech Pathology 8280
085 Pharmacy 8300
090 Laboratory 8400
095 Home Health Services 8800
100 Other Ancillary Services 8900
Routine Services:
105 Skilled Nursing Care 6110
110 Intermediate Care 6120
115 Mentally Disordered Care 6130
120 Developmentally Disabled Care 6140
125 Sub-Acute Care 6150
126 Sub-Acute Care - Pediatric 6160
128 Transitional Inpatient Care 6170
130 Hospice Inpatient Care 6180
135 Other Routine Services 6190
140 Beauty and Barber **
145 Other Non-reimbursable*** Based on Accumulated
150 Subtotal (Lines 5 through 145) $ Costs * $
155 Social Services 6600 .
160 Activities 6700 .
165 Administration 6900 .
170 Inservice Education - Nursing 6800 .
175 Total (See Instructions) $ $ $ $
CHFC 7041d-2 & MC530 (12-00)
* Apportionment factors are specified in section 4020.4 of the Second Edition, "Accounting and Reporting Manual for California
Long-term Care Facilities."
Apportionment factors must be reported to six decimal places.
** Beauty and Barber must be included in Other Ancillary Services (line 100) through column 10 and then reclassified to line 140 in column 13.
*** All Other non-reimbursable expenses must be included in appropriate cost centers through column 10 and then reclassified to line 145 in column 13.
10.1(2)
10.1(3) EXPENSE TRIAL BALANCE WORKSHEET
Facility D.B.A. Name Report Period End
ALL FACILITIES MEDI-CAL PROVIDERS, ONLY
(10) (11) (12) (13) (14)
Adjustments for Adjusted Adjustments Adjusted
Total Health Other Operating Direct to Expenses Trial Balance
Line ACCOUNT Account Care Portion Revenue Expenses for Medi-Cal for Medi-Cal Line
No. TITLE Number [C4 - (C5 + C9)] (From P 10.2) (C10 - C11) (From P10.3) (C10 + C13) No.
005 Plant Operations and Maintenance 6200 $ $ $ $ $ 005
010 Housekeeping 6300 010
015 Depreciation - Bldgs. & Improvs. 7110-7120 015
020 Depreciation - Leasehold Improvs. 7130 020
025 Depreciation - Equipment 7140 025
030 Depreciation & Amortization - Other 7150-7160 030
035 Leases and Rentals 7200 035
040 Property Taxes 7300 040
045 Property Insurance 7400 045
050 Interest - Property, Plant & Equip. 7500 050
055 Interest - Other 7600 055
060 Laundry and Linen 6400 060
065 Dietary 6500 065
070 Provision for Bad Debts 7700 070
Ancillary Services:
075 Patient Supplies 8100 075
077 Specialized Support Surfaces 8150 077
080 Physical Therapy 8200 080
081 Respiratory Therapy 8220 081
082 Occupational Therapy 8250 082
083 Speech Pathology 8280 083
085 Pharmacy 8300 085
090 Laboratory 8400 090
095 Home Health Services 8800 095
100 Other Ancillary Services 8900 100
Routine Services:
105 Skilled Nursing Care 6110 105
110 Intermediate Care 6120 110
115 Mentally Disordered Care 6130 115
120 Developmentally Disabled Care 6140 120
125 Sub-Acute Care 6150 125
126 Sub-Acute Care - Pediatric 6160 126
128 Transitional Inpatient Care 6170 128
130 Hospice Inpatient Care 6180 130
135 Other Routine Services 6190 135
140 Beauty and Barber ** 140
145 Other Non-reimbursable*** 145
150 Subtotal (Lines 5 through 145) 150
155 Social Services 6600 155
160 Activities 6700 160
165 Administration 6900 165
170 Inservice Education - Nursing 6800 170
175 Total (See Instructions) $ $ $ $ $ 175
CHFC 7041d-2 & MC530 (12-00)
** Beauty and Barber must be included in Other Ancillary Services (line 100) through column 10 and then reclassified to line 140 in column 13.
*** All Other non-reimbursable expenses must be included in appropriate cost centers through column 10 and then reclassified to line 145 in column 13.
10.1(3)
10.2 ADJUSTMENTS TO TRIAL BALANCE EXPENSES
FOR OTHER OPERATING REVENUE OFFSET
Facility D.B.A. Name Report Period End
(1) (2)
Page 10.1
Line Account Trial Balance Line
No. Description No. Amount * Line No. No.
005 Vending Machine Commissions 5710 $ 5 005
010 Laundry and Linen Revenue 5720 60 010
015 Social Services Fees 5730 155 015
020 Donated Supplies 5740 Various 020
025 Telephone Revenue 5750 165 025
030 Transfers from Restricted Funds For Operating Expenses 5760 Various 030
035 Nonpatient Food Sales 5770 65 035
040 Television / Radio Charges 5780 5 040
045 Parking Revenue 5790 5 045
050 Rebates and Refunds on Expenses 5800 Various 050
055 Nonpatient Room Rentals 5810 15, 20, 35 055
060 Nonpatient Drug Sales 5820 85 060
065 Nonpatient Supplies Sales 5830 75 065
070 Medical Records and Abstract Sales 5840 165 070
075 Cash Discounts on Purchases 5850 Various 075
080 Sale of Scrap and Waste 5860 Various 080
085 Other Operating Revenue (Describe) 5990 085
090 090
095 095
100 Total (Sum lines 5 through 95) (Must agree with Page 8, line 20) $ 100
CHFC 7041D-2 & MC530 (12-00)
* Transfer amounts in column 1 to Page 10.1(3), column 11, line number indicated in column 2.
10.2
2-00)
10.3 ADJUSTMENTS TO TRIAL BALANCE EXPENSES
(Medi-Cal Providers, Only)
Facility D.B.A. Name Report Period End
(1) (2) (3) (4) (5) (6)
Page 10.1 Amount Health
Line Description Trial Balance Basis Increase Care
No. Line No. * (Decrease) Portion Explanation of Adjustment
005 Depreciation (excess of Straight Line) $ $
010 Education (Nursing, etc.)
015 Employee and Guest Meals
020 Gift, Flower and Coffee Shops
025 Grants, Gifts, and Donations
030 Inpatient Utilization Review
035 Interest Earned on Unrestricted Funds
040 Laundry and Linen Service (Non-Patient)
045 Nonallowable Costs Related to Certain Capital
Expenditures
050 Parking Lot
055 Payments Received From Specialists
060 Radio and Television Service
065 Rebates and Refunds of Expenses
070 Recovery and Insured Loss
075 Bad Debts
080 Rental of Space
085 Rental of Quarters to Employees and Others
090 Sale of Drugs to Other than Patients
095 Sale of Medical Records and Abstracts
100 Sale of Medical and Surgical Supplies to
Other than Patients
105 Sale of Scrap, Waste, etc.
110 Telephone Service
Trade, Quantity, Time and Other Discounts
115 on Purchases
120 Vending Machine Commissions
125 Owner Compensation Adjustment
130 Travel and Entertainment (Nonallowable)
135 Revaluation Depreciation and Interest **
140 Other (Specify)
145 From Page 10.4, line 37
RELATED ORGANIZATION COSTS:
150 Interest
155 Depreciation
160 Rent/Lease
165 Related Taxes
170 Related Insurance
175 Other (Specify)
180
185 From Page 10.4, line 47
NON-REIMBURSABLE COST CENTERS:
190 Fund Raising
195 Research
200 Beauty and Barber
205 From Page 10.4, line 57
210 TOTAL (Combine lines 5 through 205) $ $
* Basis: A - Cost MC530 (12-00)
B - Amount Received
** Depreciation and interest expense related to the revaluation of assets due to change of ownership on or after July 18, 1984
Medi-Cal providers should complete this entire form.
10.3
10.4 ADJUSTMENTS TO TRIAL BALANCE EXPENSES -SUPPLEMENTAL
(Medi-Cal Providers Only)
Facility D.B.A. Name Report Period End
(1) (2) (3) (4) (5) (6)
Page 10.1 Amount Health
Line Description Trial Balance Basis Increase Care
No. Line No. * (Decrease) Portion Explanation of Adjustment
OTHER ADJUSTMENTS (Specify):
01 $ $
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37 TOTAL (Combine lines 1 through 36) $ $ To Page 10.3, line 145
RELATED ORGANIZATION
COSTS - OTHER (Specify):
38
39
40
41
42
43
44
45
46
47 TOTAL (Combine lines 38 through 46) $ $ To Page 10.3, line185
NON-REIMBURSABLE COSTS -
OTHER (Specify):
48
49
50
51
52
53
54
55
56
57 TOTAL (Combine lines 48 through 56) $ $ To Page 10.3, line 205
* Basis: A - Cost MC530 (12-00)
B - Amount Received
10.4
10.5 EXPENSE TRIAL BALANCE WORKSHEET
(Medi-Cal Providers, Only)
Facility D.B.A. Name Report Period End
Based on Adjusted Trial Balance for Medi-Cal (Page 10.1, column 14)
(1) (2) (3) (4) (5)
Salaries Staffing Other Total
Line ACCOUNT Account and Employee Agency Non-Labor Expenses
No. TITLE Number Wages Benefits Cost Expenses (Sum of Cs. 1-4)
005 Plant Operations and Maintenance 6200 $
010 Housekeeping 6300
015 Depreciation - Buildings and Improvements 7110-7120
020 Depreciation - Leasehold Improvements 7130
025 Depreciation - Equipment 7140
030 Depreciation and Amortization - Other 7150-7160
035 Leases and Rentals 7200
040 Property Taxes 7300
045 Property Insurance 7400
050 Interest - Property, Plant, and Equipment 7500
055 Interest - Other 7600
060 Laundry and Linen 6400
065 Dietary 6500
070 Provision for Bad Debts 7700
075 Patient Supplies 8100
077 Specialized Support Surfaces 8150
080 Physical Therapy 8200
081 Respiratory Therapy 8220
082 Occupational Therapy 8250
083 Speech Pathology 8280
085 Pharmacy 8300
090 Laboratory 8400
095 Home Health Services 8800
100 Other Ancillary Services 8900
101 Sub-Acute Ancillary Services * 8100-8900
102 Sub-Acute - Pediatric Ancillary Services * 8100-8900
105 Skilled Nursing Care 6110
110 Intermediate Care 6120
115 Mentally Disordered Care 6130
120 Developmentally Disabled Care 6140
125 Sub-Acute Care 6150
126 Sub-Acute Care - Pediatric 6160
128 Transitional Inpatient Care 6170
130 Hospice Inpatient Care 6180
135 Other Routine Services 6190
139 Residential Care ** 9100
140 Beauty and Barber
145 Other Non-reimbursable
155 Social Services 6600
160 Activities 6700
165 Administration (excluding reclassified amounts below) 6900
166 Medical Records - Salaries and Wages *** 6900
167 DPH Licensing Fees *** 6900
168 Liability Insurance *** 6900
169 Quality Assurance Fees *** 6900
170 Inservice Education - Nursing 6800
174 Caregiver Training *** 6900
175 Total **** $
MC530 (12-08)
* Amounts reclassified from ancillary service type accounts (lines 75 through 100)
** Complete with Direct Residential Care Costs
*** Amounts reclassified from Administration (line 165)
**** Totals in column 5 must match page 10.1, column 14, for each respective cost center (except reclasses)
(1)
10.6 CAPITAL ADDITIONS, IMPROVEMENTS AND REPLACEMENTS
(Medi-Cal Providers Only)
(INCOMPLETE, INACCURATE OR ALTERED SCHEDULES WILL NOT BE ACCEPTED FOR RATE-SETTING PURPOSES)
Facility D.B.A. Name Report Period End
Line
No. (1) (2)
005 Total Licensed Beds Prior to Modification(s):
010 Total Licensed Beds End of Period: CAPITAL THRESHOLD
015 Total Unlicensed Beds End of Period (e.g., residential care): (licensed beds end of period * $500)
Section I. Capital Additions and Improvements (Excluding Replacements)
Enter Data for each Bed Addition Project
Part A. SNF Bed Additions During the Report Period Completed During the Report Period
Line (1) (2) (3)
No. Project 1 Project 2 Project 3
025 Number of New Licensed Beds
030 Date Placed into Service
035 Total Costs
Part B. Other Additions or Improvements Completed During the Report Period (note that additions or improvements must be grouped by related project; unrelated line items will be disallowed)
Line
No. (1)
050 Project 1 Description (e.g., "HVAC System Installation", itemizing detail below):
055 Date Placed in Service (e.g., when was project completed and available for resident use?):
Itemized Detail for Project 1:
(3)
(2) Related Party (4) (5) (7) (8)
Line (1) Leased or Transaction (Yes Invoice Useful Life (in (6) Depreciation Amount
No. Detailed Description Rented? or No)? Date months)(2) Total Cost Expense Financed
056
057
058
059
060
061
062
063
064
065
066
067
068
069
070
071
072
073
074
075
076 Total Project 1 Costs:
(1)
10.6 CAPITAL ADDITIONS, IMPROVEMENTS AND REPLACEMENTS
(Medi-Cal Providers Only)
(INCOMPLETE, INACCURATE OR ALTERED SCHEDULES WILL NOT BE ACCEPTED FOR RATE-SETTING PURPOSES)
Facility D.B.A. Name Report Period End
Line
No. (1)
090 Project 2 Description (e.g., "HVAC System Installation", itemizing detail below):
095 Date Placed in Service (e.g., when was project completed and available for resident use?):
(3)
(2) Related Party (4) (5) (7) (8)
Line (1) Leased or Transaction (Yes Invoice Useful Life (in (6) Depreciation Amount
No. Detailed Description Rented? or No)? Date months)(2) Total Cost Expense Financed
Itemized Detail for Project 2:
096
097
098
099
100
101
102
103
104
105
106
107
108 Total Project 2 Costs:
Line
No. (1)
120 Project 3 Description (e.g., "HVAC System Installation", itemizing detail below):
125 Date Placed in Service (e.g., when was project completed and available for resident use?):
(3)
(2) Related Party (4) (5) (7) (8)
Line (1) Leased or Transaction (Yes Invoice Useful Life (in (6) Depreciation Amount
No. Detailed Description Rented? or No)? Date months)(2) Total Cost Expense Financed
Itemized Detail for Project 3:
126
127
128
129
130
131
132
133
134
135
136
137
138 Total Project 3 Costs:
(1)
10.6 CAPITAL ADDITIONS, IMPROVEMENTS AND REPLACEMENTS
(Medi-Cal Providers Only)
(INCOMPLETE, INACCURATE OR ALTERED SCHEDULES WILL NOT BE ACCEPTED FOR RATE-SETTING PURPOSES)
Facility D.B.A. Name Report Period End
Line
No. (1)
150 Project 4 Description (e.g., "HVAC System Installation", itemizing detail below):
155 Date Placed in Service (e.g., when was project completed and available for resident use?):
(3)
(2) Related Party (4) (5) (7) (8)
Line (1) Leased or Transaction (Yes Invoice Useful Life (in (6) Depreciation Amount
No. Detailed Description Rented? or No)? Date months)(2) Total Cost Expense Financed
Itemized Detail for Project 4:
156
157
158
159
160
161
162
163
164
165
166
167
168 Total Project 4 Costs:
Line
No. (1)
180 Project 5 Description (e.g., "HVAC System Installation", itemizing detail below):
185 Date Placed in Service (e.g., when was project completed and available for resident use?):
(3)
(2) Related Party (4) (5) (7) (8)
Line (1) Leased or Transaction (Yes Invoice Useful Life (in (6) Depreciation Amount
No. Detailed Description Rented? or No)? Date months)(2) Total Cost Expense Financed
Itemized Detail for Project 5:
186
187
188
189
190
191
192
193
194
195
196
197
198 Total Project 5 Costs:
(1)
10.6 CAPITAL ADDITIONS, IMPROVEMENTS AND REPLACEMENTS
(Medi-Cal Providers Only)
(INCOMPLETE, INACCURATE OR ALTERED SCHEDULES WILL NOT BE ACCEPTED FOR RATE-SETTING PURPOSES)
Facility D.B.A. Name Report Period End
Section II. Capital Replacements Completed During the Report Period
Part A. Acquisition Costs and Depreciation for Replacement Asset
Replacement Asset
(2) (4)
Related Party (3) Useful Life (6) (8)
Line (1) Transaction Date Placed in (in (5) Depreciation (7) Adjusted
No. Detailed Description (Yes or No)? Service months)(2) Total Cost Expense Basis Basis(3)
200
201
202
203
204
205
206
207
208
209
210 Total - Section II, Part A Only
Part B. Acquisition Costs and Depreciation of Retired Asset
Retired Asset
(2)
Section II, (3) (5) (7) (9)
Line (1) Part A Line Useful Life (in (4) Depreciation (6) Date of (8) Adjusted (10)
No. Detailed Description No. Reference months)(2) Total Cost Expense Date Acquired Disposal Basis Basis (3) Manner of Disposition (4)
230
231
232
233
234
235
236
237
238
239
240 Total - Section II, Part B Only
Notes:
(1) For the purposes of this voluntary supplemental schedule, the following definitions apply:
* Capital Addition - land, buildings, building equipment and major moveable equipment that have an estimated useful life at the time of the acquisition of at least two years, a historical cost of at least $5,000 per item, and
is not considered a replacement of a previously acquired asset.
* Capital Improvement - betterment of land, buildings, building equipment, major moveable equipment or leasehold property that either extends the useful life of at least two years beyond the original useful life of such asset
or significantly increases the productivity over the original productivity of such asset, a cost of at least $5,000 per item and is not considered a replacement of a previously acquired asset.
* Capital Replacement - land, buildings, building equipment, major moveable equipment and leasehold improvements that would be classified as a capital addition or improvement under the above definitions, except that such
asset is considered a replacement of a previously acquired asset. A replacement is an asset that fills the place, position or purpose once filled by an asset that has been lost, destroyed, discarded or is no longer usable or adequate.
(2) Refer to CMS Publication 15-1, Sections 104-117 for additional information on useful life standards.
(3) Refer to CMS Publication 15-1, Section 132 for additional information.
(4) Refer to CMS Publication 15-1, Section 104 for additional information on the manner of disposition. MC530 (12-08)
10.7 ALTERNATE ALLOCATION STATISTICS - OPTIONAL
(Medi-Cal Providers, Only)
Facility D.B.A. Name Report Period End
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
Line ACCOUNT Plant Laundry & Social Inservice Medical
No. TITLE Capital Operations Housekeeping Linen Dietary Services Activities Education Administration Records
005 Plant Operations and Maintenance
010 Housekeeping
060 Laundry and Linen
065 Dietary
075 Patient Supplies
077 Specialized Support Surfaces
080 Physical Therapy
081 Respiratory Therapy
082 Occupational Therapy
083 Speech Pathology
085 Pharmacy
090 Laboratory
095 Home Health Services
100 Other Ancillary Services
101 Sub-Acute Ancillary Services
102 Sub-Acute - Pediatric Ancillary Services
105 Skilled Nursing Care
110 Intermediate Care
115 Mentally Disordered Care
120 Developmentally Disabled Care
125 Sub-Acute Care
126 Sub-Acute Care - Pediatric
128 Transitional Inpatient Care
130 Hospice Inpatient Care
135 Other Routine Services
139 Residential Care
140 Beauty and Barber
145 Other Non-reimbursable
155 Social Services
160 Activities
165 Administration
166 Medical Records - Salaries and Wages
170 Inservice Education - Nursing
174 Caregiver Training
175 Total
MC530 (12-08)
11(1) ALLOCATION OF INDIRECT COSTS TO DIRECT COST CENTERS - HEALTH CARE ONLY
(All facilities must complete columns 2, 4, and 6, lines 10 through 85. Medi-Cal providers must complete the entire page.)
Facility D.B.A. Name Report Period End
PLANT OPERATIONS
AND MAINTENANCE
EXPENSES through LAUNDRY AND LINEN DIETARY
FROM INTEREST - OTHER
DESCRIPTION PAGE 10.1, BASIS * BASIS * BASIS*
Line COLUMN 14 Square Feet Amount Clean, Dry Amount Number of Amount Line
No. Pounds Patient Meals No.
(1) (2) (3) (4) (5) (6) (7)
5 General Service Costs $ $ $ $ 5
ANCILLARY SERVICE COST CENTERS
10 Patient Supplies 10
12 Specialized Support Surfaces 12
15 Physical Therapy 15
16 Respiratory Therapy 16
17 Occupational Therapy 17
18 Speech Pathology 18
20 Pharmacy 20
11(1)
25 Laboratory 25
30 Home Health Services 30
35 Other Ancillary Services 35
ROUTINE SERVICE COST CENTERS
40 Skilled Nursing Care 40
45 Intermediate Care 45
50 Mentally Disordered Care 50
55 Developmentally Disabled Care 55
60 Sub-Acute Care 60
61 Sub-Acute Care - Pediatric 61
63 Transitional Inpatient Care 63
65 Hospice Inpatient Care 65
70 Other Routine Services 70
CHFC 7041f-1 & MC530 (12-00)
NONREIMBURSABLE COSTS
75 Beauty And Barber 75
80 Other Nonreimbursable 80
85 TOTAL UNITS (Sum of lines 10 through 80) 85
90 UNIT COST MULTIPLIER ** 90
95 TOTAL COSTS (See Instructions) $ $ $ $ 95
* Actual amount or count required, percentages are not acceptable. Allocation statistics must be provided for Ancillary Services Cost Centers in columns 2 and 4.
** Unit Cost Multiplier must be calculated to six decimal places.
11(2) ALLOCATION OF INDIRECT COSTS TO DIRECT COST CENTERS - HEALTH CARE ONLY
(Medi-Cal Providers Only)
Facility D.B.A. Name Report Period End
SOCIAL SERVICES, TOTAL
ACTIVITIES, AND EXPENSES
INSERVICE EDUCATION - ADMINISTRATION ALL PATIENT
NURSING SERVICES
DESCRIPTION BASIS* BASIS* Sum of
Line Direct Amount Accum. Costs Amount Columns Line
No. Expenses (Cs. 1,3,5,7, & 9) 10 and 11 No.
(8) (9) (10) (11) (12)
5 General Service Costs $ $ 5
ANCILLARY SERVICE COST CENTERS
10 Patient Supplies $ 10
12 Specialized Support Surfaces 12
15 Physical Therapy 15
16 Respiratory Therapy 16
17 Occupational Therapy 17
18 Speech Pathology 18
20 Pharmacy 20
25 Laboratory 25
30 Home Health Services $ 30
11(2)
35 Other Ancillary Services 35
ROUTINE SERVICE COST CENTERS
40 Skilled Nursing Care 40
45 Intermediate Care 45
50 Mentally Disordered Care 50
55 Developmentally Disabled Care 55
60 Sub-Acute Care 60
61 Sub-Acute Care - Pediatric 61
63 Transitional Inpatient Care 63
65 Hospice Inpatient Care 65
70 Other Routine Services 70
NONREIMBURSABLE COSTS
CHFC 7041f-1 & MC530 (12-00)
75 Beauty And Barber 75
80 Other Nonreimbursable 80
85 TOTAL UNITS (Sum of lines 10 through 80) $ $ 85
90 UNIT COST MULTIPLIER ** 90
95 TOTAL COSTS (See Instructions) $ $ $ 95
Develop- Sub-Acute Transitional Hospice Other
COMPUTATION OF AVERAGE COST PER DAY Skilled Intermediate Mentally mentally Sub-Acute Care - Inpatient Inpatient Routine
Line Nursing Care Disordered Disabled Care Pediatric Care Care Services Line
No. (1) (2) (3) (4) (5) (6) (7) (8) (9) No.
Cost of Routine Services (Col. 12 above, Ls. 40 through 70) $ $ $ $ $ $ $ $ $ 100
105 Total Patient (Census) Days of Services (P. 4.1, Col. 6) 105
110 Average Cost Per Day (line 100 / line 105) $ $ $ $ $ $ $ $ $ 110
* Actual amount or count required, percentages are not acceptable. Allocation statistics must be provided for Ancillary Services Cost Centers in columns 2 and 4. ** Unit Cost Multiplier must be calculated to six decimal places.
12.1 LABOR REPORT
Facility D.B.A. Name Report Period End
(1) (2) (3)
SALARIES AND WAGES Productive Productive** Hourly Average
Line Hours* Salaries and Wages (Col. 2 / Col. 1) Line
No. No.
NURSING SERVICES - Exclude Sub-Acute Care, Sub-Acute Care -
Pediatric, and Transitional Inpatient Care :
005 Supervisors and Management $ $ 005
010 Geriatric Nurse Practitioners 010
025 Registered Nurses 025
030 Licensed Vocational Nurses 030
035 Nurse Assistants (Aides and Orderlies) 035
040 Technicians and Specialists 040
045 Psychiatric Technicians 045
060 Other Salaries and Wages 060
065 Subtotal (Sum of lines 5 through 60) $ $ 065
SUB-ACUTE CARE NURSING SERVICES - Only :
070 Supervisors and Management $ $ 070
075 Geriatric Nurse Practitioners 075
090 Registered Nurses 090
095 Licensed Vocational Nurses 095
100 Nurse Assistants (Aides and Orderlies) 100
105 Technicians and Specialists 105
110 Psychiatric Technicians 110
125 Other Salaries and Wages 125
130 Subtotal (Sum of lines 70 through 125) $ $ 130
SUB-ACUTE CARE - PEDIATRIC NURSING SERVICES - Only :
140 Supervisors and Management $ $ 140
145 Geriatric Nurse Practitioners 145
150 Registered Nurses 150
155 Licensed Vocational Nurses 155
160 Nurse Assistants (Aides and Orderlies) 160
165 Technicians and Specialists 165
170 Psychiatric Technicians 170
175 Other Salaries and Wages 175
180 Subtotal (Sum of lines 140 through 175) $ $ 180
TRANSITIONAL INPATIENT CARE - Only:
190 Supervisors and Management $ $ 190
191 Geriatric Nurse Practitioners 191
192 Registered Nurses 192
193 Licensed Vocational Nurses 193
194 Nurse Assistants (Aides and Orderlies) 194
195 Technicians and Specialists 195
196 Psychiatric Technicians 196
198 Other Salaries and Wages 198
199 Subtotal (Sum of lines 190 through 198) $ $ 199
ANCILLARY SERVICES :
200 Supervisors and Management $ $ 200
205 Registered Nurses 205
210 Licensed Vocational Nurses 210
215 Nurse Assistants (Aides and Orderlies) 215
220 Technicians and Specialists 220
225 Other Salaries and Wages 225
230 Subtotal (Sum of lines 200 through 225) $ $ 230
SUPPORT SERVICES :
250 Plant Operations and Maintenance $ $ 250
255 Housekeeping 255
260 Laundry and Linen 260
265 Dietary 265
270 Social Services 270
275 Activities 275
280 Inservice Education - Nursing 280
285 Administration 285
290 Subtotal (Sum of lines 250 through 285) $ $ 290
300 TOTAL (Sum of lines 65, 130, 180,199, 230, and 290) $ $ 300
* Productive hours are actual hours worked and exclude 1) vacation, 2) sick leave, 3) on call, 4) holiday, 5) other paid time off. CHFC 7041h-6 & MC530 (12-00)
Report to the nearest whole hour.
** For all facilities :
Column 2, line 65 must agree with the sum of Page 10.1, column 1, lines 105, 110, 115, 120, 130 and 135.
Line 130 must agree with Page 10.1, column 1, line 125. Line 180 must agree with Page 10.1, column 1, line 126. Line 199 must agree with Page 10.1, column 1, line 128.
Line 230 must agree with Page 10.1, column 1, lines 75 through 100.
Report to the nearest whole dollar.
For non-residential care facilities: For residential care facilities:
Lines 250 through 290 must agree with Report only productive hours, salaries, and wages related to health care on lines 250 through 290 of this page. If Page 10.1,
appropriate lines on Page 10.1, column 1. columns 5 through 9 are used to determine expenses related to health care, use the same method to determine productive
hours, salaries, and wages related to health care for this page.
12.1
12.2 LABOR REPORT
Facility D.B.A. Name Report Period End
(1) (2) (3)
Productive Productive** Hourly Average
Line SUPPLEMENTAL LABOR INFORMATION Hours* Salaries and Wages (Col. 2 / Col. 1) Line
No. No.
310 Social Workers (report here and include on line 270) $ $ 310
315 Activity Program Leaders (report here and include on line 275) $ $ 315
(1) (2) (3)
Line TEMPORARY STAFFING AGENCY SERVICES Hours Amount Paid Hourly Average Line
No. (Col. 2 / Col. 1) No.
NURSING SERVICES - Exclude Sub-Acute Care, Sub-Acute Care -
Pediatric, and Transitional Impatient Care:
405 Geriatric Nurse Practitioners $ $ 405
410 Registered Nurses 410
415 Licensed Vocational Nurses 415
420 Nurse Assistants (Aides and Orderlies) 420
425 Psychiatric Technicians 425
430 Other Agency Personnel 430
435 TOTAL (Sum of lines 405 through 430) $ $ 435
SUB-ACUTE CARE NURSING SERVICES - Only :
440 Geriatric Nurse Practitioners $ $ 440
445 Registered Nurses 445
450 Licensed Vocational Nurses 450
455 Nurse Assistants (Aides and Orderlies) 455
460 Psychiatric Technicians 460
465 Other Agency Personnel 465
470 TOTAL (Sum of lines 440 through 465) $ $ 470
SUB-ACUTE CARE - PEDIATRIC NURSING SERVICES - Only :
475 Geriatric Nurse Practitioners $ $ 475
480 Registered Nurses 480
485 Licensed Vocational Nurses 485
490 Nurse Assistants (Aides and Orderlies) 490
495 Psychiatric Technicians 495
500 Other Agency Personnel 500
505 TOTAL (Sum of lines 475 through 500) $ $ 505
TRANSITIONAL INPATIENT CARE NURSING SERVICES - Only:
510 Geriatric Nurse Practitioners $ $ 510
515 Registered Nurses 515
520 Licensed Vocational Nurses 520
525 Nurse Assistants (Aides and Orderlies) 525
530 Psychiatric Technicians 530
535 Other Agency Personnel 535
540 TOTAL (Sum of lines 510 through 535) $ $ 540
(1) (2) (3)
SUPPLEMENTAL LABOR INFORMATION -
Line TEMPORARY STAFFING Hours Amount Paid Hourly Average Line
No. (Col. 2 / Col. 1) No.
555 Social Workers (do not include on lines 430, 465, 500, or 535) $ $ 555
560 Activity Program Leaders (do not include in lines 430, 465, 500, or 535) $ $ 560
LABOR TURNOVER
(1) (2) (3)
Line All Direct Nursing Nurse Line
No. Employees Employees* Assistants No.
605 Number of employees at beginning of period 605
610 Number of employees at end of period 610
615 Average number of employees (See instructions) 615
620 Total number of people employed during the period ** 620
625 Turnover percentage [ (line 620 / line 615) X 100 ] - 100 % % % 625
630 Number of employees with continuous service for entire reporting period 630
CHFC 7041h-6 & MC530 (12-00)
* Include all employees (RN's, LVN's, Nurse Assistants, technicians, specialists and others) providing direct nursing care.
Do not include supervisors who provide no direct nursing care.
Do include supervisors whose duties include some provision of nursing care.
** Total number of people employed can not be less than the number of employees at the beginning of the period, less the number of employees
with continuous service for the entire period, plus the number of employees at the end of the period (line 605 - line 630 + line 610).
This calculation is the MINIMUM possible number of people employed during the period. It does not include employees who were hired
after the period began and left or were discharged before the period ended.
Therefore, in most cases, line 620 should be greater than this calculation.
12.2
13 COMPUTATION OF ANCILLARY SERVICES COST PER PATIENT DAY
(Special Care Program Contract Providers, Only)
Facility D.B.A. Name Report Period End
TOTAL FACILITY SUB-ACUTE CARE SUB-ACUTE CARE - PEDIATRIC TRANSITIONAL INPATIENT CARE
Allowable Gross Ratio of Cost Gross Ancillary Allowable Allowable Gross Ancillary Allowable Allowable Gross Ancillary Allowable Allowable
Cost Revenue to Gross Revenue for Cost for Cost per Revenue for Cost for Cost per Revenue for Cost for Cost per
Revenue Sub-Acute Sub-Acute Sub-Acute Sub-Acute Sub-Acute Sub-Acute Transitional Transitional Transitional
ANCILLARY SERVICES (page 11, (page 4.1, Care Care Care Day Care - Ped. Care - Ped. Care - Ped. Day Inpat. Care Inpat. Care Inpat. Care Day
Line col. 12) col. 10) (col. 1 / col. 2) (col. 3 x col. 4) (c.5 / c.6, l.105) (col. 3 x col. 7) (c.8 / c.9, l.105) (col. 3 x col. 10) (c.11/c.12, l.105) Line
No. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) No.
10 Patient Supplies $ $ $ $ $ $ $ $ $ $ $ 10
12 Specialized Support Surfaces 12
15 Physical Therapy 15
16 Respiratory Therapy 16
17 Occupational Therapy 17
18 Speech Pathology 18
20 Pharmacy 20
25 Laboratory 25
30 Home Health Services 30
13
35 Other Ancillary Services 35
95 TOTAL (lines 10 through 35) $ $ $ $ $ $ $ $ $ $ $ 95
105 Program Patient Days (page 4.1,
col. 6, lines 25, 30, and 35) 105
MC530 (12-00)
