REPORT ON THE RATE SETTING AUDIT MACLAY HEALTHCARE CENTER SYLMAR_part4 pdf

State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
30
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted
Adjustments
MACLAY HEALTHCARE CENTER JANUARY 13, 2007 THROUGH DECEMBER 31, 2007 LTC55583G
Report References
Cost Report
Audit Report
Explanation of Audit Adjustments
RECLASSIFICATIONS OF REPORTED COSTS
15 Not Reported 8A-2 165.07 Administration - DHS Licensing Fees $0 $28,617 $28,617
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 901,509 (28,617) 872,892 *
To reclassify DHS licensing fees for proper cost determination.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
16 Not Reported 8A-2 105.04 Skilled Nursing Care - Other - Nonlabor * $226,794 ($32,667) $194,127
Not Reported 8A-2 165.11 Administration - Other - Nonlabor * 872,892 32,667 905,559 *
To reclassify medical director expense to the appropriate cost center.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8
*Balance carried forward from prior/to subsequent adjustments Page 4
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
30
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted

Adjustments
MACLAY HEALTHCARE CENTER JANUARY 13, 2007 THROUGH DECEMBER 31, 2007 LTC55583G
Report References
Cost Report
Audit Report
Explanation of Audit Adjustments
ADJUSTMENTS TO REPORTED COSTS
17 10.1(4) 5 14 8A-2 5.00 Plant Operations and Maintenance * $4,538 ($4,538) $0
10.1(4) 40 14 8A-2 40.00 Property Taxes 75,335 46,454 121,789 *
10.1(4) 65 14 8A-2 65.00 Dietary * 6,965 (6,965) 0
10.1(4) 105 14 8A-2 105.00 Skilled Nursing Care * 82,178 (82,178) 0
10.1(4) 155 14 8A-2 155.00 Social Services * 1,347 (1,347) 0
10.1(4) 160 14 8A-2 160.00 Activities * 2,448 (2,448) 0
10.1(4) 165 14 8A-2 165.00 Administration * (27,826) 27,826 0
10.1(4) 170 14 8A-2 170.00 Inservice Education - Nursing * 3,057 (3,057) 0
To reconcile reported expenses to agree with the provider's general
ledger.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Section 2304
18 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $905,559 ($159,357) $746,202 *
To adjust home office costs to agree with the filed Home
Office Cost Report.
42 CFR 413.17 / CMS Pub. 15-1, Sections 2150.2 and 2304
19 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $746,202 ($7,960) $738,242 *
To eliminate tax penalties and fines not related to patient care.
42 CFR 413.9(c)(3) / CMS Pub. 15-1, Sections 2102.3 and 2122.1
20 10.1(4) 40 8A-2 40.00 Property Taxes * $121,789 ($56,656) $65,133
To adjust property taxes to agree with the property tax invoices.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
21 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $738,242 ($116,377) $621,865 *
To eliminate interest expenses due to insufficient documentation.

42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
22 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $621,865 ($4,102) $617,763 *
To eliminate travel expenses due to insufficient documentation.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
*Balance carried forward from prior/to subsequent adjustments Page 5
This is trial version
www.adultpdf.com
State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
30
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted
Adjustments
MACLAY HEALTHCARE CENTER JANUARY 13, 2007 THROUGH DECEMBER 31, 2007 LTC55583G
Report References
Cost Report
Audit Report
Explanation of Audit Adjustments
ADJUSTMENTS TO REPORTED COSTS
23 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $617,763 ($2,001) $615,762 *
To eliminate advertising expenses due to insufficient documentation.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
24 Not Reported 8A-2 165.08 Administration - Liability Insurance * $127,604 ($127,604) $0
To eliminate liability insurance expenses due to lack of
documentation.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
25 Not Reported 8A-2 165.11 Administration - Other - Nonlabor * $615,762 ($2,630) $613,132
To eliminate bank charges expenses due to insufficient documentation.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304

*Balance carried forward from prior/to subsequent adjustments Page 6
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www.adultpdf.com
State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
30
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted
Adjustments
MACLAY HEALTHCARE CENTER JANUARY 13, 2007 THROUGH DECEMBER 31, 2007 LTC55583G
Report References
Cost Report
Audit Report
Explanation of Audit Adjustments
ADJUSTMENT TO REPORTED STATISTICS
26 Not Reported 7 5.00 Plant Operations and Maintenance (Square Feet) 0 1,210 1,210
Not Reported 7 10.00 Housekeeping 0 322 322
Not Reported 7 60.00 Laundry and Linen 0 664 664
Not Reported 7 65.00 Dietary 0 5,629 5,629
Not Reported 7 155.00 Social Services 0 1,300 1,300
Not Reported 7 160.00 Activities 0 448 448
Not Reported 7 165.00 Administration 0 3,463 3,463
Not Reported 7 165.00 Medical Records 0 270 270
11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 32,515 13,306 45,821
11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 32,515 12,096 44,611
11.1(1 of 3) 85 2 7 N/A Total Statistics - Square Feet 32,515 11,774 44,289
To establish the correct square footage in order to properly allocate
indirect costs.
42 CFR 413.24 / CMS Pub. 15-1, Sections 2300, 2302.4B and 2306

Page 7
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www.adultpdf.com
State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
30
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted
Adjustments
MACLAY HEALTHCARE CENTER JANUARY 13, 2007 THROUGH DECEMBER 31, 2007 LTC55583G
Report References
Cost Report
Audit Report
Explanation of Audit Adjustments
ADJUSTMENT TO REPORTED PATIENT DAYS
27 4.1 05 6 1 12.00 Total Patient Days 47,261 174 47,435
To adjust total patient days to agree with the provider's
patient census reports.
42 CFR 413.20 and 413.50
CMS Pub. 15-1, Sections 2205 and 2304
Page 8
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State of California Department of Health Care Services
Provider Name Fiscal Period Provider Number
30
MC530
Adj. Page or As Increase As
No. Exhibit Line Col. Sch Line Reported (Decrease) Adjusted

Adjustments
MACLAY HEALTHCARE CENTER JANUARY 13, 2007 THROUGH DECEMBER 31, 2007 LTC55583G
Report References
Cost Report
Audit Report
Explanation of Audit Adjustments
ADJUSTMENTS TO OTHER MATTERS
28 Not Reported 1 14.00 Overpayments $0 $30,239 $30,239 *
To recover overpayments for overstated Medi-Cal patient days.
CCR, Title 22, Section 51458.1
29 Not Reported 1 14.00 Overpayments * $30,239 $2,838 $33,077 *
To recover outstanding Medi-Cal credit balances.
CCR, Title 22, Sections 50761 and 51458.1
30 Not Reported 1 14.00 Overpayments * $33,077 $129 $33,206
To recover Medi-Cal overpayments because the Share of Cost
was not properly deducted from the amount billed.
42 CFR 413.5 and 413.20 / CMS Pub. 15-1, Section 2409
*Balance carried forward from prior/to subsequent adjustments Page 9
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