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NC Department of Health and Human Services
Division of Medical Assistance
2008 Mental Health Residential Treatment Cost Report SCHEDULE A
Reporting Basis
Part I - General Cash Accrual
1. Fiscal Year Ending Date: 9. LICENSED BED Capacity for Agency by Type of Care:
2. Federal Tax ID#: Non-Treatment BEDS
3. Corporate Name: Family Setting Program/Group Setting
Street or P.O.: Family
City, State, Zip: Foster Residential Care
4. Name of Contact Person/Director/Administrator Treatment BEDS
Family Setting Program/Group Setting
5. Telephone No. Ext: Therapeutic Foster Level II PRTF
6. Email Address: Level III Other MH
7. Fax Number: Level IV
8. # of Months in Operation during reporting period: 10. Total Number of Facilities:
From: To:
Part II - Tax Information
11. Entity Type: 12. Tax Status 13. Organizational Structure
Government Non-profit Sole proprietorship Partnership
Private For profit Corporation Other
Part III - Resident Days
Non-Treatment DAYS
14. Total Number of Non-Treatment Resident Census Days: Family Foster Residential Care
15. Total LICENSED Bed Days Available for Non-Treatment Resident Care: Family Foster Residential Care
15a.Total AVAILABLE Bed Days for Non-Treatment Resident Care: Family Foster Residential Care
Treatment DAYS
16. Total Number of Treatment Days:
Family Setting Program/Group Setting
Therapeutic
Foster Level II Level III Level IV PRTF Other MH
17. Total LICENSED Bed Days Available for Treatment: 17a. Total AVAILABLE Bed Days for Treatment:
Family Setting Program/Group Setting Family Setting Program/Group Setting
Level II PRTF Level II PRTF
Therapeutic Therapeutic
Foster Level III Other MH Family Level III Other MH
Level IV Level IV
Part IV - Certification of Accuracy
The undersigned individual (company) does hereby state that the report forms (Schedule A, A-1, B, C, C-1, C-2, and D) have been prepared from
accounting records of the facility and are accurate based on recorded information and information provided.
Chief Executive/Agency
Official's Signature: Date:
Auditor's Signature: Date:
Auditor's Phone Number:
Preparer's Signature Date:
Preparer's Phone
Number:
DMA Rate Setting bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
Updated: September 28, 2007 1 of 15 Sched A
N C DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE
2008 MENTAL HEALTH RESIDENTIAL TREATMENT COST REPORT
SCHEDULE A-1
Federal Tax ID # 0
Corporate Name: 0
Multiple Sites 1 - 4
1. Name of Facility: 6. RESIDENT or OCCUPIED DAYS:
Street or P.O.: Non-Treatment DAYS:
City, State, Zip Code: Family Foster Residential Care
2. Current Medicaid
Provider #: Treatment DAYS:
3. Prior Medicaid Therapeutic
Foster Care Level II Level III
Provider Number:
4. Level of Care:
5. Licensed Bed Other
Level IV PRTF
Capacity for this facility: MH
1. Name of Facility: 6. RESIDENT or OCCUPIED DAYS:
Street or P.O.: Non-Treatment DAYS:
City, State, Zip Code: Family Foster Residential Care
2. Current Medicaid
Provider #: Treatment DAYS:
3. Prior Medicaid Therapeutic
Foster Care Level II Level III
Provider Number:
4. Level of Care:
5. Licensed Bed Other
Level IV PRTF
Capacity for this facility: MH
1. Name of Facility: 6. RESIDENT or OCCUPIED DAYS:
Street or P.O.: Non-Treatment DAYS:
City, State, Zip Code: Family Foster Residential Care
2. Current Medicaid
Provider #: Treatment DAYS:
3. Prior Medicaid Therapeutic
Foster Care Level II Level III
Provider Number:
4. Level of Care:
5. Licensed Bed Other
Level IV PRTF
Capacity for this facility: MH
1. Name of Facility: 6. RESIDENT or OCCUPIED DAYS:
Street or P.O.: Non-Treatment DAYS:
City, State, Zip Code: Family Foster Residential Care
2. Current Medicaid
Provider #: Treatment DAYS:
3. Prior Medicaid Therapeutic
Foster Care Level II Level III
Provider Number:
4. Level of Care:
5. Licensed Bed Other
Level IV PRTF
Capacity for this facility: MH
DMA Rate Setting
Updated: September 28, 2007 bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
Page 2 of 15 Schedule A-1
N C DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE
SCHEDULE A-1
Federal Tax ID # 0
Corporate Name: 0
Multiple Sites 5 - 8
1. Name of Facility: 6. RESIDENT or OCCUPIED DAYS:
Street or P.O.: Non-Treatment DAYS:
City, State, Zip Code: Family Foster Residential Care
2. Current Medicaid
Provider #: Treatment DAYS:
3. Prior Medicaid Therapeutic
Foster Care Level II Level III
Provider Number:
4. Level of Care:
5. Licensed Bed Other
Level IV PRTF
Capacity for this facility: MH
1. Name of Facility: 6. RESIDENT or OCCUPIED DAYS:
Street or P.O.: Non-Treatment DAYS:
City, State, Zip Code: Family Foster Residential Care
2. Current Medicaid
Provider #: Treatment DAYS:
3. Prior Medicaid Therapeutic
Foster Care Level II Level III
Provider Number:
4. Level of Care:
5. Licensed Bed Other
Level IV PRTF
Capacity for this facility: MH
1. Name of Facility: 6. RESIDENT or OCCUPIED DAYS:
Street or P.O.: Non-Treatment DAYS:
City, State, Zip Code: Family Foster Residential Care
2. Current Medicaid
Provider #: Treatment DAYS:
3. Prior Medicaid Therapeutic
Foster Care Level II Level III
Provider Number:
4. Level of Care:
5. Licensed Bed Other
Level IV PRTF
Capacity for this facility: MH
1. Name of Facility: 6. RESIDENT or OCCUPIED DAYS:
Street or P.O.: Non-Treatment DAYS:
City, State, Zip Code: Family Foster Residential Care
2. Current Medicaid
Provider #: Treatment DAYS:
3. Prior Medicaid Therapeutic
Foster Care Level II Level III
Provider Number:
4. Level of Care:
5. Licensed Bed Other
Level IV PRTF
Capacity for this facility: MH
DMA Rate Setting
Updated: September 28, 2007 bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
Page 3 of 15 Schedule A-1
N C DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE
SCHEDULE A-1
Federal Tax ID # 0
Corporate Name: 0
Multiple Sites 9 - 12
1. Name of Facility: 6. RESIDENT or OCCUPIED DAYS:
Street or P.O.: Non-Treatment DAYS:
City, State, Zip Code: Family Foster Residential Care
2. Current Medicaid
Provider #: Treatment DAYS:
3. Prior Medicaid Therapeutic
Foster Care Level II Level III
Provider Number:
4. Level of Care:
5. Licensed Bed Other
Level IV PRTF
Capacity for this facility: MH
1. Name of Facility: 6. RESIDENT or OCCUPIED DAYS:
Street or P.O.: Non-Treatment DAYS:
City, State, Zip Code: Family Foster Residential Care
2. Current Medicaid
Provider #: Treatment DAYS:
3. Prior Medicaid Therapeutic
Foster Care Level II Level III
Provider Number:
4. Level of Care:
5. Licensed Bed Other
Level IV PRTF
Capacity for this facility: MH
1. Name of Facility: 6. RESIDENT or OCCUPIED DAYS:
Street or P.O.: Non-Treatment DAYS:
City, State, Zip Code: Family Foster Residential Care
2. Current Medicaid
Provider #: Treatment DAYS:
3. Prior Medicaid Therapeutic
Foster Care Level II Level III
Provider Number:
4. Level of Care:
5. Licensed Bed Other
Level IV PRTF
Capacity for this facility: MH
1. Name of Facility: 6. RESIDENT or OCCUPIED DAYS:
Street or P.O.: Non-Treatment DAYS:
City, State, Zip Code: Family Foster Residential Care
2. Current Medicaid
Provider #: Treatment DAYS:
3. Prior Medicaid Therapeutic
Foster Care Level II Level III
Provider Number:
4. Level of Care:
5. Licensed Bed Other
Level IV PRTF
Capacity for this facility: MH
DMA Rate Setting
Updated: September 28, 2007 bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
Page 4 of 15 Schedule A-1
N C DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE
2008 MENTAL HEALTH RESIDENTIAL TREATMENT COST REPORT
SCHEDULE B
Federal Tax ID: 0
Corporate Name: 0
Audit Year: 1/0/1900
REVENUE:
1. MEDICAID
a. HRI-R
b. CAP-MR
c. Other Medicaid
2. TOTAL MEDICAID $ -
3. OTHER FEDERAL FUNDS
a. IV-E Funds
b. IV-B Funds
c. Federal Grants
d. USDA School Food Service
e. All Other Federal Funds
4. TOTAL OTHER FEDERAL FUNDS $ -
5. STATE FUNDS
a. State Funds (Old Grant-in-Aide)
b. JJDP Funds
c. Non-Medicaid covered treatment (including At Risk)
d. State Training Funds
e. Non IV-E Foster Care Funds (SFHF)
f. All Other State Funds (including State Grants)
6. TOTAL STATE FUNDS $ -
7. COUNTY FUNDS
8. INVESTMENT INCOME
9. PRIVATE CONTRIBUTIONS
10. OTHER
11. TOTAL REVENUE (Total of Lines 2,4,6,7,8,9,10) $ -
12. LESS: TOTAL EXPENSES
13. NET PROFIT (LOSS) $ -
DMA Rate Setting bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
Updated: September 28, 2007 5 of 15 Schedule B-Revenue
NC Department of Health and Human Services
Division of Medical Assistance
2008 Mental Health Residential Treatment Cost Report
MENTAL HEALTH RESIDENTIAL R&B
SCHEDULE C - Expenses MENTAL HEALTH RESIDENTIAL TREATMENT (INCLUDING NON-IV-E ELIGIBLE THERAPEUTIC FOSTER HOME) ADMINISTRATION
Tax ID: 0 OTHER Room & Room & Room & Room & THERAPEUTIC
Corporate Name - MHL MHL MHL MHL PRTF CAP MR Board Board Board Board FAMILY MEDICAID TOTAL
Audit Date: 1/0/00 RESIDENTIAL RESIDENTIAL RESIDENTIAL RESIDENTIAL ICF MR, etc. RESIDENTIAL RESIDENTIAL RESIDENTIAL RESIDENTIAL FOSTER OTHER FUND- Covered Non-Covered NON-MEDICAID
LEVEL l LEVEL ll LEVEL lll LEVEL lV LEVEL l LEVEL ll LEVEL lll LEVEL IV Room & Board PROGRAM RAISING Services Services Services Admin
1 2 3 4 5 6 7 8 9 10 11 12 13 14a 14b 15 16
1 Position Count/FTE's per category 0.00 0.00 0.00 0.00 0.00 0.00 -
MEDICAID TREATMENT EXPENSES:
2a Salaries and Wages - Paraprofessional Staff $ - $ - $ - $ - $ - $ - $ -
Salaries and Wages - Licensed Professional Staff (LP)
2b (may also include Qualified Professional Staff (QP) $ - $ - $ - $ - $ - $ - $ -
2c Salaries and Wages - Associate Professional Staff (AP) $ - $ - $ - $ - $ - $ - $ -
3 Employee Benefit Program $ - $ - $ - $ - $ - $ - $ -
4 Payroll Taxes $ - $ - $ - $ - $ - $ - $ -
5 TOTAL SALARIES & RELATED EXPENSES $ - $ - $ - $ - $ - $ - $ -
6 Medicaid Supplies $ - $ - $ - $ - $ - $ - $ -
7 Contract Labor $ - $ - $ - $ - $ - $ - $ -
Bloodborne Pathogen (OSHA) for Medicaid Program
8 FTE's $ - $ - $ - $ - $ - $ - $ -
Employee Criminal Records Check Fees for Medicaid
9 FTE's $ - $ - $ - $ - $ - $ - $ -
10 Other $ - $ - $ - $ - $ - $ - $ -
11 TOTAL MEDICAID TREATMENT EXPENSES $ - $ - $ - $ - $ - $ - $ -
12 TOTAL MEDICAID RESIDENT DAYS PROVIDED - - - - - - -
PROGRAM EXPENSES for Room and Board, and
Supervision
Salary Expenses (Do not include Social Work or Admin
Salary)
13 Salaries and Wages $ - $ - $ -
14 Employee Benefit Program $ - $ - $ -
15 Payroll Taxes $ - $ - $ -
16 TOTAL SALARIES & RELATED EXPENSES $ - $ - $ - $ - $ - $ - $ - $ - $ -
Social Services Salary Expense (Do Not Include Admin)
17 Salaries and Wages $ - $ - $ -
18 Employee Benefit Program $ - $ - $ -
19 Payroll Taxes $ - $ - $ -
20 TOTAL SOCIAL SERVICES SALARY EXPENSE $ - $ - $ - $ - $ - $ - $ - $ - $ -
HOUSEKEEPING/SHELTER COST
21 Cleaning Supplies $ - $ - $ -
22 Outside Laundry Service $ - $ - $ -
23 Utilities $ - $ - $ -
24 Repair & Maintenance Building & Grounds $ - $ - $ -
25 Repair & Maintenance Equipment $ - $ - $ -
26 Sanitation & Pest Control $ - $ - $ -
27 Rent- Facility $ - $ - $ -
28 Rent-Buildings/Land $ - $ - $ -
29 Linen & Bedding $ - $ - $ -
30 Equipment $ - $ - $ -
31 Miscellaneous $ - $ - $ -
Page 6 of 15
DMA Rate Setting
Updated: September 28, 2007 bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
Schedule C-Expenses
NC Department of Health and Human Services
Division of Medical Assistance
MENTAL HEALTH RESIDENTIAL R&B
SCHEDULE C - Expenses MENTAL HEALTH RESIDENTIAL TREATMENT (INCLUDING NON-IV-E ELIGIBLE THERAPEUTIC FOSTER HOME) ADMINISTRATION
Tax ID: 0 OTHER Room & Room & Room & Room & THERAPEUTIC
Corporate Name - MHL MHL MHL MHL PRTF CAP MR Board Board Board Board FAMILY MEDICAID TOTAL
Audit Date: 1/0/00 RESIDENTIAL RESIDENTIAL RESIDENTIAL RESIDENTIAL ICF MR, etc. RESIDENTIAL RESIDENTIAL RESIDENTIAL RESIDENTIAL FOSTER OTHER FUND- Covered Non-Covered NON-MEDICAID
LEVEL l LEVEL ll LEVEL lll LEVEL lV LEVEL l LEVEL ll LEVEL lll LEVEL IV Room & Board PROGRAM RAISING Services Services Services Admin
1 2 3 4 5 6 7 8 9 10 11 12 13 14a 14b 15 16
32 TOTAL HOUSEKEEPING /SHELTER COST $ - $ - $ - $ - $ - $ - $ - $ - $ -
DIETARY/FOOD COST
33 Food $ - $ - $ -
34 Dietary Supplies/Equipment $ - $ - $ -
35 Miscellaneous $ - $ - $ -
36 TOTAL DIETARY/FOOD COST $ - $ - $ - $ - $ - $ - $ - $ - $ -
PERSONAL INCIDENTALS
37 Clothing $ - $ - $ -
38 Personal Hygiene Items $ - $ - $ -
39 Medical Supplies $ - $ - $ -
40 Physician Fees & Hospitalization $ - $ - $ -
41 Non-Legend Drugs and Medical Services $ - $ - $ -
42 Beauty and Barber Shop $ - $ - $ -
43 Miscellaneous $ - $ - $ -
44 TOTAL PERSONAL NEED COSTS/CLOTHING $ - $ - $ - $ - $ - $ - $ - $ - $ -
45 RECREATIONAL COST -- Therapeutic Recreation $ - $ - $ -
46 EDUCATIONAL COST - School Supplies $ - $ - $ -
TRANSPORTATION COST
47 Transportation for Family Visitation $ - $ - $ -
48 Travel Cost $ - $ - $ -
49 Miscellaneous $ - $ - $ -
50 TOTAL TRANSPORTATION COST $ - $ - $ - $ - $ - $ - $ - $ - $ -
51 Foster Care Board Payments to Foster Parents $ -
52 TOTAL ROOM & BOARD EXPENSE $ - $ - $ - $ - $ - $ - $ - $ - $ -
OTHER COSTS
53 Office Supplies $ - $ - $ -
54 Insurance - Vehicle $ - $ - $ -
55 Insurance - Fixed Assets $ - $ - $ -
56 Insurance - General $ - $ - $ -
57 Automobile & Truck Maintenance $ - $ - $ -
58 Telephone $ - $ - $ -
59 Postage $ - $ - $ -
60 Dues & Subscriptions $ - $ - $ -
61 Legal & Accounting $ - $ - $ -
62 Interest - Automobile $ - $ - $ -
63 Interest - Mortgage $ - $ - $ -
64 Interest - Fixed Assets $ - $ - $ -
65 Interest - Operating $ - $ - $ -
66 Audit $ - $ - $ -
67 Rent - Automotive/Equipment $ - $ - $ -
Page 7 of 15
DMA Rate Setting
Updated: September 28, 2007 bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
Schedule C-Expenses
NC Department of Health and Human Services
Division of Medical Assistance
MENTAL HEALTH RESIDENTIAL R&B
SCHEDULE C - Expenses MENTAL HEALTH RESIDENTIAL TREATMENT (INCLUDING NON-IV-E ELIGIBLE THERAPEUTIC FOSTER HOME) ADMINISTRATION
Tax ID: 0 OTHER Room & Room & Room & Room & THERAPEUTIC
Corporate Name - MHL MHL MHL MHL PRTF CAP MR Board Board Board Board FAMILY MEDICAID TOTAL
Audit Date: 1/0/00 RESIDENTIAL RESIDENTIAL RESIDENTIAL RESIDENTIAL ICF MR, etc. RESIDENTIAL RESIDENTIAL RESIDENTIAL RESIDENTIAL FOSTER OTHER FUND- Covered Non-Covered NON-MEDICAID
LEVEL l LEVEL ll LEVEL lll LEVEL lV LEVEL l LEVEL ll LEVEL lll LEVEL IV Room & Board PROGRAM RAISING Services Services Services Admin
1 2 3 4 5 6 7 8 9 10 11 12 13 14a 14b 15 16
68 Rent - Office $ - $ - $ -
69 Real Estate Taxes $ - $ - $ -
70 Data Processing $ - $ - $ -
71 Travel & Entertainment $ - $ - $ -
72 Licenses for individuals $ - $ - $ -
73 Licenses for facility $ - $ - $ -
74 Bloodborne Pathogen (OSHA) for Non-Medicaid FTE's $ - $ - $ -
Employee Criminal Records Check Fees for Non-
75 Medicaid FTE's $ - $ - $ -
76 Management Services $ - $ - $ -
77 Advertising $ - $ - $ -
78 Printing $ - $ - $ -
Meetings/Seminars/Training (Include Operations
79 Personnel Costs to set up) $ - $ - $ -
80 Miscellaneous $ - $ - $ -
81 Salaries and Other Expenses including Admin. $ - $ - $ -
82 TOTAL OTHER COSTS $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ -
83 TOTAL EXPENSES BEFORE DEPRECIATION $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ -
DEPRECIATION
84 Depreciation - Building & Improvement - Office $ - $ - $ -
85 Depreciation - Automotive $ - $ - $ -
86 Depreciation - Equipment $ - $ - $ -
87 TOTAL DEPRECIATION $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ -
88 TOTAL RATE SETTING EXPENSES $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ -
NON-ALLOWABLE EXPENSES
89 Child Development $ - $ - $ -
90 Other Child and Family Services $ - $ - $ -
91 Higher Education $ - $ - $ -
92 Bad Debts $ - $ - $ -
93 Multi-Purpose Group Home $ - $ - $ -
94 Miscellaneous & Non-Allowable costs -Medicaid $ - $ - $ -
95 In Kind Donations / Contributions $ - $ - $ -
96 Penalties $ - $ - $ -
97 Extraordinary Items $ -
98 TOTAL NON-ALLOWABLE EXPENSES $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ -
99a TOTAL TO MATCH AUDIT (Line 88 plus line 98) $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ -
99b SCHEDULE B TOTAL EXPENSE FROM LINE 12: $ -
DIFFERENCE:(TOTAL COLUMN, LN 99) LESS (SCHEDULE B TOTAL
99c EXPENSE FROM LINE 12) $ -
100 TOTAL RESIDENT DAYS PROVIDED - - - - - -
TOTAL PROGRAM EXPENSES ALLOWED (excludes
101 non Medicaid allowed line items) $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ -
Page 8 of 15
DMA Rate Setting
Updated: September 28, 2007 bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
Schedule C-Expenses
NC Department of Health and Human Services
Division of Medical Assistance
2008 Mental Health Residential Treatment Cost Report
SCHEDULE C-1 MEDICAID HRI-R EXPENSES
Tax ID: 0 Mental Foster Care Therapeutic BHLTR BHLTR BHLTR BHLTR
Corporate Name 0 Health Svc Therapeutic Behavioral 4 Beds or 5 Beds or 4 Beds or 5 Beds or OTHER
Audit Date: 1/0/1900 Child Services Less More Less More CAP MR,
LEVEL l LEVEL ll LEVEL ll LEVEL lll LEVEL lll LEVEL lV LEVEL lV PRTF ICF MR, etc.
H0046 S5145 H2020 H0019 H0019 H0019 H0019 TOTAL
1 2 3 4 5 6 7 8 9 10
1 Position Count/FTE's per category -
MEDICAID TREATMENT EXPENSES
2a Salaries and Wages - Paraprofessional Staff $ -
Salaries and Wages - Licensed Professional Staff (LP)
2b (may also include Qualified Professional Staff (QP) $ -
2c Salaries and Wages - Associate Professional Staff (AP) $ -
3 Employee Benefit Program $ -
4 Payroll Taxes $ -
5 TOTAL SALARIES AND RELATED EXPENSES $ - $ - $ - $ - $ - $ - $ - $ - $ - $ -
6 Medicaid Supplies $ -
7 Contract Labor $ -
8 Bloodborne Pathogen (OSHA) for Medicaid Program FTE's $ -
9 Employee Criminal Records Check Fees for Medicaid FTE's $ -
10 Other $ -
11 TOTAL MEDICAID TREATMENT EXPENSES $ - $ - $ - $ - $ - $ - $ - $ - $ - $ -
12 TOTAL MEDICAID RESIDENT DAYS PROVIDED -
PROGRAM EXPENSES for Room and Board, and
Supervision
Salary Expenses (Do not include Social Work or Admin Salary)
13 Salaries and Wages $ -
14 Employee Benefit Program $ -
15 Payroll Taxes $ -
16 TOTAL SALARIES AND RELATED EXPENSES $ - $ - $ -
Social Services Salary Expense (Do not include Admin) $ -
17 Salaries and Wages $ -
18 Employee Benefit Program $ -
19 Payroll Taxes $ -
20 TOTAL SOCIAL SERVICES SALARY EXPENSE $ - $ - $ -
HOUSEKEEPING/SHELTER COST
DMA Rate Setting
Updated: September 28, 2007 bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
Page 9 of 15 Sched C-1 Medicaid HRI-R Codes
NC Department of Health and Human Services
Division of Medical Assistance
2008 Mental Health Residential Treatment Cost Report
SCHEDULE C-1 MEDICAID HRI-R EXPENSES
Tax ID: 0 Mental Foster Care Therapeutic BHLTR BHLTR BHLTR BHLTR
Corporate Name 0 Health Svc Therapeutic Behavioral 4 Beds or 5 Beds or 4 Beds or 5 Beds or OTHER
Audit Date: 1/0/1900 Child Services Less More Less More CAP MR,
LEVEL l LEVEL ll LEVEL ll LEVEL lll LEVEL lll LEVEL lV LEVEL lV PRTF ICF MR, etc.
H0046 S5145 H2020 H0019 H0019 H0019 H0019 TOTAL
1 2 3 4 5 6 7 8 9 10
21 Cleaning Supplies $ -
22 Outside Laundry Service $ -
23 Utilities $ -
24 Repair & Maintenance Building & Grounds $ -
25 Repair & Maintenance Equipment $ -
26 Sanitation & Pest Control $ -
27 Rent- Facility $ -
28 Rent-Buildings/Land $ -
29 Linen & Bedding $ -
30 Equipment $ -
31 Miscellaneous $ -
32 TOTAL HOUSEKEEPING /SHELTER COST $ - $ - $ -
DIETARY/FOOD COST
33 Food $ -
34 Dietary Supplies/Equipment $ -
35 Miscellaneous $ -
36 TOTAL DIETARY/FOOD COST $ - $ - $ -
PERSONAL NEED COSTS/CLOTHING
37 Clothing $ -
38 Personal Hygiene Items $ -
39 Medical Supplies $ -
40 Physician Fees & Hospitalization $ -
41 Non-Legend Drugs and Medical Services $ -
42 Beauty and Barber Shop $ -
43 Miscellaneous $ -
44 TOTAL PERSONAL NEED COSTS/CLOTHING $ - $ - $ -
45 RECREATIONAL COST -- Therapeutic Recreation $ -
DMA Rate Setting
Updated: September 28, 2007 bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
Page 10 of 15 Sched C-1 Medicaid HRI-R Codes
NC Department of Health and Human Services
Division of Medical Assistance
2008 Mental Health Residential Treatment Cost Report
SCHEDULE C-1 MEDICAID HRI-R EXPENSES
Tax ID: 0 Mental Foster Care Therapeutic BHLTR BHLTR BHLTR BHLTR
Corporate Name 0 Health Svc Therapeutic Behavioral 4 Beds or 5 Beds or 4 Beds or 5 Beds or OTHER
Audit Date: 1/0/1900 Child Services Less More Less More CAP MR,
LEVEL l LEVEL ll LEVEL ll LEVEL lll LEVEL lll LEVEL lV LEVEL lV PRTF ICF MR, etc.
H0046 S5145 H2020 H0019 H0019 H0019 H0019 TOTAL
1 2 3 4 5 6 7 8 9 10
46 EDUCATIONAL COST - School Supplies $ -
TRANSPORTATION COST
47 Transportation for Family Visitation $ -
48 Travel Cost
49 Miscellaneous $ -
50 TOTAL TRANSPORTATION COST $ - $ - $ -
51 Foster Care Board Payments to Foster Parents
52 Total Room & Board Expense $ - $ - $ -
OTHER COSTS
53 Office Supplies $ -
54 Insurance - Vehicle $ -
55 Insurance - Fixed Assets $ -
56 Insurance - General $ -
57 Automobile & Truck Maintenance $ -
58 Telephone $ -
59 Postage $ -
60 Dues & Subscriptions $ -
61 Legal & Accounting $ -
62 Interest - Automobile $ -
63 Interest - Mortgage $ -
64 Interest - Fixed Assets $ -
65 Interest - Operating $ -
66 Audit $ -
67 Rent - Automotive/Equipment $ -
68 Rent - Office $ -
69 Real Estate Taxes $ -
70 Data Processing $ -
DMA Rate Setting
Updated: September 28, 2007 bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
Page 11 of 15 Sched C-1 Medicaid HRI-R Codes
NC Department of Health and Human Services
Division of Medical Assistance
2008 Mental Health Residential Treatment Cost Report
SCHEDULE C-1 MEDICAID HRI-R EXPENSES
Tax ID: 0 Mental Foster Care Therapeutic BHLTR BHLTR BHLTR BHLTR
Corporate Name 0 Health Svc Therapeutic Behavioral 4 Beds or 5 Beds or 4 Beds or 5 Beds or OTHER
Audit Date: 1/0/1900 Child Services Less More Less More CAP MR,
LEVEL l LEVEL ll LEVEL ll LEVEL lll LEVEL lll LEVEL lV LEVEL lV PRTF ICF MR, etc.
H0046 S5145 H2020 H0019 H0019 H0019 H0019 TOTAL
1 2 3 4 5 6 7 8 9 10
71 Travel & Entertainment $ -
72 Licenses for individuals $ -
73 Licenses for facility $ -
74 Bloodborne Pathogen (OSHA) for Non-Medicaid FTE's $ -
75 Employee Criminal Records Check Fees for Non- Medicaid FTE's $ -
76 Management Services $ -
77 Advertising $ -
78 Printing $ -
Meetings/Seminars/Training (Include Operations Personnel Costs
79 to set up) $ -
80 Miscellaneous $ -
81 Salaries and Other Expenses including Admin. $ -
82 TOTAL OTHER COSTS $ - $ - $ -
83 TOTAL EXPENSES BEFORE DEPRECIATION $ - $ - $ - $ - $ - $ - $ - $ - $ - $ -
DEPRECIATION
84 Depreciation - Building & Improvement - Office $ -
85 Depreciation - Automotive $ -
86 Depreciation - Equipment $ -
87 TOTAL DEPRECIATION $ - $ - $ - $ - $ - $ - $ - $ - $ - $ -
88 TOTAL RATE SETTING EXPENSES $ - $ - $ - $ - $ - $ - $ - $ - $ - $ -
NON-ALLOWABLE EXPENSES
89 Child Development $ -
90 Other Child and Family Services $ -
91 Higher Education $ -
92 Bad Debts $ -
93 Multi-Purpose Group Home $ -
94 Miscellaneous &Non-Allowable costs - Medicaid $ -
95 In Kind Donations / Contributions $ -
96 Penalties $ -
DMA Rate Setting
Updated: September 28, 2007 bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
Page 12 of 15 Sched C-1 Medicaid HRI-R Codes
NC Department of Health and Human Services
Division of Medical Assistance
2008 Mental Health Residential Treatment Cost Report
SCHEDULE C-1 MEDICAID HRI-R EXPENSES
Tax ID: 0 Mental Foster Care Therapeutic BHLTR BHLTR BHLTR BHLTR
Corporate Name 0 Health Svc Therapeutic Behavioral 4 Beds or 5 Beds or 4 Beds or 5 Beds or OTHER
Audit Date: 1/0/1900 Child Services Less More Less More CAP MR,
LEVEL l LEVEL ll LEVEL ll LEVEL lll LEVEL lll LEVEL lV LEVEL lV PRTF ICF MR, etc.
H0046 S5145 H2020 H0019 H0019 H0019 H0019 TOTAL
1 2 3 4 5 6 7 8 9 10
97 Extraordinary Items $ -
98 TOTAL NON-ALLOWABLE EXPENSES $ -
99 TOTAL TO MATCH AUDIT (Line 88 plus line 98) $ - $ - $ - $ - $ - $ - $ - $ - $ - $ -
100 TOTAL RESIDENT DAYS PROVIDED $ - $ - $ - $ - $ - $ - $ - $ - $ - $ -
101 Total Allowable Expenses by Definition of Service $ - $ - $ - $ - $ - $ - $ - $ - $ - $ -
DMA Rate Setting
Updated: September 28, 2007 bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
Page 13 of 15 Sched C-1 Medicaid HRI-R Codes
NC Department of Health and Human Services
Division of Medical Assistance
2008 MENTAL HEALTH RESIDENTIAL TREATMENT COST REPORT
Federal Tax ID #: 0
Corporate Name: 0
SCHEDULE C-2 POSITION / FTE's by Level of Care
LIST THE JOB TITLE, LEVEL OF STAFF AND THE NUMBER OF FTEs ASSOCIATED WITH THE JOB TITLE
MEDICAID TREATMENT EXPENSES
Mental Therape 5 Beds
Health utic Group 4 Beds or 5 Beds 4 Beds or More
Service Foster Homes Less or More or Less LEVEL
LEVEL I Care LEVEL II LEVEL III LEVEL III LEVEL IV IV
JOB TITLE Staff Qualification H0046 S5145 H2020 H0019 H0019 H0019 H0019 TOTALS
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Total FTEs: - - - - - - - -
FTEs from Schedule C-1: - - - - - - - -
DMA Rate Setting
Updated: September 28, 2007 14 of 15 bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
Schedule C-2 FTE Summary
NC Department of Health and Human Services
Division of Medical Assistance
2008 Mental Health Residential Treatment Cost Report
SCHEDULE D RELATED PARTY TRANSACTIONS
Corporate Name: 0
Tax ID: 0
Number of
Description of Line Item Line Program/Cost Expense Paid Hours
(Expense/Cost) # Center/Column Name Name of Related Party Relationship Amount (If Applicable)
ROUND FUNDS TO THE NEAREST WHOLE DOLLAR.
DMA Rate Setting bf74d37a-11be-45b5-bfeb-f2a06d2abe78.xls
Updated: September 28, 2007 15 of 15 Schedule D-Related Party Trans
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