SCHEDULE 5 PROGRAM: NON CONTRACT SCHEDULE OF MEDICAL ANCILLARY COSTS_part4 ppt
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STATE OF CALIFORNIA ADULT SUBACUTE SCH 2
Provider Name: Fiscal Period Ended:
ALHAMBRA HOSPITAL MEDICAL CENTER JUNE 30, 2007
Provider No:
LTC 70043G
COST CENTER
COL. DIRECT AND ALLOCATED EXPENSE
0.00 Adult Subacute $ 2,363,723 $ 2,363,723 $ 0
1.00 Old Cap Rel Costs-Bldg & Fixtures 0 0
2.00 Old Cap Rel Costs-Movable Equipment 0 0
3.00 New Cap Rel Costs-Bldg & Fixtures 263,723 314,131 50,408
4.00 New Cap Rel Costs-Movable Equipment 0 0
4.01 00
4.02 00
4.03 00
4.04 00
4.05 00
4.06 00
4.07 00
4.08 00
5.00 Employee Benefits 22,774 21,961 (813)
6.01 Non-Patient Telephones 0 0
6.02 Data Processing 0 0
6.03 Purchasing/Receiving 0 0
6.04 Patient Admitting 0 0
6.05 Patient Business Office 0 0
6.06 00
6.07 00
6.08 00
6.00 Administrative and General 342,636 338,862 (3,774)
7.00 Maintenance and Repairs 0 0
8.00 Operation of Plant 468,926 475,280 6,354
9.00 Laundry and Linen Service 77,252 77,928 676
10.00 Housekeeping 21,924 22,490 566
11.00 Dietary 64,468 64,749 281
12.00 Cafeteria 90,463 92,332 1,869
13.00 Maintenance of Personnel 0 0
14.00 Nursing Administration 0 0
15.00 Central Services & Supply 4,164 4,392 228
16.00 Pharmacy 0 0
17.00 Medical Records and Library 91,104 44,666 (46,438)
18.00 Social Service 23,767 22,864 (903)
19.00 00
19.02 00
19.03 00
20.00 00
21.00 Nursing School 0 0
22.00 Intern & Res Service-Salary & Fringes 0 0
23.00 Intern & Res Other Program 0 0
24.00 Paramedical Ed Program 0 0
TOTAL DIRECT AND
101.00 ALLOCATED EXPENSES $ 3,834,924 $ 3,843,377 $ 8,453
(To Adult Subacute Sch 1)
* From Schedule 8, Part I, Line 36.00
SUMMARY OF ADULT SUBACUTE FACILITY EXPENSES
REPORTED AUDITED * DIFFERENCE
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STATE OF CALIFORNIA ADULT SUBACUTE SCH 3
Provider Name: Fiscal Period Ended:
ALHAMBRA HOSPITAL MEDICAL CENTER JUNE 30, 2007
Provider No:
LTC 70043G
TOTAL RATIO
TOTAL SUBACUTE
SUBACUTE
ANCILLARY CHARGES COST TO ANCILLARY ANCILLARY
COST * CHARGES CHARGES ** COSTS***
ANCILLARY COST CENTERS (Adult SA Sch 4)
37.00 Operating Room $ 3,167,973 $ 15,068,745 0.210235 $ 0 $ 0
41.00 Radiology - Diagnostic 2,434,853 10,756,349 0.226364 52,182 11,812
43.00 Radioisotope 431,248 1,854,743 0.232511 0 0
44.00 Laboratory 3,175,765 21,740,181 0.146078 295,140 43,113
46.00 Whole Blood & Packed Red 873,403 623,641 1.400490 0 0
49.00 Respiratory Therapy 2,532,287 19,155,590 0.132196 5,319,759 703,249
50.00 Physical Therapy 699,685 3,958,002 0.176777 45,027 7,960
52.00
Speech Pathology 77,916 530,593 0.146847 15,960 2,344
53.00 Electrocardiology 735,125 4,110,438 0.178843 0 0
54.00 Electroencephalography 75,249 105,813 0.711151 0 0
55.00 Med Supply Charged to Patients 3,159,034 6,182,537 0.510961 1,371,895 700,985
56.00 Drugs Charged to Patients 4,077,315 28,451,429 0.143308 3,706,006 531,100
57.00 Renal Dialysis 447,219 1,789,364 0.249932 0 0
61.00 Emergency 3,003,592 6,232,588 0.481917 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
0.000000 0 0
101.00 TOTAL $ 24,890,664 $ 120,560,013 $ 10,805,969 $ 2,000,563
(To Adult Subacute Sch
* From Schedule 8, Column 27
** Total Other Allowable Ancillary Charges included in the rate.
*** Total Other Ancillary Costs included in the rate.
SCHEDULE OF TOTAL OTHER ALLOWABLE ADULT SUBACUTE ANCILLARY COSTS**
TOTAL ANCILLARY
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STATE OF CALIFORNIA ADULT SUBACUTE SCH 4
Provider Name: Fiscal Period Ended:
ALHAMBRA HOSPITAL MEDICAL CENTER JUNE 30, 2007
Provider No:
LTC 70043G
ANCILLARY CHARGES
37.00 Operating Room $ $ $ 0
41.00 Radiology - Diagnostic 32,687 19,495 52,182
43.00 Radioisotope 0
44.00 Laboratory 272,618 22,522 295,140
46.00 Whole Blood & Packed Red 0
49.00 Respiratory Therapy 5,177,220 142,539 5,319,759
50.00 Physical Therapy 35,044 9,983 45,027
52.00
Speech Pathology 15,960 15,960
53.00 Electrocardiology 0
54.00 Electroencephalography 0
55.00 Med Supply Charged to Patients 1,355,230 16,665 1,371,895
56.00 Drugs Charged to Patients 3,607,747 98,259 3,706,006
57.00 Renal Dialysis 0
61.00 Emergency 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
101.00
TOTAL ANCILLARY CHARGES
$ 10,480,546 $ 325,423 $ 10,805,969
(Adj 29)
AUDITED
ADJUSTMENTS TO OTHER ALLOWABLE
ADULT SUBACUTE ANCILLARY CHARGES
(To Adult Subacute Sch 3)
REPORTED ADJUSTMENTS
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STATE OF CALIFORNIA
Provider Name: Fiscal Period Ended:
ALHAMBRA HOSPITAL MEDICAL CENTER JUNE 30, 2007
Provider No:
LTC 70043G
COL.
1.00 Old Cap Rel Costs-Bldg & Fixtures $ 0 $ N/A
2.00 Old Cap Rel Costs-Movable Equipment 0 N/A
3.00 New Cap Rel Costs-Bldg & Fixtures 314,131 N/A
4.00 New Cap Rel Costs-Movable Equipment 0 N/A
4.01 0N/A
4.02 0N/A
4.03 0N/A
4.04 0N/A
4.05 0N/A
4.06 0N/A
4.07 0N/A
4.08 0N/A
5.00 Employee Benefits 567 21,395
6.01 Non-Patient Telephones 0 0
6.02 Data Processing 0 0
6.03 Purchasing/Receiving 0 0
6.04 Patient Admitting 0 0
6.05 Patient Business Office 0 0
6.06 00
6.07 00
6.08 00
6.00 Administrative and General 11,782 223,796
7.00 Maintenance and Repairs 0 0
8.00 Operation of Plant 45,702 36,103
9.00 Laundry and Linen Service 5,474 5,755
10.00 Housekeeping 3,624 1,667
11.00 Dietary 3,075 29,315
12.00 Cafeteria 12,452 29,943
13.00 Maintenance of Personnel 0 0
14.00 Nursing Administration 0 0
15.00 Central Services & Supply 1,360 911
16.00 Pharmacy 0 0
17.00 Medical Records and Library 3,008 19,935
18.00 Social Service 94 18,304
19.00 00
19.02 00
19.03 00
20.00 00
21.00 Nursing School 0 0
22.00 Intern & Res Service-Salary & Fringes 0 0
23.00 Intern & Res Other Program 0 0
24.00 Paramedical Ed Program 0 0
101.00 TOTAL ALLOCATED INDIRECT EXPENSES $ 401,268 $ 387,122
(To Adult Subacute Sch 1)
ADULT SUBACUTE SCH 5
COST CENTER
EMP BENEFITS
AUDITED SAL &AUDITED CAP
ALLOCATION OF INDIRECT EXPENSES
ADULT SUBACUTE
(COL 2)
RELATED
(COL 1)ALLOCATED EXPENSES
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STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period Ended:
ALHAMBRA HOSPITAL MEDICAL CENTER JUNE 30, 2007
NET EXP FOR
OLD CAPITAL
OLD
NEW CAPITAL
NEW
TRIAL BALANCE COST ALLOC BLDG & MOVABLE BLDG & MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST
0.00 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07
COMPUTATION OF COST ALLOCATION (W/S B)
GENERAL SERVICE COST CENTER
1.00
Old Cap Rel Costs-Bldg & Fixtures
0
2.00
Old Cap Rel Costs-Movable Equipmen
0
0
3.00
New Cap Rel Costs-Bldg & Fixtures
2,769,328
0
0
4.00
New Cap Rel Costs-Movable Equipme
0
0
0
0
4.01
0
0
0
0
0
4.02
0
0
0
0
0
0
4.03
0
0
0
0
0
0
0
4.04
0
0
0
0
0
0
0
0
4.05
0
0
0
0
0
0
0
0
0
4.06
0
0
0
0
0
0
0
0
0
0
4.07
0
0
0
0
0
0
0
0
0
0
0
4.08
0
0
0
0
0
0
0
0
0
0
0
0
5.00
Employee Benefits
273,337
0
0
7,243
0
0
0
0
0
0
0
0
6.01
Non-Patient Telephones
0
0
0
0
0
0
0
0
0
0
0
0
6.02
Data Processing
0
0
0
0
0
0
0
0
0
0
0
0
6.03
Purchasing/Receiving
0
0
0
0
0
0
0
0
0
0
0
0
6.04
Patient Admitting
0
0
0
0
0
0
0
0
0
0
0
0
6.05
Patient Business Office
0
0
0
0
0
0
0
0
0
0
0
0
6.06
0
0
0
0
0
0
0
0
0
0
0
0
6.07
0
0
0
0
0
0
0
0
0
0
0
0
6.08
0
0
0
0
0
0
0
0
0
0
0
0
6.00
Administrative and General
5,130,468
0
0
185,193
0
0
0
0
0
0
0
0
7.00
Maintenance and Repairs
0
0
0
0
0
0
0
0
0
0
0
0
8.00
Operation of Plant
2,723,856
0
0
315,706
0
0
0
0
0
0
0
0
9.00
Laundry and Linen Service
260,747
0
0
20,193
0
0
0
0
0
0
0
0
10.00
Housekeeping
89,762
0
0
21,922
0
0
0
0
0
0
0
0
11.00
Dietary
824,208
0
0
39,290
0
0
0
0
0
0
0
0
12.00
Cafeteria
540,603
0
0
100,541
0
0
0
0
0
0
0
0
13.00
Maintenance of Personnel
0
0
0
0
0
0
0
0
0
0
0
0
14.00
Nursing Administration
1,085,364
0
0
28,339
0
0
0
0
0
0
0
0
15.00 Central Services & Supply 201,961 0 0 223,21500000000
16.00 Pharmacy 1,276,665 0 0 25,05400000000
17.00 Medical Records and Library 632,733 0 0 44,55500000000
18.00
Social Service
62,215
0
0
0
0
0
0
0
0
0
0
0
19.00
0
0
0
0
0
0
0
0
0
0
0
0
19.02
0
0
0
0
0
0
0
0
0
0
0
0
19.03
0
0
0
0
0
0
0
0
0
0
0
0
20.00 000000000000
21.00 Nursing School 000000000000
22.00
Intern & Res Service-Salary & Fringes
0
0
0
0
0
0
0
0
0
0
0
0
23.00Intern & Res Other Program 000000000000
24.00Paramedical Ed Program 000000000000
INPATIENT ROUTINE COST CENTERS
25.00
Adults & Pediatrics (Gen Routine)
7,252,966
0
0
289,961
0
0
0
0
0
0
0
0
26.00 Intensive Care Unit 3,114,050 0 0 101,21400000000
27.00 Coronary Care Unit 000000000000
28.00 Neonatal Intensive Care Unit 000000000000
29.00Surgical Intensive Care 000000000000
31.00 Subprovider I 2,460,484 0 0 169,15000000000
0.00 000000000000
32.00 000000000000
33.00Nursery 000000000000
34.00
Medicare Certified Nursing Facility
0
0
0
0
0
0
0
0
0
0
0
0
35.00
Distinct Part Nursing Facility
0
0
0
0
0
0
0
0
0
0
0
0
36.00
Adult Subacute Care Unit
2,363,723
0
0
314,131
0
0
0
0
0
0
0
0
36.01
Subacute Care Unit II
0
0
0
0
0
0
0
0
0
0
0
0
36.02 Transitional Care Unit 000000000000
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STATE OF CALIFORNIA SCHEDULE 8
Provider Name: Fiscal Period Ended:
ALHAMBRA HOSPITAL MEDICAL CENTER JUNE 30, 2007
NET EXP FOR
OLD CAPITAL
OLD
NEW CAPITAL
NEW
TRIAL BALANCE COST ALLOC BLDG & MOVABLE BLDG & MOVABLE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP FIXTURES EQUIP COST COST COST COST COST COST COST
0.00 1.00 2.00 3.00 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07
COMPUTATION OF COST ALLOCATION (W/S B)
ANCILLARY COST CENTERS
37.00
Operating Room
1,960,873
0
0
190,823
0
0
0
0
0
0
0
0
38.00
Recovery Room
0
0
0
0
0
0
0
0
0
0
0
0
39.00
Delivery Room and Labor Room
0
0
0
0
0
0
0
0
0
0
0
0
40.00
Anesthesiology
0
0
0
0
0
0
0
0
0
0
0
0
41.00 Radiology - Diagnostic 1,438,337 0 0 262,60200000000
41.01 000000000000
41.02
0
0
0
0
0
0
0
0
0
0
0
0
42.00
Radiology - Therapeutic
0
0
0
0
0
0
0
0
0
0
0
0
43.00 Radioisotope 365,648 0 0 3,84300000000
44.00 Laboratory 2,443,275 0 0 67,76400000000
44.01Pathological Lab 000000000000
46.00 Whole Blood 771,239 0 0 82600000000
47.00 Blood Storing and Processing 000000000000
48.00 Intravenous Therapy 000000000000
49.00 Respiratory Therapy 2,020,228 0 0 19,48200000000
50.00
Physical Therapy
371,268
0
0
93,336
0
0
0
0
0
0
0
0
51.00
Occupational Therapy
0
0
0
0
0
0
0
0
0
0
0
0
52.00 Speech Pathology 44,659 0 0 9,22200000000
53.00 Electrocardiology 529,352 0 0 34,23700000000
54.00 Electroencephalography 16,793 0 0 20,59600000000
55.00 Medical Supplies Charged to Patients 2,123,99300000000000
56.00 Drugs Charged to Patients 2,113,76300000000000
57.00
Renal Dialysis
389,381
0
0
0
0
0
0
0
0
0
0
0
58.00
ASC (Non-Distinct Part)
0
0
0
0
0
0
0
0
0
0
0
0
59.00 000000000000
59.01 000000000000
59.02 000000000000
59.03 000000000000
60.00Clinic 000000000000
60.01
Other Clinic Services
0
0
0
0
0
0
0
0
0
0
0
0
61.00
Emergency
2,277,853
0
0
120,426
0
0
0
0
0
0
0
0
62.00Observation Beds 000000000000
71.00 000000000000
82.00 000000000000
83.00 000000000000
84.00
0
0
0
0
0
0
0
0
0
0
0
0
85.00
0
0
0
0
0
0
0
0
0
0
0
0
86.00
0
0
0
0
0
0
0
0
0
0
0
0
NONREIMBURSABLE COST CENTERS
96.00 Gift, Flower, Coffee Shop & Canteen 0 0 0 9,22200000000
97.00Research 000000000000
98.00Physicians' Private Office 000000000000
99.00 Nonpaid Workers 000000000000
99.01
Marketing
0
0
0
3,843
0
0
0
0
0
0
0
0
99.02
0
0
0
0
0
0
0
0
0
0
0
0
99.03 000000000000
99.04 000000000000
99.05 000000000000
100.00 M.O.S.T 114,658 0 0 5,82200000000
100.01 Outpatient Dailysis 0 0 0 41,57700000000
100.02 Whittier - NRCC 000000000000
100.03
El Monte - NRCC
0
0
0
0
0
0
0
0
0
0
0
0
100.04 Garfield - NRCC 000000000000
TOTAL
48,043,790
0
0
2,769,328
0
0
0
0
0
0
0
0
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STATE OF CALIFORNIA
Provider Name:
ALHAMBRA HOSPITAL MEDICAL CENTER
TRIAL BALANCE
EXPENSES
GENERAL SERVICE COST CENTER
1.00
Old Cap Rel Costs-Bldg & Fixtures
2.00
Old Cap Rel Costs-Movable Equipmen
3.00
New Cap Rel Costs-Bldg & Fixtures
4.00
New Cap Rel Costs-Movable Equipme
4.01
4.02
4.03
4.04
4.05
4.06
4.07
4.08
5.00
Employee Benefits
6.01
Non-Patient Telephones
6.02
Data Processing
6.03
Purchasing/Receiving
6.04
Patient Admitting
6.05
Patient Business Office
6.06
6.07
6.08
6.00
Administrative and General
7.00
Maintenance and Repairs
8.00
Operation of Plant
9.00
Laundry and Linen Service
10.00
Housekeeping
11.00
Dietary
12.00
Cafeteria
13.00
Maintenance of Personnel
14.00
Nursing Administration
15.00 Central Services & Supply
16.00 Pharmacy
17.00 Medical Records and Library
18.00
Social Service
19.00
19.02
19.03
20.00
21.00 Nursing School
22.00
Intern & Res Service-Salary & Fringes
23.00 Intern & Res Other Program
24.00 Paramedical Ed Program
INPATIENT ROUTINE COST CENTER
25.00
Adults & Pediatrics (Gen Routine)
26.00 Intensive Care Unit
27.00 Coronary Care Unit
28.00 Neonatal Intensive Care Unit
29.00 Surgical Intensive Care
31.00 Subprovider I
0.00
32.00
33.00 Nursery
34.00
Medicare Certified Nursing Facility
35.00
Distinct Part Nursing Facility
36.00
Adult Subacute Care Unit
36.01
Subacute Care Unit II
36.02 Transitional Care Unit
SCHEDULE 8.1
Fiscal Period Ended:
JUNE 30, 2007
ADMINIS-
ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE &
COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL
4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00
COMPUTATION OF COST ALLOCATION (W/S B)
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
41,997
0
0
0
0
0
0
0
0
5,357,658
0
0
0
0
0
0
0
0
0
0
0
0
0
94
0
0
0
0
0
0
0
0
3,039,656
381,516
0
0
0
0
0
0
0
0
0
0
280,940
35,262
0
0
0
0
0
0
0
0
0
0
111,684
14,018
0
4,675
0
0
0
0
0
0
0
0
868,174
108,967
0
2,625
0
0
0
0
0
0
0
0
643,769
80,801
0
0
0
0
0
0
0
0
0
0
0
0
0
9,054
0
0
0
0
0
0
0
0
1,122,757
140,920
01,30300000000426,48053,529
010,700000000001,312,419164,725
03,73800000000681,02685,478
0
610
0
0
0
0
0
0
0
0
62,825
7,885
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0000000000 00
0000000000 00
0
0
0
0
0
0
0
0
0
0
0
0
0000000000 00
0000000000 00
0
66,254
0
0
0
0
0
0
0
0
7,609,181
955,050
026,324000000003,241,588406,861
0000000000 00
0000000000 00
0000000000 00
018,405000000002,648,039332,363
0000000000 00
0000000000 00
0000000000 00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
21,961
0
0
0
0
0
0
0
0
2,699,815
338,862
0
0
0
0
0
0
0
0
0
0
0
0
0000000000 00
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STATE OF CALIFORNIA
Provider Name:
ALHAMBRA HOSPITAL MEDICAL CENTER
TRIAL BALANCE
EXPENSES
ANCILLARY COST CENTERS
37.00
Operating Room
38.00
Recovery Room
39.00
Delivery Room and Labor Room
40.00
Anesthesiology
41.00 Radiology - Diagnostic
41.01
41.02
42.00
Radiology - Therapeutic
43.00 Radioisotope
44.00 Laboratory
44.01 Pathological Lab
46.00 Whole Blood
47.00 Blood Storing and Processing
48.00 Intravenous Therapy
49.00 Respiratory Therapy
50.00
Physical Therapy
51.00
Occupational Therapy
52.00 Speech Pathology
53.00 Electrocardiology
54.00 Electroencephalography
55.00 Medical Supplies Charged to Patients
56.00 Drugs Charged to Patients
57.00
Renal Dialysis
58.00
ASC (Non-Distinct Part)
59.00
59.01
59.02
59.03
60.00 Clinic
60.01
Other Clinic Services
61.00
Emergency
62.00 Observation Beds
71.00
82.00
83.00
84.00
85.00
86.00
NONREIMBURSABLE COST CENTER
96.00 Gift, Flower, Coffee Shop & Canteen
97.00 Research
98.00 Physicians' Private Office
99.00 Nonpaid Workers
99.01
Marketing
99.02
99.03
99.04
99.05
100.00 M.O.S.T
100.01 Outpatient Dailysis
100.02 Whittier - NRCC
100.03
El Monte - NRCC
100.04 Garfield - NRCC
TOTAL
SCHEDULE 8.1
Fiscal Period Ended:
JUNE 30, 2007
ADMINIS-
ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE &
COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL
4.08 5.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.00
COMPUTATION OF COST ALLOCATION (W/S B)
0
17,074
0
0
0
0
0
0
0
0
2,168,770
272,209
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
09,538000000001,710,477214,687
0000000000 00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0000000000369,49146,376
014,747000000002,525,786317,019
0000000000 00
0000000000772,06596,904
0000000000 00
0000000000 00
015,914000000002,055,624258,007
0
0
0
0
0
0
0
0
0
0
464,604
58,314
0
0
0
0
0
0
0
0
0
0
0
0
000000000053,8816,763
01,10900000000564,69870,877
000000000037,3894,693
00000000002,123,993266,588
00000000002,113,763265,304
0
0
0
0
0
0
0
0
0
0
389,381
48,872
0
0
0
0
0
0
0
0
0
0
0
0
0000000000 00
0000000000 00
0000000000 00
0000000000 00
0000000000 00
0
0
0
0
0
0
0
0
0
0
0
0
0
14,115
0
0
0
0
0
0
0
0
2,412,395
302,787
0000000000 00
0000000000 00
0000000000 00
0000000000 00
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
00000000009,2221,158
0000000000 00
0000000000 00
0000000000 00
0
0
0
0
0
0
0
0
0
0
3,843
482
0
0
0
0
0
0
0
0
0
0
0
0
0000000000 00
0000000000 00
0000000000 00
034100000000120,82015,165
000000000041,5775,218
0000000000 00
0
0
0
0
0
0
0
0
0
0
0
0
0000000000 00
0
280,580
0
0
0
0
0
0
0
0
48,043,790
5,357,658
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA
Provider Name:
ALHAMBRA HOSPITAL MEDICAL CENTER
TRIAL BALANCE
EXPENSES
GENERAL SERVICE COST CENTER
1.00
Old Cap Rel Costs-Bldg & Fixtures
2.00
Old Cap Rel Costs-Movable Equipmen
3.00
New Cap Rel Costs-Bldg & Fixtures
4.00
New Cap Rel Costs-Movable Equipme
4.01
4.02
4.03
4.04
4.05
4.06
4.07
4.08
5.00
Employee Benefits
6.01
Non-Patient Telephones
6.02
Data Processing
6.03
Purchasing/Receiving
6.04
Patient Admitting
6.05
Patient Business Office
6.06
6.07
6.08
6.00
Administrative and General
7.00
Maintenance and Repairs
8.00
Operation of Plant
9.00
Laundry and Linen Service
10.00
Housekeeping
11.00
Dietary
12.00
Cafeteria
13.00
Maintenance of Personnel
14.00
Nursing Administration
15.00 Central Services & Supply
16.00 Pharmacy
17.00 Medical Records and Library
18.00
Social Service
19.00
19.02
19.03
20.00
21.00 Nursing School
22.00
Intern & Res Service-Salary & Fringes
23.00 Intern & Res Other Program
24.00 Paramedical Ed Program
INPATIENT ROUTINE COST CENTER
25.00
Adults & Pediatrics (Gen Routine)
26.00 Intensive Care Unit
27.00 Coronary Care Unit
28.00 Neonatal Intensive Care Unit
29.00 Surgical Intensive Care
31.00 Subprovider I
0.00
32.00
33.00 Nursery
34.00
Medicare Certified Nursing Facility
35.00
Distinct Part Nursing Facility
36.00
Adult Subacute Care Unit
36.01
Subacute Care Unit II
36.02 Transitional Care Unit
SCHEDULE 8.2
Fiscal Period Ended:
JUNE 30, 2007
CENTRAL MEDICAL
MAINT & OPER LAUNDRY & MAINT OF NURSING SERVICE RECORDS SOCIAL
REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN & SUPPLY PHARMACY & LIBRARY SERVICE
7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00
COMPUTATION OF COST ALLOCATION (W/S B)
0
0
30,552
0
33,168
0
0
59,446
0
2,813
0
152,119
0
7,198
0
0
0
0
0
0
0
0
42,877
0
2,029
0
62,187
0
0 337,725 1,720 15,981 0 9,643 0 0
037,90601,794038,851001
067,41103,190025,9430000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
000000000000
000000000000
0
0
0
0
0
0
0
0
0
0
0
0
000000000000
000000000000
0
438,711
142,793
20,759
741,190
248,421
0
548,308
4,289
0
170,878
40,439
0 153,136 35,436 7,246 58,164 58,821 0 274,154 2,689 0 43,462 1,665
000000000000
000000000000
000000000000
0 255,924 34,000 12,110 175,297 72,717 0 274,154 57000
000000000000
000000000000
000000000000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
475,280
77,928
22,490
64,749
92,332
0
0
4,392
0
44,666
22,864
0
0
0
0
0
0
0
0
0
0
0
0
000000000000
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA
Provider Name:
ALHAMBRA HOSPITAL MEDICAL CENTER
TRIAL BALANCE
EXPENSES
ANCILLARY COST CENTERS
37.00
Operating Room
38.00
Recovery Room
39.00
Delivery Room and Labor Room
40.00
Anesthesiology
41.00 Radiology - Diagnostic
41.01
41.02
42.00
Radiology - Therapeutic
43.00 Radioisotope
44.00 Laboratory
44.01 Pathological Lab
46.00 Whole Blood
47.00 Blood Storing and Processing
48.00 Intravenous Therapy
49.00 Respiratory Therapy
50.00
Physical Therapy
51.00
Occupational Therapy
52.00 Speech Pathology
53.00 Electrocardiology
54.00 Electroencephalography
55.00 Medical Supplies Charged to Patients
56.00 Drugs Charged to Patients
57.00
Renal Dialysis
58.00
ASC (Non-Distinct Part)
59.00
59.01
59.02
59.03
60.00 Clinic
60.01
Other Clinic Services
61.00
Emergency
62.00 Observation Beds
71.00
82.00
83.00
84.00
85.00
86.00
NONREIMBURSABLE COST CENTER
96.00 Gift, Flower, Coffee Shop & Canteen
97.00 Research
98.00 Physicians' Private Office
99.00 Nonpaid Workers
99.01
Marketing
99.02
99.03
99.04
99.05
100.00 M.O.S.T
100.01 Outpatient Dailysis
100.02 Whittier - NRCC
100.03
El Monte - NRCC
100.04 Garfield - NRCC
TOTAL
SCHEDULE 8.2
Fiscal Period Ended:
JUNE 30, 2007
CENTRAL MEDICAL
MAINT & OPER LAUNDRY & MAINT OF NURSING SERVICE RECORDS SOCIAL
REPAIRS PLANT LINEN HOUSEKEEP DIETARY CAFE PERSONNEL ADMIN & SUPPLY PHARMACY & LIBRARY SERVICE
7.00 8.00 9.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00
COMPUTATION OF COST ALLOCATION (W/S B)
0
288,714
11,462
13,662
0
63,504
0
274,154
0
0
75,499
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 397,317 4,793 18,800 0 34,852 0 0 35 0 53,893 0
000000000000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
05,81402750000009,2930
0 102,527 7,911 4,851 0 56,493 0 0 52,254 0 108,925 0
000000000000
01,2500590000003,1250
000000000000
000000000000
0 29,476 0 1,395 0 53,228 0 0 38,224 0 95,975 358
0
141,218
3,374
6,682
0
0
0
0
1,058
0
19,831
4,604
0
0
0
0
0
0
0
0
0
0
0
0
013,95306600000002,6580
051,80102,451024,703000020,5950
031,16201,4750000005300
00000000737,476030,9760
0000000001,555,697142,5500
0
0
0
0
0
0
0
0
0
0
8,965
0
0
0
0
0
0
0
0
0
0
0
0
0
000000000000
000000000000
000000000000
000000000000
000000000000
0
0
0
0
0
0
0
0
0
0
0
0
0
182,205
27,337
8,622
0
33,637
0
0
4,602
0
31,227
780
000000000000
000000000000
000000000000
000000000000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
013,953066000000000
000000000000
000000000000
000000000000
0
5,814
0
275
0
5,745
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
000000000000
000000000000
000000000000
08,808041702,809000000
062,90602,97700000000
000000000000
0
0
0
0
0
0
0
0
0
0
0
0
000000000000
0
3,421,172
346,753
158,870
1,039,400
883,887
0
1,370,770
845,077
1,555,697
863,048
70,710
This is trial version
www.adultpdf.com
STATE OF CALIFORNIA
Provider Name:
ALHAMBRA HOSPITAL MEDICAL CENTER
TRIAL BALANCE
EXPENSES
GENERAL SERVICE COST CENTER
1.00
Old Cap Rel Costs-Bldg & Fixtures
2.00
Old Cap Rel Costs-Movable Equipmen
3.00
New Cap Rel Costs-Bldg & Fixtures
4.00
New Cap Rel Costs-Movable Equipme
4.01
4.02
4.03
4.04
4.05
4.06
4.07
4.08
5.00
Employee Benefits
6.01
Non-Patient Telephones
6.02
Data Processing
6.03
Purchasing/Receiving
6.04
Patient Admitting
6.05
Patient Business Office
6.06
6.07
6.08
6.00
Administrative and General
7.00
Maintenance and Repairs
8.00
Operation of Plant
9.00
Laundry and Linen Service
10.00
Housekeeping
11.00
Dietary
12.00
Cafeteria
13.00
Maintenance of Personnel
14.00
Nursing Administration
15.00 Central Services & Supply
16.00 Pharmacy
17.00 Medical Records and Library
18.00
Social Service
19.00
19.02
19.03
20.00
21.00 Nursing School
22.00
Intern & Res Service-Salary & Fringes
23.00 Intern & Res Other Program
24.00 Paramedical Ed Program
INPATIENT ROUTINE COST CENTER
25.00
Adults & Pediatrics (Gen Routine)
26.00 Intensive Care Unit
27.00 Coronary Care Unit
28.00 Neonatal Intensive Care Unit
29.00 Surgical Intensive Care
31.00 Subprovider I
0.00
32.00
33.00 Nursery
34.00
Medicare Certified Nursing Facility
35.00
Distinct Part Nursing Facility
36.00
Adult Subacute Care Unit
36.01
Subacute Care Unit II
36.02 Transitional Care Unit
SCHEDULE 8.3
Fiscal Period Ended:
JUNE 30, 2007
POST
NON- INT & RES STEP-DOWN TOTAL
ALLOC ALLOC ALLOC PHYSICIAN NURSING SALARY & INT & RES PARAMED SUBTOTAL
ADJUSTMENT
COST
COST COST COST ANESTH SCHOOL FRINGES PROGRAM EDUCAT (Adj. 4, 12)
19.00 19.02 19.03 20.00 21.00 22.00 23.00 24.00 25.00 26.00 27.00
COMPUTATION OF COST ALLOCATION (W/S B)
0
0
0
000
0000
0
0
0
0
0
000000
0000000
0
0
0
0
0
0
0
0
10,920,018
3,804,662
14,724,680
000000004,283,221 4,283,221
000000000 0
000000000 0
000000000 0
000000003,804,662 (3,804,662) 0
000000000 0
000000000 0
000000000 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
3,843,377
3,843,377
0
0
0
0
0
0
0
0
0
0
000000000 0
This is trial version
www.adultpdf.com
