Docstoc

Cost and Wage Survey - Long Version _Excel_ - Wyoming Medicaid DDD .xls

Document Sample
Cost and Wage Survey - Long Version _Excel_ - Wyoming Medicaid DDD .xls Powered By Docstoc
					                               Wyoming Department of Health
                         Home- and Community-Based Waiver Services
                            Cost and Wage Survey (Long Version)


WORKSHEET A: PROVIDER INFORMATION
 1    PROVIDER NAME:                Provider A

 2    PRIMARY NPI NUMBER:           XXXXXX

 3    CITY:                         City

 4    COUNTY:                       County

 5    SURVEY PERIOD BEGINNING:      07/01/2009

 6    SURVEY PERIOD ENDING:         06/30/2010



 7    CONTACT PERSON:               Ms. Doe

 8    TITLE:                        Chief Financial Officer

 9    PHONE NUMBER:                 XXX-XXX-XXXX

 10   EMAIL ADDRESS:                msdoe@testproviderA.com




                                              Page 1 of 22
                                                                  Wyoming Department of Health
                                                            Home- and Community-Based Waiver Services
                                                               Cost and Wage Survey (Long Version)

       PROVIDER NAME:                                                  Provider A
       REPORT PERIOD BEGINNING:                                        07/01/09
       REPORT PERIOD ENDING:                                           06/30/10
       CITY AND COUNTY:                                                City, County

WORKSHEET B: PROVIDER COSTS
                                                             1                                     2          3           4               5                6
                                                                                                                         All
                                                                                                Uniform              Costs from
                                                                                                Chart of    Other     Provider        Non-Waiver       Net Waiver
Line                                                                                            Accounts   Account    General          Program          Program
No.                                                     Cost Centers                             Code       Code       Ledger           Costs             Costs

                                                 SALARIES AND WAGES

       Program Employee Salaries and Wages - 5000
  1        Direct Care Workers Salaries and Wages                                                5010                                                               -
  2        Direct Care Trainers Salaries and Wages                                               5020                                                               -
  3        Shift and Unit Supervisors Salaries and Wages                                         5030                                                               -
  4        Case Managers Salaries and Wages                                                      5040                                                               -
  5        Job Coaches and Vocational Trainers Salaries and Wages                                5050                                                               -
  6        Dieticians Salaries and Wages                                                         5060                                                               -
  7        Nurses Salaries and Wages                                                             5070                                                               -
  8        Psychiatrists Salaries and Wages                                                      5080                                                               -
  9        Psychologists Salaries and Wages                                                      5090                                                               -
 10        Physical Therapists Salaries and Wages                                                5100                                                               -
 11        Occupational Therapists Salaries and Wages                                            5110                                                               -
 12        Speech Therapists Salaries and Wages                                                  5120                                                               -
 13        Other Program Employees Salaries and Wages (Specify)                                  5130                                                               -
 14    Total Program Employee Salaries and Wages                                                                                  -                -                -


       Program Support Employee Salaries and Wages - 5200
 15        Program Support Employees Salaries and Wages                                          5210                                                               -
 16        Other Support Employees Salaries and Wages (Specify)                                  5220                                                               -
 17    Total Program Support Employee Salaries and Wages                                                                          -                -                -


       Maintenance Employee Salaries and Wages - 5300
 18        Vehicle Maintenance Staff                                                             5310                                                               -
 19        Equipment Maintenance Staff                                                           5320                                                               -
 20        Plant Operations and Maintenance Staff                                                5330                                                               -
 21        Other Maintenance Staff (Specify)                                                     5340                                                               -
 22    Total Maintenance Employee Salaries and Wages                                                                              -                -                -




                                                                                      2 of 22
                                                                 Wyoming Department of Health
                                                           Home- and Community-Based Waiver Services
                                                              Cost and Wage Survey (Long Version)

       PROVIDER NAME:                                                      Provider A
       REPORT PERIOD BEGINNING:                                            07/01/09
       REPORT PERIOD ENDING:                                               06/30/10
       CITY AND COUNTY:                                                    City, County

WORKSHEET B: PROVIDER COSTS
                                                            1                                          2          3           4               5                6
                                                                                                                             All
                                                                                                    Uniform              Costs from
                                                                                                    Chart of    Other     Provider        Non-Waiver       Net Waiver
Line                                                                                                Accounts   Account    General          Program          Program
No.                                                    Cost Centers                                  Code       Code       Ledger           Costs             Costs

       Administration Employee Salaries and Wages - 5400
 23        Administrator/CEO/Director Salaries and Wages                                             5410                                                               -
 24        Assistant Administrator/Director Salaries and Wages                                       5420                                                               -
 25        Employee Owners, Partners or Stock Holders Salaries and Wages                             5430                                                               -
 26        Board Member Compensation                                                                 5440                                                               -
 27        Professional Administration Staff Salaries and Wages                                      5450                                                               -
 28        Clerical and Secretarial Staff Salaries and Wages                                         5460                                                               -
 29        Information Technology Staff Salaries and Wages                                           5470                                                               -
 30        Central Office Administration Employee Salaries and Wages                                 5480                                                               -
 31        Fundraising Activity Personnel Salaries and Wages                                         5490                                                               -
 32        Other Administration Employee Salaries and Wages (Specify)                                5500                                                               -
 33    Total Administration Employee Salaries and Wages                                                                               -                -                -


       Client and Other Salaries and Wages - 5600
 34         Client Salaries and Wages                                                                5610                                                               -
 35         Donated Services                                                                         5620                                                               -
 36    Total Client and Other Salaries and Wages                                                                                      -                -                -


 37                                           TOTAL SALARIES AND WAGES                                                                -                -                -




                                                                                          3 of 22
                                                                Wyoming Department of Health
                                                          Home- and Community-Based Waiver Services
                                                             Cost and Wage Survey (Long Version)

       PROVIDER NAME:                                                 Provider A
       REPORT PERIOD BEGINNING:                                       07/01/09
       REPORT PERIOD ENDING:                                          06/30/10
       CITY AND COUNTY:                                               City, County

WORKSHEET B: PROVIDER COSTS
                                                           1                                      2          3           4               5                6
                                                                                                                        All
                                                                                               Uniform              Costs from
                                                                                               Chart of    Other     Provider        Non-Waiver       Net Waiver
Line                                                                                           Accounts   Account    General          Program          Program
No.                                                   Cost Centers                              Code       Code       Ledger           Costs             Costs

                                       EMPLOYEE TAXES, INSURANCE AND BENEFITS

       Employee Payroll Taxes - 5700
 38        FICA                                                                                 5710                                                               -
 39        FUI                                                                                  5720                                                               -
 40        SUI                                                                                  5730                                                               -
 41        Workers Compensation                                                                 5740                                                               -
 42        Other Payroll Taxes                                                                  5750                                                               -
 43    Total Employee Payroll Taxes                                                                                              -                -                -


       Employee Insurance - 5800
 44        Employee Health Insurance                                                            5810                                                               -
 45        Employee Dental Insurance                                                            5820                                                               -
 46        Employee Life Insurance                                                              5830                                                               -
 47        Employee Short-Term and Long-Term Disability Insurance                               5840                                                               -
 48        Client Fringe Benefits (Specify)                                                     5850                                                               -
 49        Total Employee Insurance (Specify)                                                   5899                                                               -
 50    Total Employee Insurance                                                                                                  -                -                -


       Employee Other Benefits - 5900
 51        Retirement                                                                           5910                                                               -
 52        Other Benefits (Specify)                                                             5920                                                               -
 53    Total Employee Other Benefits                                                                                             -                -                -


 54                              TOTAL EMPLOYEE TAXES, INSURANCE AND BENEFITS                                                    -                -                -




                                                                                     4 of 22
                                                                      Wyoming Department of Health
                                                                Home- and Community-Based Waiver Services
                                                                   Cost and Wage Survey (Long Version)

       PROVIDER NAME:                                                        Provider A
       REPORT PERIOD BEGINNING:                                              07/01/09
       REPORT PERIOD ENDING:                                                 06/30/10
       CITY AND COUNTY:                                                      City, County

WORKSHEET B: PROVIDER COSTS
                                                                1                                        2          3           4               5                6
                                                                                                                               All
                                                                                                      Uniform              Costs from
                                                                                                      Chart of    Other     Provider        Non-Waiver       Net Waiver
Line                                                                                                  Accounts   Account    General          Program          Program
No.                                                     Cost Centers                                   Code       Code       Ledger           Costs             Costs
                                                 CONTRACTED SERVICES

       Contracted Program Services - 6000
 55        Direct Care Workers Contracted Program Services                                             6010                                                               -
 56        Direct Care Trainers Contracted Program Services                                            6020                                                               -
 57        Contracted Shift and Unit Supervisor                                                        6030                                                               -
 58        Case Managers Contracted Program Services                                                   6040                                                               -
 59        Job Coaches and Vocational Trainers Contracted Program Services                             6050                                                               -
 60        Dieticians Contracted Program Services                                                      6060                                                               -
 61        Nurses Contracted Program Services                                                          6070                                                               -
 62        Psychiatrists Contracted Program Services                                                   6080                                                               -
 63        Psychologists Contracted Program Services                                                   6090                                                               -
 64        Physical Therapists Contracted Program Services                                             6100                                                               -
 65        Occupational Therapists Contracted Program Services                                         6110                                                               -
 66        Speech Therapists Contracted Program Services                                               6120                                                               -
 67        Other Contracted Employee Salaries and Wages (Specify)                                      6130                                                               -
 68    Total Contracted Program Services                                                                                                -                -                -

       Contracted Maintenance Services - 6200
 69        Contracted Vehicle Maintenance Service                                                      6210                                                               -
 70        Contracted Equipment Maintenance and Repairs                                                6220                                                               -
 71        Contracted Plant Maintenance and Repairs                                                    6230                                                               -
 72    Total Contracted Maintenance Services                                                                                            -                -                -

       Contracted Administration Services - 6300
 73        Management Contract Fees                                                                    6310                                                               -
 74        Contracted Clerical Support                                                                 6320                                                               -
 75        Contracted Information Technology Support                                                   6330                                                               -
 76        Professional Service Fees                                                                   6340                                                               -
 77        Legal Expenses / Attorney Fees                                                              6350                                                               -
 78        Other Contracted Administration Services (Specify)                                          6360                                                               -
 79    Total Contracted Administration Services                                                                                         -                -                -

 80                                          TOTAL CONTRACTED SERVICES                                                                  -                -                -




                                                                                            5 of 22
                                                                    Wyoming Department of Health
                                                              Home- and Community-Based Waiver Services
                                                                 Cost and Wage Survey (Long Version)

       PROVIDER NAME:                                                    Provider A
       REPORT PERIOD BEGINNING:                                          07/01/09
       REPORT PERIOD ENDING:                                             06/30/10
       CITY AND COUNTY:                                                  City, County

WORKSHEET B: PROVIDER COSTS
                                                               1                                     2          3           4               5                6
                                                                                                                           All
                                                                                                  Uniform              Costs from
                                                                                                  Chart of    Other     Provider        Non-Waiver       Net Waiver
Line                                                                                              Accounts   Account    General          Program          Program
No.                                                       Cost Centers                             Code       Code       Ledger           Costs             Costs
                                       NON-PAYROLL ADMINISTRATION EXPENSES

       Administration Expenses - 6700
 81        Advertising                                                                             6710                                                               -
 82        Bank Service Charges / Fee                                                              6720                                                               -
 83        CARF Survey                                                                             6730                                                               -
 84        Office Supplies                                                                         6740                                                               -
 85        Postage/Shipping                                                                        6750                                                               -
 86        Printing and Publishing                                                                 6760                                                               -
 87        Central Office Other Administration Expenses                                            6770                                                               -
 88        Dues, Memberships and Subscriptions                                                     6780                                                               -
 89        Fundraising Activities                                                                  6790                                                               -
 90        Meetings Expenses                                                                       6800                                                               -
 91    Total Administration Expenses                                                                                                -                -                -

       Licenses/Taxes - 7000
 92         Ad Valorem Property Taxes                                                              7010                                                               -
 93         Other State and Federal Taxes (Specify)                                                7020                                                               -
 94         Vehicle Licenses and Registration                                                      7030                                                               -
 95    Total Licenses/Taxes                                                                                                         -                -                -

       Liability and Other Insurance - 7100
 96         General Liability Insurance                                                            7110                                                               -
 97         Directors and Officers Insurance                                                       7120                                                               -
 98         Professional Malpractice Insurance                                                     7130                                                               -
 99         Buildings, Contents and Grounds Insurance                                              7140                                                               -
 100        Vehicle Related Insurance                                                              7150                                                               -
 101   Total Liabilty and Other Insurance                                                                                           -                -                -

       Non-Payroll Related Personnel Expenses - 6600
 102       Background Checks / Drug Testing                                                        6610                                                               -
 103       Recruitment                                                                             6620                                                               -
 104       Training                                                                                6630                                                               -
 105   Total Non-Payroll Related Personnel Expenses                                                                                 -                -                -

 106                               TOTAL NON-PAYROLL ADMINISTRATION EXPENSES                                                        -                -                -




                                                                                        6 of 22
                                                                     Wyoming Department of Health
                                                               Home- and Community-Based Waiver Services
                                                                  Cost and Wage Survey (Long Version)

       PROVIDER NAME:                                                           Provider A
       REPORT PERIOD BEGINNING:                                                 07/01/09
       REPORT PERIOD ENDING:                                                    06/30/10
       CITY AND COUNTY:                                                         City, County

WORKSHEET B: PROVIDER COSTS
                                                               1                                            2          3           4               5                6
                                                                                                                                  All
                                                                                                         Uniform              Costs from
                                                                                                         Chart of    Other     Provider        Non-Waiver       Net Waiver
Line                                                                                                     Accounts   Account    General          Program          Program
No.                                                      Cost Centers                                     Code       Code       Ledger           Costs             Costs

                                      NON-PAYROLL PROGRAM SUPPORT EXPENSES

       Supplies - 6500
 107       Food and Food Service Supplies                                                                 6510                                                               -
 108       Special Dietary Supplements/Supplies                                                           6520                                                               -
 109       Other Dietary Supplies                                                                         6530                                                               -
 110       Client Incentives / Awards                                                                     6540                                                               -
 111       Medical Supplies                                                                               6550                                                               -
 112       Housekeeping/Linen and Bedding Supplies                                                        6560                                                               -
 113   Total Supplies                                                                                                                      -                -                -


       Transportation - 6900
 114       Transportation - service related (Attach Detailed Mileage Records)                             6910                                                               -
 115       Transportation/Travel - non-service related                                                    6920                                                               -
 116   Total Transportation                                                                                                                -                -                -


 117                             TOTAL NON-PAYROLL PROGRAM SUPPORT EXPENSES                                                                -                -                -




                                                                                               7 of 22
                                                               Wyoming Department of Health
                                                         Home- and Community-Based Waiver Services
                                                            Cost and Wage Survey (Long Version)

       PROVIDER NAME:                                               Provider A
       REPORT PERIOD BEGINNING:                                     07/01/09
       REPORT PERIOD ENDING:                                        06/30/10
       CITY AND COUNTY:                                             City, County

WORKSHEET B: PROVIDER COSTS
                                                          1                                     2          3           4               5                6
                                                                                                                      All
                                                                                             Uniform              Costs from
                                                                                             Chart of    Other     Provider        Non-Waiver       Net Waiver
Line                                                                                         Accounts   Account    General          Program          Program
No.                                                  Cost Centers                             Code       Code       Ledger           Costs             Costs

                              FACILITY, VEHICLE AND EQUIPMENT RELATED EXPENSES

       Rentals/Mortgage - 7200
 118       Buildings Rental/Lease                                                             7210                                                               -
 119       Buildings Mortgage Expense                                                         7220                                                               -
 120       Facility-Related Equipment Rental/Lease                                            7230                                                               -
 121       Facility-Related Interest Expense                                                  7240                                                               -
 122       Vehicle Rental/Lease                                                               7250                                                               -
 123       Vehicle Related Interest Expense                                                   7260                                                               -
 124       Interest Expense on Working Capital                                                7270                                                               -
 125   Total Rentals/Mortgage                                                                                                  -                -                -


       Maintenance and Repairs - 7300
 126       Vehicle Maintenance and Repairs                                                    7310                                                               -
 127       Equipment Maintenance and Repairs                                                  7320                                                               -
 128       Plant Maintenance and Repairs                                                      7330                                                               -
 129   Total Maintenance and Repairs                                                                                           -                -                -


       Depreciation and Amortization - 7400
 130       Vehicle Depreciation                                                               7410                                                               -
 131       Equipment Depreciation                                                             7420                                                               -
 132       Building Depreciation                                                              7430                                                               -
 133       Capital Leases Amortization                                                        7440                                                               -
 134       Land Improvements Amortization                                                     7450                                                               -
 135       Other Amortization (Specify)                                                       7460                                                               -
 136   Total Depreciation and Amortization                                                                                     -                -                -




                                                                                   8 of 22
                                                          Wyoming Department of Health
                                                    Home- and Community-Based Waiver Services
                                                       Cost and Wage Survey (Long Version)

       PROVIDER NAME:                                            Provider A
       REPORT PERIOD BEGINNING:                                  07/01/09
       REPORT PERIOD ENDING:                                     06/30/10
       CITY AND COUNTY:                                          City, County

WORKSHEET B: PROVIDER COSTS
                                                     1                                       2          3           4               5                6
                                                                                                                   All
                                                                                          Uniform              Costs from
                                                                                          Chart of    Other     Provider        Non-Waiver       Net Waiver
Line                                                                                      Accounts   Account    General          Program          Program
No.                                             Cost Centers                               Code       Code       Ledger           Costs             Costs

       Utilities - 6400
 137         Electricity                                                                   6410                                                               -
 138         Heating Fuel                                                                  6420                                                               -
 139         Water/Sewer                                                                   6430                                                               -
 140         Garbage/Waste                                                                 6440                                                               -
 141         Telephone/Telecommunications                                                  6450                                                               -
 142         Cable/Internet                                                                6460                                                               -
 143         Total Utilities (Specify)                                                     6499                                                               -
 144   Total Utilities                                                                                                      -                -                -


 145                      TOTAL FACILITY, VEHICLE AND EQUIPMENT RELATED EXPENSES                                            -                -                -


 146                                          GRAND TOTALS                                                                  -                -                -




                                                                                9 of 22
                                                     Wyoming Department of Health
                                               Home- and Community-Based Waiver Services
                                                  Cost and Wage Survey (Long Version)

       PROVIDER NAME:                             Provider A
       REPORT PERIOD BEGINNING:                   07/01/09
       REPORT PERIOD ENDING:                      06/30/10
       CITY AND COUNTY:                           City, County


WORKSHEET C: PROVIDER REVENUES
                                                  1                                        2

                                                                                           All
                                                                                      Revenue From
                                                                                        Provider
Line                                                                                    General
No.                                       Revenue Source                                 Ledger

       Patient Revenue
   1       Medicaid -- waiver program revenue
   2       Medicaid -- state plan revenue
   3       Medicare
   4       Other Patient Sources (Federal SSI, State supplemental amounts, etc.)
   5       Other Gov't (Specify)
   6       Other Insurance (Specify)
   7       Private Payor
   8   Total Patient Revenue                                                                         -

       Other Revenue
   9      Investment Income
  10      Grants- Government
  11      Grants- Private
  12      Donations
  13      Other Revenue (Specify)
  14   Total Other Revenue                                                                           -

  15                                    TOTAL REVENUE                                                -




                                                                           10 of 22
      Wyoming Department of Health
Home- and Community-Based Waiver Services
   Cost and Wage Survey (Long Version)




                 11 of 22
                                                                       Wyoming Department of Health
                                                                 Home- and Community-Based Waiver Services
                                                                    Cost and Wage Survey (Long Version)

       PROVIDER NAME:                             Provider A
       REPORT PERIOD BEGINNING:                   07/01/09
       REPORT PERIOD ENDING:                      06/30/10
       CITY AND COUNTY:                           City, County

WORKSHEET D: CAPACITY AND NUMBER OF CLIENTS SERVED
                                            1                            2          3         4              5                       6                         7                    8
                                                                                                                   NUMBER OF PARTICIPANTS SERVED
                                                                                                           High                  Both                      No High            Average Number
                                                                                 Average    High     Behavioral and/or         High Medical                Medical or         Hours Per Week
Line                                                                  Service    Daily     Medical    Mental Health           and Behavioral         High Behavioral and/or    Clients Away
No.                             Participant Information               Capacity   Census     Need           Need          and/or Mental Health Need    Mental Health Need      From Residence
 1     Residential Habilitation Services - Group Setting
 2     Special Family Habilitation Home
 3     Supported Living Services
 4     Day Habilitation Services




                                                                                           Page 12 of 22
                                                                            Wyoming Department of Health
                                                                      Home- and Community-Based Waiver Services
                                                                         Cost and Wage Survey (Long Version)

        PROVIDER NAME:                                                          Provider A
        REPORT PERIOD BEGINNING:                                                07/01/09
        REPORT PERIOD ENDING:                                                   06/30/10
        CITY AND COUNTY:                                                        City, County

WORKSHEET E: WAGES BY EMPLOYEE
                                                                                    2            3           4          5          6           7          8             9               10            11          12
                                                                                            TOTAL WAGES                     OVERTIME WAGES                        SUMMARY OF EMPLOYEE HOURS AND BENEFITS
                                                                                                                                                        Direct                         Holiday,
                                                                                   Total                   Average   Total OT                Average    Client      Other Program    Sick, Vacation
 Line                                                                             Hours        Total       Hourly     Hours       Total OT     OT      Contact        Support       and Other Paid    Training   Total
 No.                                           Description                         Paid        Wages        Wage       Paid        Wages      Wage      Hours          Hours             Hours         Hours     Hours
        Program Employee Salaries and Wages - 5000
 1           Direct Care Workers Salaries and Wages                                                              -                                 -                                                               -
 2           Direct Care Trainers Salaries and Wages                                                             -                                 -                                                               -
 3           Shift and Unit Supervisors Salaries and Wages                                                       -                                 -                                                               -
 4           Case Managers Salaries and Wages                                                                    -                                 -                                                               -
 5           Job Coaches and Vocational Trainers Salaries and Wages                                              -                                 -                                                               -
 6           Dieticians Salaries and Wages                                                                       -                                 -                                                               -
 7           Nurses Salaries and Wages                                                                           -                                 -                                                               -
 8           Psychiatrists Salaries and Wages                                                                    -                                 -                                                               -
 9           Psychologists Salaries and Wages                                                                    -                                 -                                                               -
 10          Physical Therapists Salaries and Wages                                                              -                                 -                                                               -
 11          Occupational Therapists Salaries and Wages                                                          -                                 -                                                               -
 12          Speech Therapists Salaries and Wages                                                                -                                 -                                                               -
 13          Other Program Employees Salaries and Wages (Specify)                                                -                                 -                                                               -
 14     TOTAL - All Staffing                                                            -              -         -            -        -           -          -                 -                 -        -       -




                                                                                             Page 13 of 22
                                                                               Wyoming Department of Health
                                                                         Home- and Community-Based Waiver Services
                                                                            Cost and Wage Survey (Long Version)

        PROVIDER NAME:                                             Provider A
        SNAPSHOT DATE
        CITY AND COUNTY:                                           City, County

WORKSHEET F: DIRECT SERVICE EMPLOYEE STAFFING AND TURNOVER
                                                         1                              2              3                 4                5                 6                  7                8             9        10      11           12


                                                                                                                                                                                                             NUMBER OF               WAGE
                                                                                                                                              NUMBER OF                                                      UNFILLED                RATE
                                                                                                                                              EMPLOYEES                                                      POSITIONS              RANGE
                                                                                                                  Full Time Employees                                  Part Time Employees                                    Low       High


                                                                                    HOURS PER                        Number                                                Number
                                                                                    WEEK USED     Number on        Continously     Number who          Number on         Continously     Number who
                                                                                    TO DEFINE    Payroll at End     Employed      Left the Agency     Payroll at End      Employed      Left the Agency
 Line                                                                                FULL TIME    of Provider     During Provider During the Fiscal    of Provider      During Provider During the Fiscal    Full      Part   Hourly   Hourly
 No.                                                 Description                    EMPLOYEES     Fiscal Year       Fiscal Year         Year           Fiscal Year        Fiscal Year         Year          Time      Time    Wage     Wage
        Program Employee Salaries and Wages - 5000
  1     Direct Care Workers Salaries and Wages
  2     Direct Care Trainers Salaries and Wages
  3     Shift and Unit Supervisors Salaries and Wages
  4     Case Managers Salaries and Wages
  5     Job Coaches and Vocational Trainers Salaries and Wages
  6     Dieticians Salaries and Wages
  7     Nurses Salaries and Wages
  8     Psychiatrists Salaries and Wages
  9     Psychologists Salaries and Wages
 10     Physical Therapists Salaries and Wages
 11     Occupational Therapists Salaries and Wages
 12     Speech Therapists Salaries and Wages
 13     Other Program Employees Salaries and Wages (Specify)
 14     TOTAL EMPLOYEES                                                                                    -                  -                -                 -                  -                -            -      -
 15     Hours Per Week Used to Define F/T and P/T




                                                                                            Page 14 of 22
                                                   Wyoming Department of Health
                                             Home- and Community-Based Waiver Services
                                                Cost and Wage Survey (Long Version)
PROVIDER NAME:                      Provider A
SNAPSHOT DATE                       12/01/09
CITY AND COUNTY:                    City, County

WORKSHEET G: DIRECT SERVICE EMPLOYEE RETENTION

1. Rank in order the TOP THREE most frequent reasons the employees included in this survey cite for separation, with 1
  indicating most frequent. You may mark other reasons that apply with an "X".

 1.1 Direct Care Employees (non-licensed):

            Work location
            Work schedule
            Salary concerns
            Sign up bonuses at new employer
            Benefits package
            Nature of the work
            Co-worker conflicts
            Relocation
            Career advancement
            Other (specify)
            Other (specify)
            Other (specify)




                                                               Page 15 of 22
                                                 Wyoming Department of Health
                                           Home- and Community-Based Waiver Services
                                              Cost and Wage Survey (Long Version)
PROVIDER NAME:                     Provider A
SNAPSHOT DATE                      12/01/09
CITY AND COUNTY:                   City, County

WORKSHEET G: DIRECT SERVICE EMPLOYEE RETENTION

 1.2 Therapists, Nurses, Psychologists, Unit Supervisors, Staff Supervisors and Case Managers:

            Work location
            Work schedule
            Salary concerns
            Sign up bonuses at new employer
            Benefits package
            Nature of the work
            Co-worker conflicts
            Relocation
            Career advancement
            Other (specify)
            Other (specify)
            Other (specify)




                                                                     Page 16 of 22
                                                  Wyoming Department of Health
                                            Home- and Community-Based Waiver Services
                                               Cost and Wage Survey (Long Version)
PROVIDER NAME:                      Provider A
SNAPSHOT DATE                       12/01/09
CITY AND COUNTY:                    City, County

WORKSHEET G: DIRECT SERVICE EMPLOYEE RETENTION

2. Impact of employee turnover. Rank in order the TOP THREE most significant impacts resulting from turnover of employees
  for your organization, with 1 indicating most frequent. You may mark other reasons that apply with an "X".


           Reduced continuity of care
           Reduced staff-to-client ratios
           Increased safety risks
           Difficulty meeting safety or health standards
           Reduction in services (either amount or type) because of increased costs or lack of staff
           Increased training costs
           Increased hiring or recruitment costs
           Inability to fulfill paperwork requirements
           Burnout of existing staff
           Inability to terminate undesirable or marginal staff
           Lower qualification of new employees
           Administrative staff working direct care
           Reduced training for new employees
           Other (specify)
           Other (specify)
           Other (specify)




                                                                  Page 17 of 22
                                                                                Wyoming Department of Health
                                                                          Home- and Community-Based Waiver Services
                                                                             Cost and Wage Survey (Long Version)

        PROVIDER NAME:                                      Provider A
        REPORT PERIOD BEGINNING:                            07/01/09
        REPORT PERIOD ENDING:                               06/30/10
        CITY AND COUNTY:                                    City, County

WORKSHEET H: EMPLOYEE BENEFITS
Check box to indicate if the following benefits are offered to full-time and part-time employees (included in this survey) at your agency.

                                  1                               2           3             4             5          6             7            8         9           10            11        12           13           14

                                                                 Non-Licensed Direct Service                                                                                         Administrative Staff - Non
                                                                                                              Licensed Professionals
                                                                         Professionals                                                       Administrative Staff - Managerial               Managerial
                                                                                        Employee                               Employee                            Employee                             Employee
Line                                                                        Part-     contribution                 Part-     contribution                Part-   contribution                Part-    contribution
No.                            Category                      Full-time      time       required?      Full-time    time       required?      Full-time   time     required?      Full-time   time      required?     Comments
  1    Health insurance for employee, including employer
       contributions to Health Savings Accounts

  2    Health insurance for employee's family
  3    Supplemental medical insurance
  4    Dental Insurance
  5    Dental Insurance for families                                                                              FALSE
  6    Life insurance
  7    Long-term care insurance
  8    Flexible spending accounts
  9    Supplemental disability insurance
  10   Payments in lieu of health insurance (health
       insurance premium reimbursement)
  11   Short-term disability
  12   Long-term disability
  13   401 (k) without employer match
  14   401 (k) with employer match                                                                                                                                                                        FALSE
  15   403 (B) with employer match
  16   403 (B) without employer match
  17   Pension Plan (defined benefit, including State
       Retirement)
  18   Employee Stock Ownership Purchase Plan
  19   Qualified Stock Purchase Plan
  20   Profit Sharing Plan
  21   Severance pay
  22   Unpaid leave of absence
  23   Payment for unused vacation days
  24   Expense account
  25   Housing or residence allowance




                                                                                                                Page 18 of 22
                                                                                Wyoming Department of Health
                                                                          Home- and Community-Based Waiver Services
                                                                             Cost and Wage Survey (Long Version)

        PROVIDER NAME:                                      Provider A
        REPORT PERIOD BEGINNING:                            07/01/09
        REPORT PERIOD ENDING:                               06/30/10
        CITY AND COUNTY:                                    City, County

WORKSHEET H: EMPLOYEE BENEFITS
Check box to indicate if the following benefits are offered to full-time and part-time employees (included in this survey) at your agency.

                                 1                                2           3             4             5          6             7            8         9           10            11        12           13           14

                                                                 Non-Licensed Direct Service                                                                                         Administrative Staff - Non
                                                                                                              Licensed Professionals
                                                                         Professionals                                                       Administrative Staff - Managerial               Managerial
                                                                                        Employee                               Employee                            Employee                             Employee
Line                                                                        Part-     contribution                 Part-     contribution                Part-   contribution                Part-    contribution
No.                         Category                         Full-time      time       required?      Full-time    time       required?      Full-time   time     required?      Full-time   time      required?     Comments
  26   Other room and board
  27   Professional membership
  28   Wellness Program
  29   Other (Specify):
                                                                           FALSE




                                                                                                                Page 19 of 22
      Wyoming Department of Health
Home- and Community-Based Waiver Services
   Cost and Wage Survey (Long Version)




               Page 20 of 22
      Wyoming Department of Health
Home- and Community-Based Waiver Services
   Cost and Wage Survey (Long Version)




               Page 21 of 22
                                                                                       Wyoming Department of Health
                                                                                 Home- and Community-Based Waiver Services
                                                                                    Cost and Wage Survey (Long Version)




PROVIDER NAME:                                                        Provider A
REPORT PERIOD BEGINNING:                                              07/01/09
REPORT PERIOD ENDING:                                                 06/30/10
CITY AND COUNTY:                                                      City, County


WORKSHEET I: ERROR SELF-CHECK
        1                                                                                          2                                                                  3    4     5
    Worksheet                                                                               Error Check                                                              Yes   No   N/A
Worksheet B      1.    Have you included all of the costs from your general ledger in the appropriate cost center and line number?

                 2.    Have you reported all of your "Non-Waiver Program Costs" in Column 5, within the appropriate cost center and line number?

                 3.    Have you excluded room and board costs from the costs reported in Column 4, "All Costs from the Provider Ledger" and included them
                       in Column 5, "Non-Waiver Program Costs"?
                 4.    If you have reported costs in any of the "Other" expenses rows, have you entered a description of the expense(s) in the designated cell?
Worksheet C      5.    Have you reported all of your revenue, by category, in the worksheet?
                 6.    Are revenues reported for "Other Patient Sources" (Line 4) less than or equal to the amounts reported as "Non-Waiver Program"
                       room and board costs reported in Column 5 on worksheet B?
Worksheet D      7.    Did you record information for all clients served in any of the four settings listed on the worksheet?
                 8.    Is the "Average Daily Census" amount reported (Column 3) equal to the sum of types of participants (Columns 4 through 7) for each of
                       the four settings listed on the worksheet?
Worksheet E      9.    For each type of program employee, do "Total Wages" (Column 3) equal the Salaries and Wages reported in worksheet B, lines 1-13?
                 10.   Is the amount reported for each employee type line in Column 3 (Total Wages) equal to the amount reported on worksheet B, Column 6, for the
                       same employee type line?

                 11.   For every line that "Total Hours Paid" are reported (Column 2), are "Total Wages" also reported (Column 3)?
                 12.   For every line that "Total Wages" are reported (Column 3), are "Total Hours Paid" also reported (Column 2)?
                 13.   For every line that "Total Overtime Hours Paid" are reported (Column 5), are "Total Overtime Wages" also reported (Column 6)?
                 14.   For every line that "Total Overtime Wages" are reported (Column 6), are "Total Overtime Hours Paid" reported (Column 5)?
                 15.   For every line that "Total Hours Paid" are reported (Column 2), are the hours equal to "Total Hours" (Column 12)?
                 16.   Are the reported "Direct Client Contact Hours" for Case Managers (Column 8, Line 4) equal to the number of hours that would have
                       been reported over the course of the reporting period on the Case Management Monthly Review Report?
Worksheet F      17.   Are the number of hours per week used to define Full-Time employees reported (Line 15, Column 2)?

                 18.   Have you reported a number of employees for each type (Lines 1-13) for which you reported "Total Wages" (Column 3) on Worksheet E?

                 19.   Did you enter in a snapshot date in the cell at the top of the worksheet?

Worksheet G      20.   For Questions 1 and 2, did you numerically order the top three responses and mark any other applicable responses with an "X"?

Worksheet H      21.   Have you checked all boxes for the benefits that apply to Full-Time and Part-Time employees and indicated with a checkmark whether
                       an employee contribution is required for any employee benefit you offer?




                                                                                                   Page 22 of 22

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:4
posted:8/9/2012
language:English
pages:22
suchufp suchufp http://
About