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REPORT ON THE
COST REPORT REVIEW
CHINO VALLEY MEDICAL CENTER CHINO CALIFORNIA
NATIONAL PROVIDER IDENTIFIER 1962407460
FISCAL PERIOD ENDED DECEMBER 31 2011
Audits SectionmdashRancho Cucamonga Financial Audits Branch
Audits and Investigations Department of Health Care Services
Section Chief Julio M Cueto Audit Supervisor Bina Matani Auditor Kristine Lim
A
r
Sttate of CalifoorniamdashHealth and Humman Servicees Agency DDepartmment of HHealth CCare Seervices
TOOBY DOUGLAS EDMUNDD G BROWN JR DIRECTOR GOVERNOR
Decembber 6 2013
Martin MMansukhanii Chief Finnancial Off icer Inland VValley Regioonal of Primme Healthcaare 3300 Eaast Guasti RRoad 2nd Floor Ontario CA 91761
CHINO VVALLEY MMEDICAL CENTER NATIONNAL PROVIDER IDENNTIFIER (NPPI) 19624077460 FISCAL PERIOD EENDED DECEMBER 331 2011
We havee examinedd the providders Medi-CCal Cost Reeport for thee above-refferenced fisscal period Our examinnation was made undeer the authoority of Secction 141700 of the Wellfare and Insttitutions Code and acccordingly inncluded succh tests of the accounnting recordds and such other audditing proceedures as wwe considerred necessaary in the circumstancces
In our oppinion the audited setttlement forr the fiscal pperiod due the provideer in the amount of $237252 presented in the Summary of FFindings reppresents a proper determinnation in acccordance wwith the reimmbursemennt principless of applicaable progra ms
This audit report inncludes the
1 SSummary off Findings
2 CComputationn of Medi-CCal Reimbursement Seettlement (NNONCONTTRACT SSchedules)
3 AAudit Adjusttments Schedule
The auddited settlemment will bee incorporatted into a SStatement oof Account SStatus whicch may reflect tentativve retroactivve adjustmeent determiinations paayments froom the provvider and otheer financial transactionns initiated by the Deppartment TThe Statement of Accoount Status wwill be forwaarded to thee provider bby the Statees fiscal inttermediary Instructio ns regardinng paymentt will be inclluded with tthe Statemeent of Accoount Status
Notwithsstanding thiis audit repport overpaayments to tthe provideer are subjeect to recoveery pursuannt to Sectionn 514581 Article 6 of Division 3 Title 22 CCalifornia Coode of Regulatiions
Financial Auudits BranchA udits Section ndashndash Rancho Cucaamonga 9439 Archibald Aveenue Suite 1077 MS 2105 Raancho Cucamoonga CA 917300
(909) 481-34220 (909) 481--3442 fax Internet Address wwwdhccscagov
Martin Mansukhani Page 2
If you disagree with the decision of the Department you may appeal by writing to
Chief Department of Health Care Services Office of Administrative Hearings and Appeals 1029 J Street Suite 200 Sacramento CA 95814 (916) 322-5603
The written notice of disagreement must be received by the Department within 60 calendar days from the day you receive this letter A copy of this notice should be sent to
United States Postal Service (USPS) Courier (UPS FedEx etc) Assistant Chief Counsel Assistant Chief Counsel Department of Health Care Services Department of Health Care Services Office of Legal Services Office of Legal Services MS 0010 MS 0010 PO Box 997413 1501 Capitol Avenue Suite 715001 Sacramento CA 95899 Sacramento CA 95814
(916) 440-7700
The procedures that govern an appeal are contained in Welfare and Institutions Code Section 14171 and California Code of Regulations Title 22 Section 51016 et seq
Martin Mansukhani Page 3
If you have questions regarding this report you may call the Audits SectionmdashRancho Cucamonga at (909) 481-3420
Original Signed By
Julio M Cueto Chief Audits SectionmdashRancho Cucamonga Financial Audits Branch
Certified
cc Pete Lou Controller Inland Valley Regional Chino Valley Medical Center
Jeffrey Brown Chief Executive Officer Hospital Management Services 211 East Imperial Highway Suite 102 Fullerton CA 92835
SUMMARY OF FINDINGS
Provider Name Fiscal Period Ended
CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
SETTLEMENT COST
1 Medi-Cal Noncontract Settlement (SCHEDULE 1) Provider NPI 1962407460 Reported
Net Change
Audited Amount Due Provider (State)
$ 1285626
$ (1048374)
$ 237252
2 Subprovider I (SCHEDULE 1-1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
3 Subprovider II (SCHEDULE 1-2) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
4 Medi-Cal Contract Cost (CONTRACT SCH 1) Provider NPI 1962407460 Reported
Net Change
Audited Cost
Audited Amount Due Provider (State)
$
$
$
0
0
0
$ 0
5 Distinct Part Nursing Facility (DPNF SCH 1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
6 Distinct Part Nursing Facility (DPNF SCH 1-1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
7 Adult Subacute (ADULT SUBACUTE SCH 1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
8 Total Medi-Cal Settlement Due Provider (State) - (Lines 1 through 7) $ 237252
9 Total Medi-Cal Cost $ 0
SUMMARY OF FINDINGS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
SETTLEMENT COST
10 Subacute (SUBACUTE SCH 1-1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
11 Rural Health Clinic (RHC SCH 1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
12 Rural Health Clinic (RHC 95-210 SCH 1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
13 Rural Health Clinic (RHC 95-210 SCH 1-1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
14 County Medical Services Program (CMSP SCH 1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
15 Transitional Care (TC SCH 1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
16 Total Other Settlement Due Provider - (Lines 10 through 15) $ 0
17 Total Combined Audited Settlement Due Provider (StateCMSPRHC) - (Line 8 + Line 16) $ 237252
STATE OF CALIFORNIA SCHEDULE 1 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
1 Net Cost of Covered Services Rendered to Medi-Cal Patients (Schedule 3) $ 7914460 $ 7802163
2 Excess Reasonable Cost Over Charges (Schedule 2) $ 0 $ 0
3 Medi-Cal Inpatient Hospital Based Physician Services $ 0 $ NA
4 $ 0 $ 0
5 TOTAL COST-Reimbursable to Provider (Lines 1 through 4) $ 7914460 $ 7802163
6 Interim Payments (Adj 35) $ (6628834) $ (7256881)
7 Balance Due Provider (State) $ 1285626 $ 545282
8 Medi-Cal Overpayments (Adjs 37-38) $ 0 $ (23344)
9 AB 5 and AB 1183 Reduction (Sch A) $ $ (284686)
10 Protested Amount (Adj 2) $ 0 $ 0
11 TOTAL MEDI-CAL SETTLEMENT Due Provider (State) $ 1285626 $ 237252 (To Summary of Findings)
STATE OF CALIFORNIA SCHEDULE A PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT AB 5 and AB 1183 - SUMMARY OF REDUCTIONS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER December 31 2011
Provider No 1962407460
1 10 Reduction to Noncontract Services for 070108 Through 93008 (SCHEDULE A-1) $ 0
2 Reduction to Noncontract Services for 100108 Through 040509 (SCHEDULE A-2) 0
3 10 Reduction to Noncontract Services for 010111 Through 041211 (SCHEDULE A-3) 284686
4 10 Reduction to HFPAs lt 3 Hospitals for 070108 Through 041211 (SCHEDULE A-4) 0
5 10 Reduction to Rural Health Hospitals for 070108 Through 103108 (SCHEDULE A-5) 0
6 10 Reduction to Rural Health Hospitals for 070109 Through 022410 (SCHEDULE A-6) 0
7 Total Noncontract AB 5 AND AB 1183 Reductions $ 284686 (To Schedule 1 Line 9)
STATE OF CALIFORNIA SCHEDULE A-3 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT AB 5 - 10 REDUCTION TO SERVICES FROM APRIL 6 2009 THROUGH April 12 2011 - NONCONTRACT HOSPITALS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER December 31 2011
Provider No 1962407460
Audited Medi-Cal Cost Per Day
1 Medi-Cal Cost of Covered Services (Schedule 3 Line 8) $ 8000826
2 Less Medi-Cal Administrative Day Cost (Schedule 4A Lines 33 and 36)
3 Less Medi-Cal Administrative Ancillary Cost (Schedule A-7)
4 Total Medi-Cal Cost of Covered Services Subject to Reductions (Line 1 - Lines 2 and 3) $ 8000826
5 Total Audited Medi-Cal Days (Schedules 4 4A and 4B excludes Administrative Days) 309425
6 Audited Medi-Cal Cost Per Day (Line 4 Line 5) $ 258571
AB 5 - 10 Cost Reduction For Services From 010111 Through 041211
7 Audited Medi-Cal Days of Service from 010111 Through 041211(excludes Administrative Days) 1101
8 Audited Medi-Cal Cost Per Day For 010111 Through 041211(Line 6 Line 7) $ 2846864
9 AB 5 - 10 Cost Reduction for 010111 Through 041211 (Line 8 10) $ 284686 (To Schedule A Line 3)
0
STATE OF CALIFORNIA SCHEDULE 2 PROGRAM NONCONTRACT
COMPUTATION OF LESSER OF MEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
REASONABLE COST OF MEDI-CAL INPATIENT SERVICES
1 Cost of Covered Services (Schedule 3) $ 8095037 $ 8000826
CHARGES FOR MEDI-CAL INPATIENT SERVICES
2 Inpatient Routine Service Charges (Adj 33) $ 6182850 $ 8491100
3 Inpatient Ancillary Service Charges (Adj 33) $ 20623381 $ 22454058
4 Total Charges - Medi-Cal Inpatient Services $ 26806231 $ 30945158
5 Excess of Customary Charges Over Reasonable Cost (Line 4 minus Line 1) $ 18711194 $ 22944332
6 Excess of Reasonable Cost Over Customary Charges (Line 1 minus Line 4) $ 0 $ 0
(To Schedule 1)
If charges exceed reasonable cost no further calculation necessary for this schedule
STATE OF CALIFORNIA SCHEDULE 3 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL NET COSTS OF COVERED SERVICES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
1 Medi-Cal Inpatient Ancillary Services (Schedule 5) $ 3996748 $ 3799513
2 Medi-Cal Inpatient Routine Services (Schedule 4) $ 4098289 $ 4201313
3 Medi-Cal Inpatient Hospital Based Physician for Intern and Resident Services (Sch ) $ 0 $ 0
4 $ 0 $ 0
5 $ 0 $ 0
6 SUBTOTAL (Sum of Lines 1 through 5) $ 8095037 $ 8000826
7 Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Schedule 7) $ (See Schedule 1) $ 0
8 SUBTOTAL $ 8095037 $ 8000826 (To Schedule 2)
9 Medi-Cal Deductible (Adj 34) $ (19255) $ (18887) 10 Medi-Cal Coinsurance (Adj 34) $ (161322) $ (179776)
11 Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ 7914460 $ 7802163
(To Schedule 1)
STATE OF CALIFORNIA SCHEDULE 4 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED AUDITED
INPATIENT DAYS 1 Total Inpatient Days (include private amp swing-bed) (Adj ) 15592 15592 2 Inpatient Days (include private exclude swing-bed) 15592 15592 3 Private Room Days (exclude swing-bed private room) (Adj ) 0 0 4 Semi-Private Room Days (exclude swing-bed) (Adj ) 15592 15592 5 Medicare NF Swing-Bed Days through Dec 31 (Adj ) 0 0 6 Medicare NF Swing-Bed Days after Dec 31 (Adj ) 0 0 7 Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 0 0 8 Medi-Cal NF Swing-Bed Days after July 31 (Adj ) 0 0 9 Medi-Cal Days (excluding swing-bed) (Adjs 31 36) 229500 270850
SW ING-BED ADJUSTMENT 17 Medicare NF Swing-Bed Rates through Dec 31 (Adj ) $ 000 $ 000 18 Medicare NF Swing-Bed Rates after Dec 31 (Adj ) $ 000 $ 000 19 Medi-Cal NF Swing-Bed Rates through July 31 (Adj ) $ 000 $ 000 20 Medi-Cal NF Swing-Bed Rates after July 31 (Adj ) $ 000 $ 000 21 Total Routine Serv Cost (Sch 8 Line 30 Col 26) $ 22365373 $ 19534607 22 Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17) $ 0 $ 0 23 Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18) $ 0 $ 0 24 Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19) $ 0 $ 0 25 Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20) $ 0 $ 0 26 Total Swing-Bed Cost (Sum of Lines 22 to 25) $ 0 $ 0 27 Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26) $ 22365373 $ 19534607
PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 Gen Inpatient Routine Serv Charges (excl swing-bed charges) $ 0 $ 0 29 Private Room Charges (excluding swing-bed charges) $ 50416207 $ 50416207 30 Semi-Private Room Charges (excluding swing-bed charges) $ (50416207) $ (50416207) 31 Gen Inpatient Routine Service CostCharge Ratio (L 27 divide L 28) $ 0000000 $ 0000000 32 Average Private Room Per Diem Charge (L 29 divide L 3) $ 000 $ 000 33 Average Semi-Private Room Per Diem Charge (L 30 divide L 4) $ (323347) $ (323347) 34 Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33) $ 000 $ 000 35 Average Per Diem Private Room Cost Differential (L 31 x L 34) $ 000 $ 000 36 Private Room Cost Differential Adjustment (L 35 x L 3) $ 0 $ 0 37 Inpatient Rout Cost Net of Swing-Bed amp Prvt Rm (L 27 minus L 36) $ 22365373 $ 19534607
PROGRAM INPATIENT OPERATING COST 38 Adjusted General Inpatient Routine Cost Per Diem (L 37 divide L 2) $ 143441 $ 125286 39 Program General Inpatient Routine Service Cost (L 9 x L 38) $ 3291971 $ 3393371
40 Cost Applicable to Medi-Cal (Sch 4A) $ 806318 $ 807942 41 Cost Applicable to Medi-Cal (Sch 4B) $ 0 $ 0
42 TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 3940 amp 41) $ 4098289 $ 4201313 ( To Schedule 3 )
STATE OF CALIFORNIA SCHEDULE 4A PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE ANDOR NURSERY UNITS REPORTED AUDITED
NURSERY 1 Total Inpatient Routine Cost (Sch 8 Line 43 Col 26)
2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
000
0
$
$
$
00
00000
INTENSIVE CARE UNIT 6 Total Inpatient Routine Cost (Sch 8 Line 31 Col 26)
7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost
9 Medi-Cal Inpatient Days (Adjs 31 36) 10 Cost Applicable to Medi-Cal
$ 50006362059
$ 24286733200
$ 806318
$
$
$
43125232059
20944738575
807942
CORONARY CARE UNIT 11 Total Inpatient Routine Cost (Sch 8 Line 32 Col 26)
12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost 14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
BURN INTENSIVE CARE UNIT 16 Total Inpatient Routine Cost (Sch 8 Line 33 Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
SURGICAL INTENSIVE CARE UNIT 21 Total Inpatient Routine Cost (Sch 8 Line 34 Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
OTHER SPECIAL CARE (SPECIFY) 26 Total Inpatient Routine Cost (Sch 8 Line 35 Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
ADMINISTRATIVE DAYS 31 Per Diem Rate (Adj )32 Medi-Cal Inpatient Days (Adj ) 33 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
ADMINISTRATIVE DAYS 34 Per Diem Rate (Adj )35 Medi-Cal Inpatient Days (Adj ) 36 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
37 Medi-Cal Routine Cost (Sum of Lines 510152025303336) $ 806318 $ 807942 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 4B PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE UNITS REPORTED AUDITED
1 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
6 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost 9 Medi-Cal Inpatient Days (Adj ) 10 Cost Applicable to Medi-Cal
$ 00
$ 0000
$ 0
$
$
$
00
0000 0
11 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
16 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
21 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
26 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
31 Medi-Cal Routine Cost (Sum of Lines 51015202530) $ 0 $ 0 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 5 PROGRAM NONCONTRACT
SCHEDULE OF MEDI-CAL ANCILLARY COSTS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
TOTAL ANCILLARY
COST
TOTAL ANCILLARY CHARGES
(Adj )
RATIO COST TO CHARGES
CHARGES (From Schedule 6)
MEDI-CAL COST
MEDI-CAL
ANCILLARY COST CENTERS 5000 Operating Room $ 3554239 $ 14309479 0248384 $ 2584884 $ 642043 5100 Recovery Room 0 0 0000000 0 0 5300 Anesthesiology 39629 5867250 0006754 879414 5940 5400 Radiology-Diagnostic 2271078 10793343 0210415 794869 167252 5401 Ultra Sound 643680 5098375 0126252 295897 37358 5600 Radioisotope 382848 1732875 0220932 206257 45569 5700 Computed Tomography (CT) Scan 761998 17089310 0044589 1166436 52010 5800 Magnetic Resonance Imaging (MRI) 22902 144113 0158919 0 0 5900 Cardiac Catheterization 0 0 0000000 0 0 6000 Laboratory 4858864 20925490 0232198 2503211 581241 6001 GI Lab 510896 4588397 0111345 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0000000 0 0 6200 W hole Blood amp Packed Red Blood Cells 3056 451924 0006762 176584 1194 6300 Blood Storing Processing amp Trans 0 0 0000000 0 0 6400 Intravenous Therapy 0 0 0000000 0 0 6500 Respiratory Therapy 1638618 10623110 0154250 2225217 343240 6600 Physical Therapy 777505 1187297 0654853 154359 101082 6700 Occupational Therapy 0 0 0000000 0 0 6800 Speech Pathology 0 0 0000000 0 0 6900 Electrocardiology 421192 9169134 0045936 1956860 89890 7000 Electroencephalography 0 0 0000000 0 0 7100 Medical Supplies Charged to Patients 4248079 9775274 0434574 1732396 752854 7200 Implantable Devices Charged to Patients 729822 5181268 0140858 574210 80882 7300 Drugs Charged to Patients 3010434 30786573 0097784 4573271 447193 7400 Renal Dialysis 333141 1165060 0285943 284460 81339 7500 ASC (Non-Distinct Part) 0 0 0000000 0 0 7501 Other Ancillary (specify) 283 41845 0006754 0 0 7700 0 0 0000000 0 0 7800 0 0 0000000 0 0 7900 0 0 0000000 0 0 8000 0 0 0000000 0 0 8100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0 8700 0 0 0000000 0 0 8701 0 0 0000000 0 0 8800 Rural Health Clinic (RHC) 0 0 0000000 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0000000 0 0 9000 Clinic 0 0 0000000 0 0 9100 Emergency 7660663 48511384 0157915 2345733 370426 9200 Observation Beds 0 0 0000000 0 0 9300 Other Outpatient Services (Specify) 0 0 0000000 0 0 9301 0 0 0000000 0 0 9302 0 0 0000000 0 0 9303 0 0 0000000 0 0 9304 0 0 0000000 0 0 9305 0 0 0000000 0 0
TOTAL $ 31868926 $ 197441501 $ 22454058 $ 3799513 (To Schedule 3)
From Schedule 8 Column 26
STATE OF CALIFORNIA SCHEDULE 6 PROGRAM NONCONTRACT
ADJUSTMENTS TO MEDI-CAL CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
ANCILLARY CHARGES REPORTED ADJUSTMENTS
(Adj 32) AUDITED
5000 Operating Room $ 2372682 $ 212202 $ 2584884 5100 Recovery Room 0 5300 Anesthesiology 812663 66751 879414 5400 Radiology-Diagnostic 744425 50444 794869 5401 Ultra Sound 273774 22123 295897 5600 Radioisotope 201256 5001 206257 5700 Computed Tomography (CT) Scan 1104906 61530 1166436 5800 Magnetic Resonance Imaging (MRI) 0 0 5900 Cardiac Catheterization 0 0 6000 Laboratory 2539230 (36019) 2503211 6001 GI Lab 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 6200 W hole Blood amp Packed Red Blood Cells 168194 8390 176584 6300 Blood Storing Processing amp Trans 0 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1944943 280274 2225217 6600 Physical Therapy 140110 14249 154359 6700 Occupational Therapy 0 0 6800 Speech Pathology 0 0 6900 Electrocardiology 1664507 292353 1956860 7000 Electroencephalography 0 0 7100 Medical Supplies Charged to Patients 1472234 260162 1732396 7200 Implantable Devices Charged to Patients 496326 77884 574210 7300 Drugs Charged to Patients 4193928 379343 4573271 7400 Renal Dialysis 266026 18434 284460 7500 ASC (Non-Distinct Part) 0 0 7501 Other Ancillary (specify) 0 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 2228177 117556 2345733 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
TOTAL MEDI-CAL ANCILLARY CHARGES $ 20623381 $ 1830677 $ 22454058 (To Schedule 5)
STATE OF CALIFORNIA SCHEDULE 7 PROGRAM NONCONTRACT
COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED
PHYSICIANS REMUNERATION
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
PROFESSIONAL SERVICE
COST CENTERS REMUNERATION
HBP
(Adj )
TOTAL CHARGES TO ALL PATIENTS
(Adj )
RATIO OF REMUNERATION
TO CHARGES
MEDI-CAL
(Adj )
CHARGES COST MEDI-CAL
5300 Anesthesiology $ 0 $ 0 0000000 $ $ 0 5400 Radiology - Diagnostic 0 0 0000000 0 5500 Radioisotope 0 0 0000000 0 6000 Laboratory 0 0 0000000 0 6900 Electrocardiology 0 0 0000000 0 7000 Electroencephalography 0 0 0000000 0 9100 Emergency 0 0 0000000 0
0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0
TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 2744664 200 Capital Related Costs-Movable Equipment 2187999 0 300 Other Capital Related Costs 0 0 0 301 0 0 0 0 302 0 0 0 0 0 303 0 0 0 0 0 0 304 0 0 0 0 0 0 0 305 0 0 0 0 0 0 0 0 306 0 0 0 0 0 0 0 0 0 307 0 0 0 0 0 0 0 0 0 0 308 0 0 0 0 0 0 0 0 0 0 0 309 0 0 0 0 0 0 0 0 0 0 0 0 400 Employee Benefits 1058934 84358 67249 0 0 0 0 0 0 0 0 0 501 0 0 0 0 0 0 0 0 0 0 0 0 502 0 0 0 0 0 0 0 0 0 0 0 0 503 0 0 0 0 0 0 0 0 0 0 0 0 504 0 0 0 0 0 0 0 0 0 0 0 0 505 0 0 0 0 0 0 0 0 0 0 0 0 506 0 0 0 0 0 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 0 0 0 500 Administrative and General 10629665 247119 196999 0 0 0 0 0 0 0 0 0 600 Maintenance and Repairs 565321 88028 70174 0 0 0 0 0 0 0 0 0 700 Operation of Plant 2017048 317029 252730 0 0 0 0 0 0 0 0 0 800 Laundry and Linen Service 263543 28979 23102 0 0 0 0 0 0 0 0 0 900 Housekeeping 755766 13085 10431 0 0 0 0 0 0 0 0 0
1000 Dietary 807098 83603 66647 0 0 0 0 0 0 0 0 0 1100 Cafeteria 159362 24177 19274 0 0 0 0 0 0 0 0 0 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 1482354 17467 13924 0 0 0 0 0 0 0 0 0 1400 Central Services and Supply 305730 124660 99377 0 0 0 0 0 0 0 0 0 1500 Pharmacy 1132927 24932 19875 0 0 0 0 0 0 0 0 0 1600 Medical Records amp Library 1178942 32900 26228 0 0 0 0 0 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 193276 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9131110 741734 591297 0 0 0 0 0 0 0 0 0
3100 Intensive Care Unit 2477587 130112 103723 0 0 0 0 0 0 0 0 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
ANCILLARY COST CENTERS 5000 Operating Room 1636558 166158 132458 0 0 0 0 0 0 0 0 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 1301021 99078 78983 0 0 0 0 0 0 0 0 0 5401 Ultra Sound 454209 3711 2959 0 0 0 0 0 0 0 0 0 5600 Radioisotope 206030 19816 15797 0 0 0 0 0 0 0 0 0 5700 Computed Tomography (CT) Scan 458725 10002 7974 0 0 0 0 0 0 0 0 0 5800 Magnetic Resonance Imaging (MRI) 16908 0 0 0 0 0 0 0 0 0 0 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 3398341 64417 51352 0 0 0 0 0 0 0 0 0 6001 GI Lab 292049 14678 11701 0 0 0 0 0 0 0 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 3 0 0 0 0 0 0 0 0 0 0 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 1123538 24030 19157 0 0 0 0 0 0 0 0 0 6600 Physical Therapy 241010 97338 77596 0 0 0 0 0 0 0 0 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 266558 2936 2340 0 0 0 0 0 0 0 0 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 2563528 0 0 0 0 0 0 0 0 0 0 0 7200 Implantable Devices Charged to Patients 558092 0 0 0 0 0 0 0 0 0 0 0 7300 Drugs Charged to Patients 972254 0 0 0 0 0 0 0 0 0 0 0 7400 Renal Dialysis 260774 126 100 0 0 0 0 0 0 0 0 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 4126916 138542 110443 0 0 0 0 0 0 0 0 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 5683 4530 0 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 137766 109825 0 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 512225 2202 1755 0 0 0 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 57057440 2744664 2187999 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 0 501 0 0 502 0 0 0 503 0 0 0 0 504 0 0 0 0 0 505 0 0 0 0 0 0 506 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 500 Administrative and General 0 154558 0 0 0 0 0 0 0 0 11228341 600 Maintenance and Repairs 0 0 0 0 0 0 0 0 0 0 723523 177266 700 Operation of Plant 0 22951 0 0 0 0 0 0 0 0 2609759 639403 800 Laundry and Linen Service 0 634 0 0 0 0 0 0 0 0 316257 77484 900 Housekeeping 0 17935 0 0 0 0 0 0 0 0 797216 195322
1000 Dietary 0 12138 0 0 0 0 0 0 0 0 969486 237529 1100 Cafeteria 0 3630 0 0 0 0 0 0 0 0 206442 50579 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 0 51300 0 0 0 0 0 0 0 0 1565046 383443 1400 Central Services and Supply 0 4664 0 0 0 0 0 0 0 0 534431 130938 1500 Pharmacy 0 40906 0 0 0 0 0 0 0 0 1218641 298573 1600 Medical Records amp Library 0 27157 0 0 0 0 0 0 0 0 1265227 309986 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 49131 0 0 0 0 0 0 0 0 1626506 398501 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 193276 47354 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 316959 0 0 0 0 0 0 0 0 10781100 2641419
3100 Intensive Care Unit 0 83801 0 0 0 0 0 0 0 0 2795223 684843 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
ANCILLARY COST CENTERS 5000 Operating Room 0 57734 0 0 0 0 0 0 0 0 1992908 488272 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 0 35520 0 0 0 0 0 0 0 0 1514602 371085 5401 Ultra Sound 0 16650 0 0 0 0 0 0 0 0 477530 116997 5600 Radioisotope 0 4554 0 0 0 0 0 0 0 0 246197 60319 5700 Computed Tomography (CT) Scan 0 17260 0 0 0 0 0 0 0 0 493961 121023 5800 Magnetic Resonance Imaging (MRI) 0 562 0 0 0 0 0 0 0 0 17470 4280 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 104001 0 0 0 0 0 0 0 0 3618110 886454 6001 GI Lab 0 10400 0 0 0 0 0 0 0 0 328829 80565 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3 1 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 33287 0 0 0 0 0 0 0 0 1200012 294009 6600 Physical Therapy 0 0 0 0 0 0 0 0 0 0 415944 101908 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 7758 0 0 0 0 0 0 0 0 279591 68501 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 2563528 628076 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 558092 136735 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 972254 238207 7400 Renal Dialysis 0 0 0 0 0 0 0 0 0 0 261000 63946 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 136296 0 0 0 0 0 0 0 0 4512197 1105509 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 0 0 10213 2502 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 0 0 247590 60661 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 755 0 0 0 0 0 0 0 0 516937 126652 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 1210541 0 0 0 0 0 0 0 0 57057440 11228341
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 122820 800 Laundry and Linen Service 11227 48661 900 Housekeeping 5069 21971 0
1000 Dietary 32389 140383 0 43356 1100 Cafeteria 9366 40597 0 12538 0 1200 Maintenance of Personnel 0 0 0 0 0 0 1300 Nursing Administration 6767 29330 0 9058 0 32774 0 1400 Central Services and Supply 48295 209325 0 64647 0 2815 0 0 1500 Pharmacy 9659 41865 0 12929 0 10368 0 0 0 1600 Medical Records amp Library 12746 55245 0 17062 0 13812 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 287355 1245493 194159 384654 1279497 101907 0 1122397 0 0 282741 0
3100 Intensive Care Unit 50407 218480 44463 67475 122109 22988 0 230707 0 0 57778 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
ANCILLARY COST CENTERS 5000 Operating Room 64371 279006 26097 86167 289 16495 0 179089 0 0 96649 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 39629 0 5400 Radiology-Diagnostic 38384 166369 32393 51381 0 12357 0 11607 0 0 72900 0 5401 Ultra Sound 1438 6232 0 1925 0 5123 0 0 0 0 34435 0 5600 Radioisotope 7677 33274 1304 10276 0 1680 0 10418 0 0 11704 0 5700 Computed Tomography (CT) Scan 3875 16795 0 5187 0 5733 0 0 0 0 115424 0 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 178 0 0 0 0 973 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 24956 108166 597 33406 0 35158 0 10684 0 0 141335 0 6001 GI Lab 5686 24647 1652 7612 0 3106 0 27809 0 0 30991 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3052 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 9310 40351 0 12462 0 10725 0 0 0 0 71751 0 6600 Physical Therapy 37710 163446 0 50478 0 0 0 0 0 0 8019 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 1137 4929 709 1522 0 2871 0 0 0 0 61930 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 990451 0 66024 0 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 34995 0 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 1592035 207938 0 7400 Renal Dialysis 49 211 0 65 0 0 0 0 0 0 7869 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 283 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 53672 232634 152254 71846 21247 41134 0 433708 0 0 327655 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
A
r
Sttate of CalifoorniamdashHealth and Humman Servicees Agency DDepartmment of HHealth CCare Seervices
TOOBY DOUGLAS EDMUNDD G BROWN JR DIRECTOR GOVERNOR
Decembber 6 2013
Martin MMansukhanii Chief Finnancial Off icer Inland VValley Regioonal of Primme Healthcaare 3300 Eaast Guasti RRoad 2nd Floor Ontario CA 91761
CHINO VVALLEY MMEDICAL CENTER NATIONNAL PROVIDER IDENNTIFIER (NPPI) 19624077460 FISCAL PERIOD EENDED DECEMBER 331 2011
We havee examinedd the providders Medi-CCal Cost Reeport for thee above-refferenced fisscal period Our examinnation was made undeer the authoority of Secction 141700 of the Wellfare and Insttitutions Code and acccordingly inncluded succh tests of the accounnting recordds and such other audditing proceedures as wwe considerred necessaary in the circumstancces
In our oppinion the audited setttlement forr the fiscal pperiod due the provideer in the amount of $237252 presented in the Summary of FFindings reppresents a proper determinnation in acccordance wwith the reimmbursemennt principless of applicaable progra ms
This audit report inncludes the
1 SSummary off Findings
2 CComputationn of Medi-CCal Reimbursement Seettlement (NNONCONTTRACT SSchedules)
3 AAudit Adjusttments Schedule
The auddited settlemment will bee incorporatted into a SStatement oof Account SStatus whicch may reflect tentativve retroactivve adjustmeent determiinations paayments froom the provvider and otheer financial transactionns initiated by the Deppartment TThe Statement of Accoount Status wwill be forwaarded to thee provider bby the Statees fiscal inttermediary Instructio ns regardinng paymentt will be inclluded with tthe Statemeent of Accoount Status
Notwithsstanding thiis audit repport overpaayments to tthe provideer are subjeect to recoveery pursuannt to Sectionn 514581 Article 6 of Division 3 Title 22 CCalifornia Coode of Regulatiions
Financial Auudits BranchA udits Section ndashndash Rancho Cucaamonga 9439 Archibald Aveenue Suite 1077 MS 2105 Raancho Cucamoonga CA 917300
(909) 481-34220 (909) 481--3442 fax Internet Address wwwdhccscagov
Martin Mansukhani Page 2
If you disagree with the decision of the Department you may appeal by writing to
Chief Department of Health Care Services Office of Administrative Hearings and Appeals 1029 J Street Suite 200 Sacramento CA 95814 (916) 322-5603
The written notice of disagreement must be received by the Department within 60 calendar days from the day you receive this letter A copy of this notice should be sent to
United States Postal Service (USPS) Courier (UPS FedEx etc) Assistant Chief Counsel Assistant Chief Counsel Department of Health Care Services Department of Health Care Services Office of Legal Services Office of Legal Services MS 0010 MS 0010 PO Box 997413 1501 Capitol Avenue Suite 715001 Sacramento CA 95899 Sacramento CA 95814
(916) 440-7700
The procedures that govern an appeal are contained in Welfare and Institutions Code Section 14171 and California Code of Regulations Title 22 Section 51016 et seq
Martin Mansukhani Page 3
If you have questions regarding this report you may call the Audits SectionmdashRancho Cucamonga at (909) 481-3420
Original Signed By
Julio M Cueto Chief Audits SectionmdashRancho Cucamonga Financial Audits Branch
Certified
cc Pete Lou Controller Inland Valley Regional Chino Valley Medical Center
Jeffrey Brown Chief Executive Officer Hospital Management Services 211 East Imperial Highway Suite 102 Fullerton CA 92835
SUMMARY OF FINDINGS
Provider Name Fiscal Period Ended
CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
SETTLEMENT COST
1 Medi-Cal Noncontract Settlement (SCHEDULE 1) Provider NPI 1962407460 Reported
Net Change
Audited Amount Due Provider (State)
$ 1285626
$ (1048374)
$ 237252
2 Subprovider I (SCHEDULE 1-1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
3 Subprovider II (SCHEDULE 1-2) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
4 Medi-Cal Contract Cost (CONTRACT SCH 1) Provider NPI 1962407460 Reported
Net Change
Audited Cost
Audited Amount Due Provider (State)
$
$
$
0
0
0
$ 0
5 Distinct Part Nursing Facility (DPNF SCH 1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
6 Distinct Part Nursing Facility (DPNF SCH 1-1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
7 Adult Subacute (ADULT SUBACUTE SCH 1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
8 Total Medi-Cal Settlement Due Provider (State) - (Lines 1 through 7) $ 237252
9 Total Medi-Cal Cost $ 0
SUMMARY OF FINDINGS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
SETTLEMENT COST
10 Subacute (SUBACUTE SCH 1-1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
11 Rural Health Clinic (RHC SCH 1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
12 Rural Health Clinic (RHC 95-210 SCH 1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
13 Rural Health Clinic (RHC 95-210 SCH 1-1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
14 County Medical Services Program (CMSP SCH 1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
15 Transitional Care (TC SCH 1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
16 Total Other Settlement Due Provider - (Lines 10 through 15) $ 0
17 Total Combined Audited Settlement Due Provider (StateCMSPRHC) - (Line 8 + Line 16) $ 237252
STATE OF CALIFORNIA SCHEDULE 1 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
1 Net Cost of Covered Services Rendered to Medi-Cal Patients (Schedule 3) $ 7914460 $ 7802163
2 Excess Reasonable Cost Over Charges (Schedule 2) $ 0 $ 0
3 Medi-Cal Inpatient Hospital Based Physician Services $ 0 $ NA
4 $ 0 $ 0
5 TOTAL COST-Reimbursable to Provider (Lines 1 through 4) $ 7914460 $ 7802163
6 Interim Payments (Adj 35) $ (6628834) $ (7256881)
7 Balance Due Provider (State) $ 1285626 $ 545282
8 Medi-Cal Overpayments (Adjs 37-38) $ 0 $ (23344)
9 AB 5 and AB 1183 Reduction (Sch A) $ $ (284686)
10 Protested Amount (Adj 2) $ 0 $ 0
11 TOTAL MEDI-CAL SETTLEMENT Due Provider (State) $ 1285626 $ 237252 (To Summary of Findings)
STATE OF CALIFORNIA SCHEDULE A PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT AB 5 and AB 1183 - SUMMARY OF REDUCTIONS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER December 31 2011
Provider No 1962407460
1 10 Reduction to Noncontract Services for 070108 Through 93008 (SCHEDULE A-1) $ 0
2 Reduction to Noncontract Services for 100108 Through 040509 (SCHEDULE A-2) 0
3 10 Reduction to Noncontract Services for 010111 Through 041211 (SCHEDULE A-3) 284686
4 10 Reduction to HFPAs lt 3 Hospitals for 070108 Through 041211 (SCHEDULE A-4) 0
5 10 Reduction to Rural Health Hospitals for 070108 Through 103108 (SCHEDULE A-5) 0
6 10 Reduction to Rural Health Hospitals for 070109 Through 022410 (SCHEDULE A-6) 0
7 Total Noncontract AB 5 AND AB 1183 Reductions $ 284686 (To Schedule 1 Line 9)
STATE OF CALIFORNIA SCHEDULE A-3 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT AB 5 - 10 REDUCTION TO SERVICES FROM APRIL 6 2009 THROUGH April 12 2011 - NONCONTRACT HOSPITALS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER December 31 2011
Provider No 1962407460
Audited Medi-Cal Cost Per Day
1 Medi-Cal Cost of Covered Services (Schedule 3 Line 8) $ 8000826
2 Less Medi-Cal Administrative Day Cost (Schedule 4A Lines 33 and 36)
3 Less Medi-Cal Administrative Ancillary Cost (Schedule A-7)
4 Total Medi-Cal Cost of Covered Services Subject to Reductions (Line 1 - Lines 2 and 3) $ 8000826
5 Total Audited Medi-Cal Days (Schedules 4 4A and 4B excludes Administrative Days) 309425
6 Audited Medi-Cal Cost Per Day (Line 4 Line 5) $ 258571
AB 5 - 10 Cost Reduction For Services From 010111 Through 041211
7 Audited Medi-Cal Days of Service from 010111 Through 041211(excludes Administrative Days) 1101
8 Audited Medi-Cal Cost Per Day For 010111 Through 041211(Line 6 Line 7) $ 2846864
9 AB 5 - 10 Cost Reduction for 010111 Through 041211 (Line 8 10) $ 284686 (To Schedule A Line 3)
0
STATE OF CALIFORNIA SCHEDULE 2 PROGRAM NONCONTRACT
COMPUTATION OF LESSER OF MEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
REASONABLE COST OF MEDI-CAL INPATIENT SERVICES
1 Cost of Covered Services (Schedule 3) $ 8095037 $ 8000826
CHARGES FOR MEDI-CAL INPATIENT SERVICES
2 Inpatient Routine Service Charges (Adj 33) $ 6182850 $ 8491100
3 Inpatient Ancillary Service Charges (Adj 33) $ 20623381 $ 22454058
4 Total Charges - Medi-Cal Inpatient Services $ 26806231 $ 30945158
5 Excess of Customary Charges Over Reasonable Cost (Line 4 minus Line 1) $ 18711194 $ 22944332
6 Excess of Reasonable Cost Over Customary Charges (Line 1 minus Line 4) $ 0 $ 0
(To Schedule 1)
If charges exceed reasonable cost no further calculation necessary for this schedule
STATE OF CALIFORNIA SCHEDULE 3 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL NET COSTS OF COVERED SERVICES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
1 Medi-Cal Inpatient Ancillary Services (Schedule 5) $ 3996748 $ 3799513
2 Medi-Cal Inpatient Routine Services (Schedule 4) $ 4098289 $ 4201313
3 Medi-Cal Inpatient Hospital Based Physician for Intern and Resident Services (Sch ) $ 0 $ 0
4 $ 0 $ 0
5 $ 0 $ 0
6 SUBTOTAL (Sum of Lines 1 through 5) $ 8095037 $ 8000826
7 Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Schedule 7) $ (See Schedule 1) $ 0
8 SUBTOTAL $ 8095037 $ 8000826 (To Schedule 2)
9 Medi-Cal Deductible (Adj 34) $ (19255) $ (18887) 10 Medi-Cal Coinsurance (Adj 34) $ (161322) $ (179776)
11 Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ 7914460 $ 7802163
(To Schedule 1)
STATE OF CALIFORNIA SCHEDULE 4 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED AUDITED
INPATIENT DAYS 1 Total Inpatient Days (include private amp swing-bed) (Adj ) 15592 15592 2 Inpatient Days (include private exclude swing-bed) 15592 15592 3 Private Room Days (exclude swing-bed private room) (Adj ) 0 0 4 Semi-Private Room Days (exclude swing-bed) (Adj ) 15592 15592 5 Medicare NF Swing-Bed Days through Dec 31 (Adj ) 0 0 6 Medicare NF Swing-Bed Days after Dec 31 (Adj ) 0 0 7 Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 0 0 8 Medi-Cal NF Swing-Bed Days after July 31 (Adj ) 0 0 9 Medi-Cal Days (excluding swing-bed) (Adjs 31 36) 229500 270850
SW ING-BED ADJUSTMENT 17 Medicare NF Swing-Bed Rates through Dec 31 (Adj ) $ 000 $ 000 18 Medicare NF Swing-Bed Rates after Dec 31 (Adj ) $ 000 $ 000 19 Medi-Cal NF Swing-Bed Rates through July 31 (Adj ) $ 000 $ 000 20 Medi-Cal NF Swing-Bed Rates after July 31 (Adj ) $ 000 $ 000 21 Total Routine Serv Cost (Sch 8 Line 30 Col 26) $ 22365373 $ 19534607 22 Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17) $ 0 $ 0 23 Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18) $ 0 $ 0 24 Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19) $ 0 $ 0 25 Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20) $ 0 $ 0 26 Total Swing-Bed Cost (Sum of Lines 22 to 25) $ 0 $ 0 27 Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26) $ 22365373 $ 19534607
PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 Gen Inpatient Routine Serv Charges (excl swing-bed charges) $ 0 $ 0 29 Private Room Charges (excluding swing-bed charges) $ 50416207 $ 50416207 30 Semi-Private Room Charges (excluding swing-bed charges) $ (50416207) $ (50416207) 31 Gen Inpatient Routine Service CostCharge Ratio (L 27 divide L 28) $ 0000000 $ 0000000 32 Average Private Room Per Diem Charge (L 29 divide L 3) $ 000 $ 000 33 Average Semi-Private Room Per Diem Charge (L 30 divide L 4) $ (323347) $ (323347) 34 Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33) $ 000 $ 000 35 Average Per Diem Private Room Cost Differential (L 31 x L 34) $ 000 $ 000 36 Private Room Cost Differential Adjustment (L 35 x L 3) $ 0 $ 0 37 Inpatient Rout Cost Net of Swing-Bed amp Prvt Rm (L 27 minus L 36) $ 22365373 $ 19534607
PROGRAM INPATIENT OPERATING COST 38 Adjusted General Inpatient Routine Cost Per Diem (L 37 divide L 2) $ 143441 $ 125286 39 Program General Inpatient Routine Service Cost (L 9 x L 38) $ 3291971 $ 3393371
40 Cost Applicable to Medi-Cal (Sch 4A) $ 806318 $ 807942 41 Cost Applicable to Medi-Cal (Sch 4B) $ 0 $ 0
42 TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 3940 amp 41) $ 4098289 $ 4201313 ( To Schedule 3 )
STATE OF CALIFORNIA SCHEDULE 4A PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE ANDOR NURSERY UNITS REPORTED AUDITED
NURSERY 1 Total Inpatient Routine Cost (Sch 8 Line 43 Col 26)
2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
000
0
$
$
$
00
00000
INTENSIVE CARE UNIT 6 Total Inpatient Routine Cost (Sch 8 Line 31 Col 26)
7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost
9 Medi-Cal Inpatient Days (Adjs 31 36) 10 Cost Applicable to Medi-Cal
$ 50006362059
$ 24286733200
$ 806318
$
$
$
43125232059
20944738575
807942
CORONARY CARE UNIT 11 Total Inpatient Routine Cost (Sch 8 Line 32 Col 26)
12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost 14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
BURN INTENSIVE CARE UNIT 16 Total Inpatient Routine Cost (Sch 8 Line 33 Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
SURGICAL INTENSIVE CARE UNIT 21 Total Inpatient Routine Cost (Sch 8 Line 34 Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
OTHER SPECIAL CARE (SPECIFY) 26 Total Inpatient Routine Cost (Sch 8 Line 35 Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
ADMINISTRATIVE DAYS 31 Per Diem Rate (Adj )32 Medi-Cal Inpatient Days (Adj ) 33 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
ADMINISTRATIVE DAYS 34 Per Diem Rate (Adj )35 Medi-Cal Inpatient Days (Adj ) 36 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
37 Medi-Cal Routine Cost (Sum of Lines 510152025303336) $ 806318 $ 807942 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 4B PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE UNITS REPORTED AUDITED
1 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
6 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost 9 Medi-Cal Inpatient Days (Adj ) 10 Cost Applicable to Medi-Cal
$ 00
$ 0000
$ 0
$
$
$
00
0000 0
11 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
16 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
21 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
26 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
31 Medi-Cal Routine Cost (Sum of Lines 51015202530) $ 0 $ 0 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 5 PROGRAM NONCONTRACT
SCHEDULE OF MEDI-CAL ANCILLARY COSTS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
TOTAL ANCILLARY
COST
TOTAL ANCILLARY CHARGES
(Adj )
RATIO COST TO CHARGES
CHARGES (From Schedule 6)
MEDI-CAL COST
MEDI-CAL
ANCILLARY COST CENTERS 5000 Operating Room $ 3554239 $ 14309479 0248384 $ 2584884 $ 642043 5100 Recovery Room 0 0 0000000 0 0 5300 Anesthesiology 39629 5867250 0006754 879414 5940 5400 Radiology-Diagnostic 2271078 10793343 0210415 794869 167252 5401 Ultra Sound 643680 5098375 0126252 295897 37358 5600 Radioisotope 382848 1732875 0220932 206257 45569 5700 Computed Tomography (CT) Scan 761998 17089310 0044589 1166436 52010 5800 Magnetic Resonance Imaging (MRI) 22902 144113 0158919 0 0 5900 Cardiac Catheterization 0 0 0000000 0 0 6000 Laboratory 4858864 20925490 0232198 2503211 581241 6001 GI Lab 510896 4588397 0111345 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0000000 0 0 6200 W hole Blood amp Packed Red Blood Cells 3056 451924 0006762 176584 1194 6300 Blood Storing Processing amp Trans 0 0 0000000 0 0 6400 Intravenous Therapy 0 0 0000000 0 0 6500 Respiratory Therapy 1638618 10623110 0154250 2225217 343240 6600 Physical Therapy 777505 1187297 0654853 154359 101082 6700 Occupational Therapy 0 0 0000000 0 0 6800 Speech Pathology 0 0 0000000 0 0 6900 Electrocardiology 421192 9169134 0045936 1956860 89890 7000 Electroencephalography 0 0 0000000 0 0 7100 Medical Supplies Charged to Patients 4248079 9775274 0434574 1732396 752854 7200 Implantable Devices Charged to Patients 729822 5181268 0140858 574210 80882 7300 Drugs Charged to Patients 3010434 30786573 0097784 4573271 447193 7400 Renal Dialysis 333141 1165060 0285943 284460 81339 7500 ASC (Non-Distinct Part) 0 0 0000000 0 0 7501 Other Ancillary (specify) 283 41845 0006754 0 0 7700 0 0 0000000 0 0 7800 0 0 0000000 0 0 7900 0 0 0000000 0 0 8000 0 0 0000000 0 0 8100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0 8700 0 0 0000000 0 0 8701 0 0 0000000 0 0 8800 Rural Health Clinic (RHC) 0 0 0000000 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0000000 0 0 9000 Clinic 0 0 0000000 0 0 9100 Emergency 7660663 48511384 0157915 2345733 370426 9200 Observation Beds 0 0 0000000 0 0 9300 Other Outpatient Services (Specify) 0 0 0000000 0 0 9301 0 0 0000000 0 0 9302 0 0 0000000 0 0 9303 0 0 0000000 0 0 9304 0 0 0000000 0 0 9305 0 0 0000000 0 0
TOTAL $ 31868926 $ 197441501 $ 22454058 $ 3799513 (To Schedule 3)
From Schedule 8 Column 26
STATE OF CALIFORNIA SCHEDULE 6 PROGRAM NONCONTRACT
ADJUSTMENTS TO MEDI-CAL CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
ANCILLARY CHARGES REPORTED ADJUSTMENTS
(Adj 32) AUDITED
5000 Operating Room $ 2372682 $ 212202 $ 2584884 5100 Recovery Room 0 5300 Anesthesiology 812663 66751 879414 5400 Radiology-Diagnostic 744425 50444 794869 5401 Ultra Sound 273774 22123 295897 5600 Radioisotope 201256 5001 206257 5700 Computed Tomography (CT) Scan 1104906 61530 1166436 5800 Magnetic Resonance Imaging (MRI) 0 0 5900 Cardiac Catheterization 0 0 6000 Laboratory 2539230 (36019) 2503211 6001 GI Lab 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 6200 W hole Blood amp Packed Red Blood Cells 168194 8390 176584 6300 Blood Storing Processing amp Trans 0 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1944943 280274 2225217 6600 Physical Therapy 140110 14249 154359 6700 Occupational Therapy 0 0 6800 Speech Pathology 0 0 6900 Electrocardiology 1664507 292353 1956860 7000 Electroencephalography 0 0 7100 Medical Supplies Charged to Patients 1472234 260162 1732396 7200 Implantable Devices Charged to Patients 496326 77884 574210 7300 Drugs Charged to Patients 4193928 379343 4573271 7400 Renal Dialysis 266026 18434 284460 7500 ASC (Non-Distinct Part) 0 0 7501 Other Ancillary (specify) 0 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 2228177 117556 2345733 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
TOTAL MEDI-CAL ANCILLARY CHARGES $ 20623381 $ 1830677 $ 22454058 (To Schedule 5)
STATE OF CALIFORNIA SCHEDULE 7 PROGRAM NONCONTRACT
COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED
PHYSICIANS REMUNERATION
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
PROFESSIONAL SERVICE
COST CENTERS REMUNERATION
HBP
(Adj )
TOTAL CHARGES TO ALL PATIENTS
(Adj )
RATIO OF REMUNERATION
TO CHARGES
MEDI-CAL
(Adj )
CHARGES COST MEDI-CAL
5300 Anesthesiology $ 0 $ 0 0000000 $ $ 0 5400 Radiology - Diagnostic 0 0 0000000 0 5500 Radioisotope 0 0 0000000 0 6000 Laboratory 0 0 0000000 0 6900 Electrocardiology 0 0 0000000 0 7000 Electroencephalography 0 0 0000000 0 9100 Emergency 0 0 0000000 0
0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0
TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 2744664 200 Capital Related Costs-Movable Equipment 2187999 0 300 Other Capital Related Costs 0 0 0 301 0 0 0 0 302 0 0 0 0 0 303 0 0 0 0 0 0 304 0 0 0 0 0 0 0 305 0 0 0 0 0 0 0 0 306 0 0 0 0 0 0 0 0 0 307 0 0 0 0 0 0 0 0 0 0 308 0 0 0 0 0 0 0 0 0 0 0 309 0 0 0 0 0 0 0 0 0 0 0 0 400 Employee Benefits 1058934 84358 67249 0 0 0 0 0 0 0 0 0 501 0 0 0 0 0 0 0 0 0 0 0 0 502 0 0 0 0 0 0 0 0 0 0 0 0 503 0 0 0 0 0 0 0 0 0 0 0 0 504 0 0 0 0 0 0 0 0 0 0 0 0 505 0 0 0 0 0 0 0 0 0 0 0 0 506 0 0 0 0 0 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 0 0 0 500 Administrative and General 10629665 247119 196999 0 0 0 0 0 0 0 0 0 600 Maintenance and Repairs 565321 88028 70174 0 0 0 0 0 0 0 0 0 700 Operation of Plant 2017048 317029 252730 0 0 0 0 0 0 0 0 0 800 Laundry and Linen Service 263543 28979 23102 0 0 0 0 0 0 0 0 0 900 Housekeeping 755766 13085 10431 0 0 0 0 0 0 0 0 0
1000 Dietary 807098 83603 66647 0 0 0 0 0 0 0 0 0 1100 Cafeteria 159362 24177 19274 0 0 0 0 0 0 0 0 0 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 1482354 17467 13924 0 0 0 0 0 0 0 0 0 1400 Central Services and Supply 305730 124660 99377 0 0 0 0 0 0 0 0 0 1500 Pharmacy 1132927 24932 19875 0 0 0 0 0 0 0 0 0 1600 Medical Records amp Library 1178942 32900 26228 0 0 0 0 0 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 193276 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9131110 741734 591297 0 0 0 0 0 0 0 0 0
3100 Intensive Care Unit 2477587 130112 103723 0 0 0 0 0 0 0 0 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
ANCILLARY COST CENTERS 5000 Operating Room 1636558 166158 132458 0 0 0 0 0 0 0 0 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 1301021 99078 78983 0 0 0 0 0 0 0 0 0 5401 Ultra Sound 454209 3711 2959 0 0 0 0 0 0 0 0 0 5600 Radioisotope 206030 19816 15797 0 0 0 0 0 0 0 0 0 5700 Computed Tomography (CT) Scan 458725 10002 7974 0 0 0 0 0 0 0 0 0 5800 Magnetic Resonance Imaging (MRI) 16908 0 0 0 0 0 0 0 0 0 0 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 3398341 64417 51352 0 0 0 0 0 0 0 0 0 6001 GI Lab 292049 14678 11701 0 0 0 0 0 0 0 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 3 0 0 0 0 0 0 0 0 0 0 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 1123538 24030 19157 0 0 0 0 0 0 0 0 0 6600 Physical Therapy 241010 97338 77596 0 0 0 0 0 0 0 0 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 266558 2936 2340 0 0 0 0 0 0 0 0 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 2563528 0 0 0 0 0 0 0 0 0 0 0 7200 Implantable Devices Charged to Patients 558092 0 0 0 0 0 0 0 0 0 0 0 7300 Drugs Charged to Patients 972254 0 0 0 0 0 0 0 0 0 0 0 7400 Renal Dialysis 260774 126 100 0 0 0 0 0 0 0 0 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 4126916 138542 110443 0 0 0 0 0 0 0 0 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 5683 4530 0 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 137766 109825 0 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 512225 2202 1755 0 0 0 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 57057440 2744664 2187999 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 0 501 0 0 502 0 0 0 503 0 0 0 0 504 0 0 0 0 0 505 0 0 0 0 0 0 506 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 500 Administrative and General 0 154558 0 0 0 0 0 0 0 0 11228341 600 Maintenance and Repairs 0 0 0 0 0 0 0 0 0 0 723523 177266 700 Operation of Plant 0 22951 0 0 0 0 0 0 0 0 2609759 639403 800 Laundry and Linen Service 0 634 0 0 0 0 0 0 0 0 316257 77484 900 Housekeeping 0 17935 0 0 0 0 0 0 0 0 797216 195322
1000 Dietary 0 12138 0 0 0 0 0 0 0 0 969486 237529 1100 Cafeteria 0 3630 0 0 0 0 0 0 0 0 206442 50579 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 0 51300 0 0 0 0 0 0 0 0 1565046 383443 1400 Central Services and Supply 0 4664 0 0 0 0 0 0 0 0 534431 130938 1500 Pharmacy 0 40906 0 0 0 0 0 0 0 0 1218641 298573 1600 Medical Records amp Library 0 27157 0 0 0 0 0 0 0 0 1265227 309986 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 49131 0 0 0 0 0 0 0 0 1626506 398501 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 193276 47354 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 316959 0 0 0 0 0 0 0 0 10781100 2641419
3100 Intensive Care Unit 0 83801 0 0 0 0 0 0 0 0 2795223 684843 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
ANCILLARY COST CENTERS 5000 Operating Room 0 57734 0 0 0 0 0 0 0 0 1992908 488272 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 0 35520 0 0 0 0 0 0 0 0 1514602 371085 5401 Ultra Sound 0 16650 0 0 0 0 0 0 0 0 477530 116997 5600 Radioisotope 0 4554 0 0 0 0 0 0 0 0 246197 60319 5700 Computed Tomography (CT) Scan 0 17260 0 0 0 0 0 0 0 0 493961 121023 5800 Magnetic Resonance Imaging (MRI) 0 562 0 0 0 0 0 0 0 0 17470 4280 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 104001 0 0 0 0 0 0 0 0 3618110 886454 6001 GI Lab 0 10400 0 0 0 0 0 0 0 0 328829 80565 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3 1 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 33287 0 0 0 0 0 0 0 0 1200012 294009 6600 Physical Therapy 0 0 0 0 0 0 0 0 0 0 415944 101908 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 7758 0 0 0 0 0 0 0 0 279591 68501 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 2563528 628076 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 558092 136735 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 972254 238207 7400 Renal Dialysis 0 0 0 0 0 0 0 0 0 0 261000 63946 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 136296 0 0 0 0 0 0 0 0 4512197 1105509 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 0 0 10213 2502 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 0 0 247590 60661 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 755 0 0 0 0 0 0 0 0 516937 126652 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 1210541 0 0 0 0 0 0 0 0 57057440 11228341
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 122820 800 Laundry and Linen Service 11227 48661 900 Housekeeping 5069 21971 0
1000 Dietary 32389 140383 0 43356 1100 Cafeteria 9366 40597 0 12538 0 1200 Maintenance of Personnel 0 0 0 0 0 0 1300 Nursing Administration 6767 29330 0 9058 0 32774 0 1400 Central Services and Supply 48295 209325 0 64647 0 2815 0 0 1500 Pharmacy 9659 41865 0 12929 0 10368 0 0 0 1600 Medical Records amp Library 12746 55245 0 17062 0 13812 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 287355 1245493 194159 384654 1279497 101907 0 1122397 0 0 282741 0
3100 Intensive Care Unit 50407 218480 44463 67475 122109 22988 0 230707 0 0 57778 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
ANCILLARY COST CENTERS 5000 Operating Room 64371 279006 26097 86167 289 16495 0 179089 0 0 96649 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 39629 0 5400 Radiology-Diagnostic 38384 166369 32393 51381 0 12357 0 11607 0 0 72900 0 5401 Ultra Sound 1438 6232 0 1925 0 5123 0 0 0 0 34435 0 5600 Radioisotope 7677 33274 1304 10276 0 1680 0 10418 0 0 11704 0 5700 Computed Tomography (CT) Scan 3875 16795 0 5187 0 5733 0 0 0 0 115424 0 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 178 0 0 0 0 973 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 24956 108166 597 33406 0 35158 0 10684 0 0 141335 0 6001 GI Lab 5686 24647 1652 7612 0 3106 0 27809 0 0 30991 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3052 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 9310 40351 0 12462 0 10725 0 0 0 0 71751 0 6600 Physical Therapy 37710 163446 0 50478 0 0 0 0 0 0 8019 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 1137 4929 709 1522 0 2871 0 0 0 0 61930 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 990451 0 66024 0 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 34995 0 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 1592035 207938 0 7400 Renal Dialysis 49 211 0 65 0 0 0 0 0 0 7869 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 283 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 53672 232634 152254 71846 21247 41134 0 433708 0 0 327655 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
Martin Mansukhani Page 2
If you disagree with the decision of the Department you may appeal by writing to
Chief Department of Health Care Services Office of Administrative Hearings and Appeals 1029 J Street Suite 200 Sacramento CA 95814 (916) 322-5603
The written notice of disagreement must be received by the Department within 60 calendar days from the day you receive this letter A copy of this notice should be sent to
United States Postal Service (USPS) Courier (UPS FedEx etc) Assistant Chief Counsel Assistant Chief Counsel Department of Health Care Services Department of Health Care Services Office of Legal Services Office of Legal Services MS 0010 MS 0010 PO Box 997413 1501 Capitol Avenue Suite 715001 Sacramento CA 95899 Sacramento CA 95814
(916) 440-7700
The procedures that govern an appeal are contained in Welfare and Institutions Code Section 14171 and California Code of Regulations Title 22 Section 51016 et seq
Martin Mansukhani Page 3
If you have questions regarding this report you may call the Audits SectionmdashRancho Cucamonga at (909) 481-3420
Original Signed By
Julio M Cueto Chief Audits SectionmdashRancho Cucamonga Financial Audits Branch
Certified
cc Pete Lou Controller Inland Valley Regional Chino Valley Medical Center
Jeffrey Brown Chief Executive Officer Hospital Management Services 211 East Imperial Highway Suite 102 Fullerton CA 92835
SUMMARY OF FINDINGS
Provider Name Fiscal Period Ended
CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
SETTLEMENT COST
1 Medi-Cal Noncontract Settlement (SCHEDULE 1) Provider NPI 1962407460 Reported
Net Change
Audited Amount Due Provider (State)
$ 1285626
$ (1048374)
$ 237252
2 Subprovider I (SCHEDULE 1-1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
3 Subprovider II (SCHEDULE 1-2) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
4 Medi-Cal Contract Cost (CONTRACT SCH 1) Provider NPI 1962407460 Reported
Net Change
Audited Cost
Audited Amount Due Provider (State)
$
$
$
0
0
0
$ 0
5 Distinct Part Nursing Facility (DPNF SCH 1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
6 Distinct Part Nursing Facility (DPNF SCH 1-1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
7 Adult Subacute (ADULT SUBACUTE SCH 1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
8 Total Medi-Cal Settlement Due Provider (State) - (Lines 1 through 7) $ 237252
9 Total Medi-Cal Cost $ 0
SUMMARY OF FINDINGS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
SETTLEMENT COST
10 Subacute (SUBACUTE SCH 1-1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
11 Rural Health Clinic (RHC SCH 1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
12 Rural Health Clinic (RHC 95-210 SCH 1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
13 Rural Health Clinic (RHC 95-210 SCH 1-1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
14 County Medical Services Program (CMSP SCH 1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
15 Transitional Care (TC SCH 1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
16 Total Other Settlement Due Provider - (Lines 10 through 15) $ 0
17 Total Combined Audited Settlement Due Provider (StateCMSPRHC) - (Line 8 + Line 16) $ 237252
STATE OF CALIFORNIA SCHEDULE 1 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
1 Net Cost of Covered Services Rendered to Medi-Cal Patients (Schedule 3) $ 7914460 $ 7802163
2 Excess Reasonable Cost Over Charges (Schedule 2) $ 0 $ 0
3 Medi-Cal Inpatient Hospital Based Physician Services $ 0 $ NA
4 $ 0 $ 0
5 TOTAL COST-Reimbursable to Provider (Lines 1 through 4) $ 7914460 $ 7802163
6 Interim Payments (Adj 35) $ (6628834) $ (7256881)
7 Balance Due Provider (State) $ 1285626 $ 545282
8 Medi-Cal Overpayments (Adjs 37-38) $ 0 $ (23344)
9 AB 5 and AB 1183 Reduction (Sch A) $ $ (284686)
10 Protested Amount (Adj 2) $ 0 $ 0
11 TOTAL MEDI-CAL SETTLEMENT Due Provider (State) $ 1285626 $ 237252 (To Summary of Findings)
STATE OF CALIFORNIA SCHEDULE A PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT AB 5 and AB 1183 - SUMMARY OF REDUCTIONS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER December 31 2011
Provider No 1962407460
1 10 Reduction to Noncontract Services for 070108 Through 93008 (SCHEDULE A-1) $ 0
2 Reduction to Noncontract Services for 100108 Through 040509 (SCHEDULE A-2) 0
3 10 Reduction to Noncontract Services for 010111 Through 041211 (SCHEDULE A-3) 284686
4 10 Reduction to HFPAs lt 3 Hospitals for 070108 Through 041211 (SCHEDULE A-4) 0
5 10 Reduction to Rural Health Hospitals for 070108 Through 103108 (SCHEDULE A-5) 0
6 10 Reduction to Rural Health Hospitals for 070109 Through 022410 (SCHEDULE A-6) 0
7 Total Noncontract AB 5 AND AB 1183 Reductions $ 284686 (To Schedule 1 Line 9)
STATE OF CALIFORNIA SCHEDULE A-3 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT AB 5 - 10 REDUCTION TO SERVICES FROM APRIL 6 2009 THROUGH April 12 2011 - NONCONTRACT HOSPITALS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER December 31 2011
Provider No 1962407460
Audited Medi-Cal Cost Per Day
1 Medi-Cal Cost of Covered Services (Schedule 3 Line 8) $ 8000826
2 Less Medi-Cal Administrative Day Cost (Schedule 4A Lines 33 and 36)
3 Less Medi-Cal Administrative Ancillary Cost (Schedule A-7)
4 Total Medi-Cal Cost of Covered Services Subject to Reductions (Line 1 - Lines 2 and 3) $ 8000826
5 Total Audited Medi-Cal Days (Schedules 4 4A and 4B excludes Administrative Days) 309425
6 Audited Medi-Cal Cost Per Day (Line 4 Line 5) $ 258571
AB 5 - 10 Cost Reduction For Services From 010111 Through 041211
7 Audited Medi-Cal Days of Service from 010111 Through 041211(excludes Administrative Days) 1101
8 Audited Medi-Cal Cost Per Day For 010111 Through 041211(Line 6 Line 7) $ 2846864
9 AB 5 - 10 Cost Reduction for 010111 Through 041211 (Line 8 10) $ 284686 (To Schedule A Line 3)
0
STATE OF CALIFORNIA SCHEDULE 2 PROGRAM NONCONTRACT
COMPUTATION OF LESSER OF MEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
REASONABLE COST OF MEDI-CAL INPATIENT SERVICES
1 Cost of Covered Services (Schedule 3) $ 8095037 $ 8000826
CHARGES FOR MEDI-CAL INPATIENT SERVICES
2 Inpatient Routine Service Charges (Adj 33) $ 6182850 $ 8491100
3 Inpatient Ancillary Service Charges (Adj 33) $ 20623381 $ 22454058
4 Total Charges - Medi-Cal Inpatient Services $ 26806231 $ 30945158
5 Excess of Customary Charges Over Reasonable Cost (Line 4 minus Line 1) $ 18711194 $ 22944332
6 Excess of Reasonable Cost Over Customary Charges (Line 1 minus Line 4) $ 0 $ 0
(To Schedule 1)
If charges exceed reasonable cost no further calculation necessary for this schedule
STATE OF CALIFORNIA SCHEDULE 3 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL NET COSTS OF COVERED SERVICES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
1 Medi-Cal Inpatient Ancillary Services (Schedule 5) $ 3996748 $ 3799513
2 Medi-Cal Inpatient Routine Services (Schedule 4) $ 4098289 $ 4201313
3 Medi-Cal Inpatient Hospital Based Physician for Intern and Resident Services (Sch ) $ 0 $ 0
4 $ 0 $ 0
5 $ 0 $ 0
6 SUBTOTAL (Sum of Lines 1 through 5) $ 8095037 $ 8000826
7 Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Schedule 7) $ (See Schedule 1) $ 0
8 SUBTOTAL $ 8095037 $ 8000826 (To Schedule 2)
9 Medi-Cal Deductible (Adj 34) $ (19255) $ (18887) 10 Medi-Cal Coinsurance (Adj 34) $ (161322) $ (179776)
11 Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ 7914460 $ 7802163
(To Schedule 1)
STATE OF CALIFORNIA SCHEDULE 4 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED AUDITED
INPATIENT DAYS 1 Total Inpatient Days (include private amp swing-bed) (Adj ) 15592 15592 2 Inpatient Days (include private exclude swing-bed) 15592 15592 3 Private Room Days (exclude swing-bed private room) (Adj ) 0 0 4 Semi-Private Room Days (exclude swing-bed) (Adj ) 15592 15592 5 Medicare NF Swing-Bed Days through Dec 31 (Adj ) 0 0 6 Medicare NF Swing-Bed Days after Dec 31 (Adj ) 0 0 7 Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 0 0 8 Medi-Cal NF Swing-Bed Days after July 31 (Adj ) 0 0 9 Medi-Cal Days (excluding swing-bed) (Adjs 31 36) 229500 270850
SW ING-BED ADJUSTMENT 17 Medicare NF Swing-Bed Rates through Dec 31 (Adj ) $ 000 $ 000 18 Medicare NF Swing-Bed Rates after Dec 31 (Adj ) $ 000 $ 000 19 Medi-Cal NF Swing-Bed Rates through July 31 (Adj ) $ 000 $ 000 20 Medi-Cal NF Swing-Bed Rates after July 31 (Adj ) $ 000 $ 000 21 Total Routine Serv Cost (Sch 8 Line 30 Col 26) $ 22365373 $ 19534607 22 Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17) $ 0 $ 0 23 Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18) $ 0 $ 0 24 Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19) $ 0 $ 0 25 Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20) $ 0 $ 0 26 Total Swing-Bed Cost (Sum of Lines 22 to 25) $ 0 $ 0 27 Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26) $ 22365373 $ 19534607
PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 Gen Inpatient Routine Serv Charges (excl swing-bed charges) $ 0 $ 0 29 Private Room Charges (excluding swing-bed charges) $ 50416207 $ 50416207 30 Semi-Private Room Charges (excluding swing-bed charges) $ (50416207) $ (50416207) 31 Gen Inpatient Routine Service CostCharge Ratio (L 27 divide L 28) $ 0000000 $ 0000000 32 Average Private Room Per Diem Charge (L 29 divide L 3) $ 000 $ 000 33 Average Semi-Private Room Per Diem Charge (L 30 divide L 4) $ (323347) $ (323347) 34 Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33) $ 000 $ 000 35 Average Per Diem Private Room Cost Differential (L 31 x L 34) $ 000 $ 000 36 Private Room Cost Differential Adjustment (L 35 x L 3) $ 0 $ 0 37 Inpatient Rout Cost Net of Swing-Bed amp Prvt Rm (L 27 minus L 36) $ 22365373 $ 19534607
PROGRAM INPATIENT OPERATING COST 38 Adjusted General Inpatient Routine Cost Per Diem (L 37 divide L 2) $ 143441 $ 125286 39 Program General Inpatient Routine Service Cost (L 9 x L 38) $ 3291971 $ 3393371
40 Cost Applicable to Medi-Cal (Sch 4A) $ 806318 $ 807942 41 Cost Applicable to Medi-Cal (Sch 4B) $ 0 $ 0
42 TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 3940 amp 41) $ 4098289 $ 4201313 ( To Schedule 3 )
STATE OF CALIFORNIA SCHEDULE 4A PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE ANDOR NURSERY UNITS REPORTED AUDITED
NURSERY 1 Total Inpatient Routine Cost (Sch 8 Line 43 Col 26)
2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
000
0
$
$
$
00
00000
INTENSIVE CARE UNIT 6 Total Inpatient Routine Cost (Sch 8 Line 31 Col 26)
7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost
9 Medi-Cal Inpatient Days (Adjs 31 36) 10 Cost Applicable to Medi-Cal
$ 50006362059
$ 24286733200
$ 806318
$
$
$
43125232059
20944738575
807942
CORONARY CARE UNIT 11 Total Inpatient Routine Cost (Sch 8 Line 32 Col 26)
12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost 14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
BURN INTENSIVE CARE UNIT 16 Total Inpatient Routine Cost (Sch 8 Line 33 Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
SURGICAL INTENSIVE CARE UNIT 21 Total Inpatient Routine Cost (Sch 8 Line 34 Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
OTHER SPECIAL CARE (SPECIFY) 26 Total Inpatient Routine Cost (Sch 8 Line 35 Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
ADMINISTRATIVE DAYS 31 Per Diem Rate (Adj )32 Medi-Cal Inpatient Days (Adj ) 33 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
ADMINISTRATIVE DAYS 34 Per Diem Rate (Adj )35 Medi-Cal Inpatient Days (Adj ) 36 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
37 Medi-Cal Routine Cost (Sum of Lines 510152025303336) $ 806318 $ 807942 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 4B PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE UNITS REPORTED AUDITED
1 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
6 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost 9 Medi-Cal Inpatient Days (Adj ) 10 Cost Applicable to Medi-Cal
$ 00
$ 0000
$ 0
$
$
$
00
0000 0
11 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
16 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
21 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
26 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
31 Medi-Cal Routine Cost (Sum of Lines 51015202530) $ 0 $ 0 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 5 PROGRAM NONCONTRACT
SCHEDULE OF MEDI-CAL ANCILLARY COSTS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
TOTAL ANCILLARY
COST
TOTAL ANCILLARY CHARGES
(Adj )
RATIO COST TO CHARGES
CHARGES (From Schedule 6)
MEDI-CAL COST
MEDI-CAL
ANCILLARY COST CENTERS 5000 Operating Room $ 3554239 $ 14309479 0248384 $ 2584884 $ 642043 5100 Recovery Room 0 0 0000000 0 0 5300 Anesthesiology 39629 5867250 0006754 879414 5940 5400 Radiology-Diagnostic 2271078 10793343 0210415 794869 167252 5401 Ultra Sound 643680 5098375 0126252 295897 37358 5600 Radioisotope 382848 1732875 0220932 206257 45569 5700 Computed Tomography (CT) Scan 761998 17089310 0044589 1166436 52010 5800 Magnetic Resonance Imaging (MRI) 22902 144113 0158919 0 0 5900 Cardiac Catheterization 0 0 0000000 0 0 6000 Laboratory 4858864 20925490 0232198 2503211 581241 6001 GI Lab 510896 4588397 0111345 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0000000 0 0 6200 W hole Blood amp Packed Red Blood Cells 3056 451924 0006762 176584 1194 6300 Blood Storing Processing amp Trans 0 0 0000000 0 0 6400 Intravenous Therapy 0 0 0000000 0 0 6500 Respiratory Therapy 1638618 10623110 0154250 2225217 343240 6600 Physical Therapy 777505 1187297 0654853 154359 101082 6700 Occupational Therapy 0 0 0000000 0 0 6800 Speech Pathology 0 0 0000000 0 0 6900 Electrocardiology 421192 9169134 0045936 1956860 89890 7000 Electroencephalography 0 0 0000000 0 0 7100 Medical Supplies Charged to Patients 4248079 9775274 0434574 1732396 752854 7200 Implantable Devices Charged to Patients 729822 5181268 0140858 574210 80882 7300 Drugs Charged to Patients 3010434 30786573 0097784 4573271 447193 7400 Renal Dialysis 333141 1165060 0285943 284460 81339 7500 ASC (Non-Distinct Part) 0 0 0000000 0 0 7501 Other Ancillary (specify) 283 41845 0006754 0 0 7700 0 0 0000000 0 0 7800 0 0 0000000 0 0 7900 0 0 0000000 0 0 8000 0 0 0000000 0 0 8100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0 8700 0 0 0000000 0 0 8701 0 0 0000000 0 0 8800 Rural Health Clinic (RHC) 0 0 0000000 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0000000 0 0 9000 Clinic 0 0 0000000 0 0 9100 Emergency 7660663 48511384 0157915 2345733 370426 9200 Observation Beds 0 0 0000000 0 0 9300 Other Outpatient Services (Specify) 0 0 0000000 0 0 9301 0 0 0000000 0 0 9302 0 0 0000000 0 0 9303 0 0 0000000 0 0 9304 0 0 0000000 0 0 9305 0 0 0000000 0 0
TOTAL $ 31868926 $ 197441501 $ 22454058 $ 3799513 (To Schedule 3)
From Schedule 8 Column 26
STATE OF CALIFORNIA SCHEDULE 6 PROGRAM NONCONTRACT
ADJUSTMENTS TO MEDI-CAL CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
ANCILLARY CHARGES REPORTED ADJUSTMENTS
(Adj 32) AUDITED
5000 Operating Room $ 2372682 $ 212202 $ 2584884 5100 Recovery Room 0 5300 Anesthesiology 812663 66751 879414 5400 Radiology-Diagnostic 744425 50444 794869 5401 Ultra Sound 273774 22123 295897 5600 Radioisotope 201256 5001 206257 5700 Computed Tomography (CT) Scan 1104906 61530 1166436 5800 Magnetic Resonance Imaging (MRI) 0 0 5900 Cardiac Catheterization 0 0 6000 Laboratory 2539230 (36019) 2503211 6001 GI Lab 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 6200 W hole Blood amp Packed Red Blood Cells 168194 8390 176584 6300 Blood Storing Processing amp Trans 0 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1944943 280274 2225217 6600 Physical Therapy 140110 14249 154359 6700 Occupational Therapy 0 0 6800 Speech Pathology 0 0 6900 Electrocardiology 1664507 292353 1956860 7000 Electroencephalography 0 0 7100 Medical Supplies Charged to Patients 1472234 260162 1732396 7200 Implantable Devices Charged to Patients 496326 77884 574210 7300 Drugs Charged to Patients 4193928 379343 4573271 7400 Renal Dialysis 266026 18434 284460 7500 ASC (Non-Distinct Part) 0 0 7501 Other Ancillary (specify) 0 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 2228177 117556 2345733 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
TOTAL MEDI-CAL ANCILLARY CHARGES $ 20623381 $ 1830677 $ 22454058 (To Schedule 5)
STATE OF CALIFORNIA SCHEDULE 7 PROGRAM NONCONTRACT
COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED
PHYSICIANS REMUNERATION
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
PROFESSIONAL SERVICE
COST CENTERS REMUNERATION
HBP
(Adj )
TOTAL CHARGES TO ALL PATIENTS
(Adj )
RATIO OF REMUNERATION
TO CHARGES
MEDI-CAL
(Adj )
CHARGES COST MEDI-CAL
5300 Anesthesiology $ 0 $ 0 0000000 $ $ 0 5400 Radiology - Diagnostic 0 0 0000000 0 5500 Radioisotope 0 0 0000000 0 6000 Laboratory 0 0 0000000 0 6900 Electrocardiology 0 0 0000000 0 7000 Electroencephalography 0 0 0000000 0 9100 Emergency 0 0 0000000 0
0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0
TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 2744664 200 Capital Related Costs-Movable Equipment 2187999 0 300 Other Capital Related Costs 0 0 0 301 0 0 0 0 302 0 0 0 0 0 303 0 0 0 0 0 0 304 0 0 0 0 0 0 0 305 0 0 0 0 0 0 0 0 306 0 0 0 0 0 0 0 0 0 307 0 0 0 0 0 0 0 0 0 0 308 0 0 0 0 0 0 0 0 0 0 0 309 0 0 0 0 0 0 0 0 0 0 0 0 400 Employee Benefits 1058934 84358 67249 0 0 0 0 0 0 0 0 0 501 0 0 0 0 0 0 0 0 0 0 0 0 502 0 0 0 0 0 0 0 0 0 0 0 0 503 0 0 0 0 0 0 0 0 0 0 0 0 504 0 0 0 0 0 0 0 0 0 0 0 0 505 0 0 0 0 0 0 0 0 0 0 0 0 506 0 0 0 0 0 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 0 0 0 500 Administrative and General 10629665 247119 196999 0 0 0 0 0 0 0 0 0 600 Maintenance and Repairs 565321 88028 70174 0 0 0 0 0 0 0 0 0 700 Operation of Plant 2017048 317029 252730 0 0 0 0 0 0 0 0 0 800 Laundry and Linen Service 263543 28979 23102 0 0 0 0 0 0 0 0 0 900 Housekeeping 755766 13085 10431 0 0 0 0 0 0 0 0 0
1000 Dietary 807098 83603 66647 0 0 0 0 0 0 0 0 0 1100 Cafeteria 159362 24177 19274 0 0 0 0 0 0 0 0 0 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 1482354 17467 13924 0 0 0 0 0 0 0 0 0 1400 Central Services and Supply 305730 124660 99377 0 0 0 0 0 0 0 0 0 1500 Pharmacy 1132927 24932 19875 0 0 0 0 0 0 0 0 0 1600 Medical Records amp Library 1178942 32900 26228 0 0 0 0 0 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 193276 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9131110 741734 591297 0 0 0 0 0 0 0 0 0
3100 Intensive Care Unit 2477587 130112 103723 0 0 0 0 0 0 0 0 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
ANCILLARY COST CENTERS 5000 Operating Room 1636558 166158 132458 0 0 0 0 0 0 0 0 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 1301021 99078 78983 0 0 0 0 0 0 0 0 0 5401 Ultra Sound 454209 3711 2959 0 0 0 0 0 0 0 0 0 5600 Radioisotope 206030 19816 15797 0 0 0 0 0 0 0 0 0 5700 Computed Tomography (CT) Scan 458725 10002 7974 0 0 0 0 0 0 0 0 0 5800 Magnetic Resonance Imaging (MRI) 16908 0 0 0 0 0 0 0 0 0 0 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 3398341 64417 51352 0 0 0 0 0 0 0 0 0 6001 GI Lab 292049 14678 11701 0 0 0 0 0 0 0 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 3 0 0 0 0 0 0 0 0 0 0 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 1123538 24030 19157 0 0 0 0 0 0 0 0 0 6600 Physical Therapy 241010 97338 77596 0 0 0 0 0 0 0 0 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 266558 2936 2340 0 0 0 0 0 0 0 0 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 2563528 0 0 0 0 0 0 0 0 0 0 0 7200 Implantable Devices Charged to Patients 558092 0 0 0 0 0 0 0 0 0 0 0 7300 Drugs Charged to Patients 972254 0 0 0 0 0 0 0 0 0 0 0 7400 Renal Dialysis 260774 126 100 0 0 0 0 0 0 0 0 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 4126916 138542 110443 0 0 0 0 0 0 0 0 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 5683 4530 0 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 137766 109825 0 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 512225 2202 1755 0 0 0 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 57057440 2744664 2187999 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 0 501 0 0 502 0 0 0 503 0 0 0 0 504 0 0 0 0 0 505 0 0 0 0 0 0 506 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 500 Administrative and General 0 154558 0 0 0 0 0 0 0 0 11228341 600 Maintenance and Repairs 0 0 0 0 0 0 0 0 0 0 723523 177266 700 Operation of Plant 0 22951 0 0 0 0 0 0 0 0 2609759 639403 800 Laundry and Linen Service 0 634 0 0 0 0 0 0 0 0 316257 77484 900 Housekeeping 0 17935 0 0 0 0 0 0 0 0 797216 195322
1000 Dietary 0 12138 0 0 0 0 0 0 0 0 969486 237529 1100 Cafeteria 0 3630 0 0 0 0 0 0 0 0 206442 50579 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 0 51300 0 0 0 0 0 0 0 0 1565046 383443 1400 Central Services and Supply 0 4664 0 0 0 0 0 0 0 0 534431 130938 1500 Pharmacy 0 40906 0 0 0 0 0 0 0 0 1218641 298573 1600 Medical Records amp Library 0 27157 0 0 0 0 0 0 0 0 1265227 309986 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 49131 0 0 0 0 0 0 0 0 1626506 398501 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 193276 47354 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 316959 0 0 0 0 0 0 0 0 10781100 2641419
3100 Intensive Care Unit 0 83801 0 0 0 0 0 0 0 0 2795223 684843 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
ANCILLARY COST CENTERS 5000 Operating Room 0 57734 0 0 0 0 0 0 0 0 1992908 488272 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 0 35520 0 0 0 0 0 0 0 0 1514602 371085 5401 Ultra Sound 0 16650 0 0 0 0 0 0 0 0 477530 116997 5600 Radioisotope 0 4554 0 0 0 0 0 0 0 0 246197 60319 5700 Computed Tomography (CT) Scan 0 17260 0 0 0 0 0 0 0 0 493961 121023 5800 Magnetic Resonance Imaging (MRI) 0 562 0 0 0 0 0 0 0 0 17470 4280 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 104001 0 0 0 0 0 0 0 0 3618110 886454 6001 GI Lab 0 10400 0 0 0 0 0 0 0 0 328829 80565 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3 1 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 33287 0 0 0 0 0 0 0 0 1200012 294009 6600 Physical Therapy 0 0 0 0 0 0 0 0 0 0 415944 101908 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 7758 0 0 0 0 0 0 0 0 279591 68501 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 2563528 628076 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 558092 136735 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 972254 238207 7400 Renal Dialysis 0 0 0 0 0 0 0 0 0 0 261000 63946 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 136296 0 0 0 0 0 0 0 0 4512197 1105509 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 0 0 10213 2502 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 0 0 247590 60661 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 755 0 0 0 0 0 0 0 0 516937 126652 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 1210541 0 0 0 0 0 0 0 0 57057440 11228341
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 122820 800 Laundry and Linen Service 11227 48661 900 Housekeeping 5069 21971 0
1000 Dietary 32389 140383 0 43356 1100 Cafeteria 9366 40597 0 12538 0 1200 Maintenance of Personnel 0 0 0 0 0 0 1300 Nursing Administration 6767 29330 0 9058 0 32774 0 1400 Central Services and Supply 48295 209325 0 64647 0 2815 0 0 1500 Pharmacy 9659 41865 0 12929 0 10368 0 0 0 1600 Medical Records amp Library 12746 55245 0 17062 0 13812 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 287355 1245493 194159 384654 1279497 101907 0 1122397 0 0 282741 0
3100 Intensive Care Unit 50407 218480 44463 67475 122109 22988 0 230707 0 0 57778 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
ANCILLARY COST CENTERS 5000 Operating Room 64371 279006 26097 86167 289 16495 0 179089 0 0 96649 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 39629 0 5400 Radiology-Diagnostic 38384 166369 32393 51381 0 12357 0 11607 0 0 72900 0 5401 Ultra Sound 1438 6232 0 1925 0 5123 0 0 0 0 34435 0 5600 Radioisotope 7677 33274 1304 10276 0 1680 0 10418 0 0 11704 0 5700 Computed Tomography (CT) Scan 3875 16795 0 5187 0 5733 0 0 0 0 115424 0 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 178 0 0 0 0 973 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 24956 108166 597 33406 0 35158 0 10684 0 0 141335 0 6001 GI Lab 5686 24647 1652 7612 0 3106 0 27809 0 0 30991 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3052 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 9310 40351 0 12462 0 10725 0 0 0 0 71751 0 6600 Physical Therapy 37710 163446 0 50478 0 0 0 0 0 0 8019 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 1137 4929 709 1522 0 2871 0 0 0 0 61930 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 990451 0 66024 0 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 34995 0 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 1592035 207938 0 7400 Renal Dialysis 49 211 0 65 0 0 0 0 0 0 7869 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 283 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 53672 232634 152254 71846 21247 41134 0 433708 0 0 327655 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
Martin Mansukhani Page 3
If you have questions regarding this report you may call the Audits SectionmdashRancho Cucamonga at (909) 481-3420
Original Signed By
Julio M Cueto Chief Audits SectionmdashRancho Cucamonga Financial Audits Branch
Certified
cc Pete Lou Controller Inland Valley Regional Chino Valley Medical Center
Jeffrey Brown Chief Executive Officer Hospital Management Services 211 East Imperial Highway Suite 102 Fullerton CA 92835
SUMMARY OF FINDINGS
Provider Name Fiscal Period Ended
CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
SETTLEMENT COST
1 Medi-Cal Noncontract Settlement (SCHEDULE 1) Provider NPI 1962407460 Reported
Net Change
Audited Amount Due Provider (State)
$ 1285626
$ (1048374)
$ 237252
2 Subprovider I (SCHEDULE 1-1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
3 Subprovider II (SCHEDULE 1-2) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
4 Medi-Cal Contract Cost (CONTRACT SCH 1) Provider NPI 1962407460 Reported
Net Change
Audited Cost
Audited Amount Due Provider (State)
$
$
$
0
0
0
$ 0
5 Distinct Part Nursing Facility (DPNF SCH 1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
6 Distinct Part Nursing Facility (DPNF SCH 1-1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
7 Adult Subacute (ADULT SUBACUTE SCH 1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
8 Total Medi-Cal Settlement Due Provider (State) - (Lines 1 through 7) $ 237252
9 Total Medi-Cal Cost $ 0
SUMMARY OF FINDINGS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
SETTLEMENT COST
10 Subacute (SUBACUTE SCH 1-1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
11 Rural Health Clinic (RHC SCH 1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
12 Rural Health Clinic (RHC 95-210 SCH 1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
13 Rural Health Clinic (RHC 95-210 SCH 1-1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
14 County Medical Services Program (CMSP SCH 1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
15 Transitional Care (TC SCH 1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
16 Total Other Settlement Due Provider - (Lines 10 through 15) $ 0
17 Total Combined Audited Settlement Due Provider (StateCMSPRHC) - (Line 8 + Line 16) $ 237252
STATE OF CALIFORNIA SCHEDULE 1 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
1 Net Cost of Covered Services Rendered to Medi-Cal Patients (Schedule 3) $ 7914460 $ 7802163
2 Excess Reasonable Cost Over Charges (Schedule 2) $ 0 $ 0
3 Medi-Cal Inpatient Hospital Based Physician Services $ 0 $ NA
4 $ 0 $ 0
5 TOTAL COST-Reimbursable to Provider (Lines 1 through 4) $ 7914460 $ 7802163
6 Interim Payments (Adj 35) $ (6628834) $ (7256881)
7 Balance Due Provider (State) $ 1285626 $ 545282
8 Medi-Cal Overpayments (Adjs 37-38) $ 0 $ (23344)
9 AB 5 and AB 1183 Reduction (Sch A) $ $ (284686)
10 Protested Amount (Adj 2) $ 0 $ 0
11 TOTAL MEDI-CAL SETTLEMENT Due Provider (State) $ 1285626 $ 237252 (To Summary of Findings)
STATE OF CALIFORNIA SCHEDULE A PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT AB 5 and AB 1183 - SUMMARY OF REDUCTIONS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER December 31 2011
Provider No 1962407460
1 10 Reduction to Noncontract Services for 070108 Through 93008 (SCHEDULE A-1) $ 0
2 Reduction to Noncontract Services for 100108 Through 040509 (SCHEDULE A-2) 0
3 10 Reduction to Noncontract Services for 010111 Through 041211 (SCHEDULE A-3) 284686
4 10 Reduction to HFPAs lt 3 Hospitals for 070108 Through 041211 (SCHEDULE A-4) 0
5 10 Reduction to Rural Health Hospitals for 070108 Through 103108 (SCHEDULE A-5) 0
6 10 Reduction to Rural Health Hospitals for 070109 Through 022410 (SCHEDULE A-6) 0
7 Total Noncontract AB 5 AND AB 1183 Reductions $ 284686 (To Schedule 1 Line 9)
STATE OF CALIFORNIA SCHEDULE A-3 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT AB 5 - 10 REDUCTION TO SERVICES FROM APRIL 6 2009 THROUGH April 12 2011 - NONCONTRACT HOSPITALS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER December 31 2011
Provider No 1962407460
Audited Medi-Cal Cost Per Day
1 Medi-Cal Cost of Covered Services (Schedule 3 Line 8) $ 8000826
2 Less Medi-Cal Administrative Day Cost (Schedule 4A Lines 33 and 36)
3 Less Medi-Cal Administrative Ancillary Cost (Schedule A-7)
4 Total Medi-Cal Cost of Covered Services Subject to Reductions (Line 1 - Lines 2 and 3) $ 8000826
5 Total Audited Medi-Cal Days (Schedules 4 4A and 4B excludes Administrative Days) 309425
6 Audited Medi-Cal Cost Per Day (Line 4 Line 5) $ 258571
AB 5 - 10 Cost Reduction For Services From 010111 Through 041211
7 Audited Medi-Cal Days of Service from 010111 Through 041211(excludes Administrative Days) 1101
8 Audited Medi-Cal Cost Per Day For 010111 Through 041211(Line 6 Line 7) $ 2846864
9 AB 5 - 10 Cost Reduction for 010111 Through 041211 (Line 8 10) $ 284686 (To Schedule A Line 3)
0
STATE OF CALIFORNIA SCHEDULE 2 PROGRAM NONCONTRACT
COMPUTATION OF LESSER OF MEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
REASONABLE COST OF MEDI-CAL INPATIENT SERVICES
1 Cost of Covered Services (Schedule 3) $ 8095037 $ 8000826
CHARGES FOR MEDI-CAL INPATIENT SERVICES
2 Inpatient Routine Service Charges (Adj 33) $ 6182850 $ 8491100
3 Inpatient Ancillary Service Charges (Adj 33) $ 20623381 $ 22454058
4 Total Charges - Medi-Cal Inpatient Services $ 26806231 $ 30945158
5 Excess of Customary Charges Over Reasonable Cost (Line 4 minus Line 1) $ 18711194 $ 22944332
6 Excess of Reasonable Cost Over Customary Charges (Line 1 minus Line 4) $ 0 $ 0
(To Schedule 1)
If charges exceed reasonable cost no further calculation necessary for this schedule
STATE OF CALIFORNIA SCHEDULE 3 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL NET COSTS OF COVERED SERVICES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
1 Medi-Cal Inpatient Ancillary Services (Schedule 5) $ 3996748 $ 3799513
2 Medi-Cal Inpatient Routine Services (Schedule 4) $ 4098289 $ 4201313
3 Medi-Cal Inpatient Hospital Based Physician for Intern and Resident Services (Sch ) $ 0 $ 0
4 $ 0 $ 0
5 $ 0 $ 0
6 SUBTOTAL (Sum of Lines 1 through 5) $ 8095037 $ 8000826
7 Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Schedule 7) $ (See Schedule 1) $ 0
8 SUBTOTAL $ 8095037 $ 8000826 (To Schedule 2)
9 Medi-Cal Deductible (Adj 34) $ (19255) $ (18887) 10 Medi-Cal Coinsurance (Adj 34) $ (161322) $ (179776)
11 Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ 7914460 $ 7802163
(To Schedule 1)
STATE OF CALIFORNIA SCHEDULE 4 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED AUDITED
INPATIENT DAYS 1 Total Inpatient Days (include private amp swing-bed) (Adj ) 15592 15592 2 Inpatient Days (include private exclude swing-bed) 15592 15592 3 Private Room Days (exclude swing-bed private room) (Adj ) 0 0 4 Semi-Private Room Days (exclude swing-bed) (Adj ) 15592 15592 5 Medicare NF Swing-Bed Days through Dec 31 (Adj ) 0 0 6 Medicare NF Swing-Bed Days after Dec 31 (Adj ) 0 0 7 Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 0 0 8 Medi-Cal NF Swing-Bed Days after July 31 (Adj ) 0 0 9 Medi-Cal Days (excluding swing-bed) (Adjs 31 36) 229500 270850
SW ING-BED ADJUSTMENT 17 Medicare NF Swing-Bed Rates through Dec 31 (Adj ) $ 000 $ 000 18 Medicare NF Swing-Bed Rates after Dec 31 (Adj ) $ 000 $ 000 19 Medi-Cal NF Swing-Bed Rates through July 31 (Adj ) $ 000 $ 000 20 Medi-Cal NF Swing-Bed Rates after July 31 (Adj ) $ 000 $ 000 21 Total Routine Serv Cost (Sch 8 Line 30 Col 26) $ 22365373 $ 19534607 22 Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17) $ 0 $ 0 23 Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18) $ 0 $ 0 24 Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19) $ 0 $ 0 25 Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20) $ 0 $ 0 26 Total Swing-Bed Cost (Sum of Lines 22 to 25) $ 0 $ 0 27 Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26) $ 22365373 $ 19534607
PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 Gen Inpatient Routine Serv Charges (excl swing-bed charges) $ 0 $ 0 29 Private Room Charges (excluding swing-bed charges) $ 50416207 $ 50416207 30 Semi-Private Room Charges (excluding swing-bed charges) $ (50416207) $ (50416207) 31 Gen Inpatient Routine Service CostCharge Ratio (L 27 divide L 28) $ 0000000 $ 0000000 32 Average Private Room Per Diem Charge (L 29 divide L 3) $ 000 $ 000 33 Average Semi-Private Room Per Diem Charge (L 30 divide L 4) $ (323347) $ (323347) 34 Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33) $ 000 $ 000 35 Average Per Diem Private Room Cost Differential (L 31 x L 34) $ 000 $ 000 36 Private Room Cost Differential Adjustment (L 35 x L 3) $ 0 $ 0 37 Inpatient Rout Cost Net of Swing-Bed amp Prvt Rm (L 27 minus L 36) $ 22365373 $ 19534607
PROGRAM INPATIENT OPERATING COST 38 Adjusted General Inpatient Routine Cost Per Diem (L 37 divide L 2) $ 143441 $ 125286 39 Program General Inpatient Routine Service Cost (L 9 x L 38) $ 3291971 $ 3393371
40 Cost Applicable to Medi-Cal (Sch 4A) $ 806318 $ 807942 41 Cost Applicable to Medi-Cal (Sch 4B) $ 0 $ 0
42 TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 3940 amp 41) $ 4098289 $ 4201313 ( To Schedule 3 )
STATE OF CALIFORNIA SCHEDULE 4A PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE ANDOR NURSERY UNITS REPORTED AUDITED
NURSERY 1 Total Inpatient Routine Cost (Sch 8 Line 43 Col 26)
2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
000
0
$
$
$
00
00000
INTENSIVE CARE UNIT 6 Total Inpatient Routine Cost (Sch 8 Line 31 Col 26)
7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost
9 Medi-Cal Inpatient Days (Adjs 31 36) 10 Cost Applicable to Medi-Cal
$ 50006362059
$ 24286733200
$ 806318
$
$
$
43125232059
20944738575
807942
CORONARY CARE UNIT 11 Total Inpatient Routine Cost (Sch 8 Line 32 Col 26)
12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost 14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
BURN INTENSIVE CARE UNIT 16 Total Inpatient Routine Cost (Sch 8 Line 33 Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
SURGICAL INTENSIVE CARE UNIT 21 Total Inpatient Routine Cost (Sch 8 Line 34 Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
OTHER SPECIAL CARE (SPECIFY) 26 Total Inpatient Routine Cost (Sch 8 Line 35 Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
ADMINISTRATIVE DAYS 31 Per Diem Rate (Adj )32 Medi-Cal Inpatient Days (Adj ) 33 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
ADMINISTRATIVE DAYS 34 Per Diem Rate (Adj )35 Medi-Cal Inpatient Days (Adj ) 36 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
37 Medi-Cal Routine Cost (Sum of Lines 510152025303336) $ 806318 $ 807942 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 4B PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE UNITS REPORTED AUDITED
1 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
6 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost 9 Medi-Cal Inpatient Days (Adj ) 10 Cost Applicable to Medi-Cal
$ 00
$ 0000
$ 0
$
$
$
00
0000 0
11 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
16 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
21 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
26 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
31 Medi-Cal Routine Cost (Sum of Lines 51015202530) $ 0 $ 0 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 5 PROGRAM NONCONTRACT
SCHEDULE OF MEDI-CAL ANCILLARY COSTS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
TOTAL ANCILLARY
COST
TOTAL ANCILLARY CHARGES
(Adj )
RATIO COST TO CHARGES
CHARGES (From Schedule 6)
MEDI-CAL COST
MEDI-CAL
ANCILLARY COST CENTERS 5000 Operating Room $ 3554239 $ 14309479 0248384 $ 2584884 $ 642043 5100 Recovery Room 0 0 0000000 0 0 5300 Anesthesiology 39629 5867250 0006754 879414 5940 5400 Radiology-Diagnostic 2271078 10793343 0210415 794869 167252 5401 Ultra Sound 643680 5098375 0126252 295897 37358 5600 Radioisotope 382848 1732875 0220932 206257 45569 5700 Computed Tomography (CT) Scan 761998 17089310 0044589 1166436 52010 5800 Magnetic Resonance Imaging (MRI) 22902 144113 0158919 0 0 5900 Cardiac Catheterization 0 0 0000000 0 0 6000 Laboratory 4858864 20925490 0232198 2503211 581241 6001 GI Lab 510896 4588397 0111345 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0000000 0 0 6200 W hole Blood amp Packed Red Blood Cells 3056 451924 0006762 176584 1194 6300 Blood Storing Processing amp Trans 0 0 0000000 0 0 6400 Intravenous Therapy 0 0 0000000 0 0 6500 Respiratory Therapy 1638618 10623110 0154250 2225217 343240 6600 Physical Therapy 777505 1187297 0654853 154359 101082 6700 Occupational Therapy 0 0 0000000 0 0 6800 Speech Pathology 0 0 0000000 0 0 6900 Electrocardiology 421192 9169134 0045936 1956860 89890 7000 Electroencephalography 0 0 0000000 0 0 7100 Medical Supplies Charged to Patients 4248079 9775274 0434574 1732396 752854 7200 Implantable Devices Charged to Patients 729822 5181268 0140858 574210 80882 7300 Drugs Charged to Patients 3010434 30786573 0097784 4573271 447193 7400 Renal Dialysis 333141 1165060 0285943 284460 81339 7500 ASC (Non-Distinct Part) 0 0 0000000 0 0 7501 Other Ancillary (specify) 283 41845 0006754 0 0 7700 0 0 0000000 0 0 7800 0 0 0000000 0 0 7900 0 0 0000000 0 0 8000 0 0 0000000 0 0 8100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0 8700 0 0 0000000 0 0 8701 0 0 0000000 0 0 8800 Rural Health Clinic (RHC) 0 0 0000000 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0000000 0 0 9000 Clinic 0 0 0000000 0 0 9100 Emergency 7660663 48511384 0157915 2345733 370426 9200 Observation Beds 0 0 0000000 0 0 9300 Other Outpatient Services (Specify) 0 0 0000000 0 0 9301 0 0 0000000 0 0 9302 0 0 0000000 0 0 9303 0 0 0000000 0 0 9304 0 0 0000000 0 0 9305 0 0 0000000 0 0
TOTAL $ 31868926 $ 197441501 $ 22454058 $ 3799513 (To Schedule 3)
From Schedule 8 Column 26
STATE OF CALIFORNIA SCHEDULE 6 PROGRAM NONCONTRACT
ADJUSTMENTS TO MEDI-CAL CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
ANCILLARY CHARGES REPORTED ADJUSTMENTS
(Adj 32) AUDITED
5000 Operating Room $ 2372682 $ 212202 $ 2584884 5100 Recovery Room 0 5300 Anesthesiology 812663 66751 879414 5400 Radiology-Diagnostic 744425 50444 794869 5401 Ultra Sound 273774 22123 295897 5600 Radioisotope 201256 5001 206257 5700 Computed Tomography (CT) Scan 1104906 61530 1166436 5800 Magnetic Resonance Imaging (MRI) 0 0 5900 Cardiac Catheterization 0 0 6000 Laboratory 2539230 (36019) 2503211 6001 GI Lab 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 6200 W hole Blood amp Packed Red Blood Cells 168194 8390 176584 6300 Blood Storing Processing amp Trans 0 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1944943 280274 2225217 6600 Physical Therapy 140110 14249 154359 6700 Occupational Therapy 0 0 6800 Speech Pathology 0 0 6900 Electrocardiology 1664507 292353 1956860 7000 Electroencephalography 0 0 7100 Medical Supplies Charged to Patients 1472234 260162 1732396 7200 Implantable Devices Charged to Patients 496326 77884 574210 7300 Drugs Charged to Patients 4193928 379343 4573271 7400 Renal Dialysis 266026 18434 284460 7500 ASC (Non-Distinct Part) 0 0 7501 Other Ancillary (specify) 0 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 2228177 117556 2345733 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
TOTAL MEDI-CAL ANCILLARY CHARGES $ 20623381 $ 1830677 $ 22454058 (To Schedule 5)
STATE OF CALIFORNIA SCHEDULE 7 PROGRAM NONCONTRACT
COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED
PHYSICIANS REMUNERATION
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
PROFESSIONAL SERVICE
COST CENTERS REMUNERATION
HBP
(Adj )
TOTAL CHARGES TO ALL PATIENTS
(Adj )
RATIO OF REMUNERATION
TO CHARGES
MEDI-CAL
(Adj )
CHARGES COST MEDI-CAL
5300 Anesthesiology $ 0 $ 0 0000000 $ $ 0 5400 Radiology - Diagnostic 0 0 0000000 0 5500 Radioisotope 0 0 0000000 0 6000 Laboratory 0 0 0000000 0 6900 Electrocardiology 0 0 0000000 0 7000 Electroencephalography 0 0 0000000 0 9100 Emergency 0 0 0000000 0
0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0
TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 2744664 200 Capital Related Costs-Movable Equipment 2187999 0 300 Other Capital Related Costs 0 0 0 301 0 0 0 0 302 0 0 0 0 0 303 0 0 0 0 0 0 304 0 0 0 0 0 0 0 305 0 0 0 0 0 0 0 0 306 0 0 0 0 0 0 0 0 0 307 0 0 0 0 0 0 0 0 0 0 308 0 0 0 0 0 0 0 0 0 0 0 309 0 0 0 0 0 0 0 0 0 0 0 0 400 Employee Benefits 1058934 84358 67249 0 0 0 0 0 0 0 0 0 501 0 0 0 0 0 0 0 0 0 0 0 0 502 0 0 0 0 0 0 0 0 0 0 0 0 503 0 0 0 0 0 0 0 0 0 0 0 0 504 0 0 0 0 0 0 0 0 0 0 0 0 505 0 0 0 0 0 0 0 0 0 0 0 0 506 0 0 0 0 0 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 0 0 0 500 Administrative and General 10629665 247119 196999 0 0 0 0 0 0 0 0 0 600 Maintenance and Repairs 565321 88028 70174 0 0 0 0 0 0 0 0 0 700 Operation of Plant 2017048 317029 252730 0 0 0 0 0 0 0 0 0 800 Laundry and Linen Service 263543 28979 23102 0 0 0 0 0 0 0 0 0 900 Housekeeping 755766 13085 10431 0 0 0 0 0 0 0 0 0
1000 Dietary 807098 83603 66647 0 0 0 0 0 0 0 0 0 1100 Cafeteria 159362 24177 19274 0 0 0 0 0 0 0 0 0 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 1482354 17467 13924 0 0 0 0 0 0 0 0 0 1400 Central Services and Supply 305730 124660 99377 0 0 0 0 0 0 0 0 0 1500 Pharmacy 1132927 24932 19875 0 0 0 0 0 0 0 0 0 1600 Medical Records amp Library 1178942 32900 26228 0 0 0 0 0 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 193276 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9131110 741734 591297 0 0 0 0 0 0 0 0 0
3100 Intensive Care Unit 2477587 130112 103723 0 0 0 0 0 0 0 0 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
ANCILLARY COST CENTERS 5000 Operating Room 1636558 166158 132458 0 0 0 0 0 0 0 0 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 1301021 99078 78983 0 0 0 0 0 0 0 0 0 5401 Ultra Sound 454209 3711 2959 0 0 0 0 0 0 0 0 0 5600 Radioisotope 206030 19816 15797 0 0 0 0 0 0 0 0 0 5700 Computed Tomography (CT) Scan 458725 10002 7974 0 0 0 0 0 0 0 0 0 5800 Magnetic Resonance Imaging (MRI) 16908 0 0 0 0 0 0 0 0 0 0 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 3398341 64417 51352 0 0 0 0 0 0 0 0 0 6001 GI Lab 292049 14678 11701 0 0 0 0 0 0 0 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 3 0 0 0 0 0 0 0 0 0 0 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 1123538 24030 19157 0 0 0 0 0 0 0 0 0 6600 Physical Therapy 241010 97338 77596 0 0 0 0 0 0 0 0 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 266558 2936 2340 0 0 0 0 0 0 0 0 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 2563528 0 0 0 0 0 0 0 0 0 0 0 7200 Implantable Devices Charged to Patients 558092 0 0 0 0 0 0 0 0 0 0 0 7300 Drugs Charged to Patients 972254 0 0 0 0 0 0 0 0 0 0 0 7400 Renal Dialysis 260774 126 100 0 0 0 0 0 0 0 0 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 4126916 138542 110443 0 0 0 0 0 0 0 0 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 5683 4530 0 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 137766 109825 0 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 512225 2202 1755 0 0 0 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 57057440 2744664 2187999 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 0 501 0 0 502 0 0 0 503 0 0 0 0 504 0 0 0 0 0 505 0 0 0 0 0 0 506 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 500 Administrative and General 0 154558 0 0 0 0 0 0 0 0 11228341 600 Maintenance and Repairs 0 0 0 0 0 0 0 0 0 0 723523 177266 700 Operation of Plant 0 22951 0 0 0 0 0 0 0 0 2609759 639403 800 Laundry and Linen Service 0 634 0 0 0 0 0 0 0 0 316257 77484 900 Housekeeping 0 17935 0 0 0 0 0 0 0 0 797216 195322
1000 Dietary 0 12138 0 0 0 0 0 0 0 0 969486 237529 1100 Cafeteria 0 3630 0 0 0 0 0 0 0 0 206442 50579 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 0 51300 0 0 0 0 0 0 0 0 1565046 383443 1400 Central Services and Supply 0 4664 0 0 0 0 0 0 0 0 534431 130938 1500 Pharmacy 0 40906 0 0 0 0 0 0 0 0 1218641 298573 1600 Medical Records amp Library 0 27157 0 0 0 0 0 0 0 0 1265227 309986 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 49131 0 0 0 0 0 0 0 0 1626506 398501 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 193276 47354 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 316959 0 0 0 0 0 0 0 0 10781100 2641419
3100 Intensive Care Unit 0 83801 0 0 0 0 0 0 0 0 2795223 684843 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
ANCILLARY COST CENTERS 5000 Operating Room 0 57734 0 0 0 0 0 0 0 0 1992908 488272 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 0 35520 0 0 0 0 0 0 0 0 1514602 371085 5401 Ultra Sound 0 16650 0 0 0 0 0 0 0 0 477530 116997 5600 Radioisotope 0 4554 0 0 0 0 0 0 0 0 246197 60319 5700 Computed Tomography (CT) Scan 0 17260 0 0 0 0 0 0 0 0 493961 121023 5800 Magnetic Resonance Imaging (MRI) 0 562 0 0 0 0 0 0 0 0 17470 4280 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 104001 0 0 0 0 0 0 0 0 3618110 886454 6001 GI Lab 0 10400 0 0 0 0 0 0 0 0 328829 80565 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3 1 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 33287 0 0 0 0 0 0 0 0 1200012 294009 6600 Physical Therapy 0 0 0 0 0 0 0 0 0 0 415944 101908 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 7758 0 0 0 0 0 0 0 0 279591 68501 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 2563528 628076 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 558092 136735 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 972254 238207 7400 Renal Dialysis 0 0 0 0 0 0 0 0 0 0 261000 63946 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 136296 0 0 0 0 0 0 0 0 4512197 1105509 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 0 0 10213 2502 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 0 0 247590 60661 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 755 0 0 0 0 0 0 0 0 516937 126652 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 1210541 0 0 0 0 0 0 0 0 57057440 11228341
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 122820 800 Laundry and Linen Service 11227 48661 900 Housekeeping 5069 21971 0
1000 Dietary 32389 140383 0 43356 1100 Cafeteria 9366 40597 0 12538 0 1200 Maintenance of Personnel 0 0 0 0 0 0 1300 Nursing Administration 6767 29330 0 9058 0 32774 0 1400 Central Services and Supply 48295 209325 0 64647 0 2815 0 0 1500 Pharmacy 9659 41865 0 12929 0 10368 0 0 0 1600 Medical Records amp Library 12746 55245 0 17062 0 13812 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 287355 1245493 194159 384654 1279497 101907 0 1122397 0 0 282741 0
3100 Intensive Care Unit 50407 218480 44463 67475 122109 22988 0 230707 0 0 57778 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
ANCILLARY COST CENTERS 5000 Operating Room 64371 279006 26097 86167 289 16495 0 179089 0 0 96649 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 39629 0 5400 Radiology-Diagnostic 38384 166369 32393 51381 0 12357 0 11607 0 0 72900 0 5401 Ultra Sound 1438 6232 0 1925 0 5123 0 0 0 0 34435 0 5600 Radioisotope 7677 33274 1304 10276 0 1680 0 10418 0 0 11704 0 5700 Computed Tomography (CT) Scan 3875 16795 0 5187 0 5733 0 0 0 0 115424 0 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 178 0 0 0 0 973 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 24956 108166 597 33406 0 35158 0 10684 0 0 141335 0 6001 GI Lab 5686 24647 1652 7612 0 3106 0 27809 0 0 30991 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3052 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 9310 40351 0 12462 0 10725 0 0 0 0 71751 0 6600 Physical Therapy 37710 163446 0 50478 0 0 0 0 0 0 8019 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 1137 4929 709 1522 0 2871 0 0 0 0 61930 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 990451 0 66024 0 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 34995 0 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 1592035 207938 0 7400 Renal Dialysis 49 211 0 65 0 0 0 0 0 0 7869 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 283 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 53672 232634 152254 71846 21247 41134 0 433708 0 0 327655 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
SUMMARY OF FINDINGS
Provider Name Fiscal Period Ended
CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
SETTLEMENT COST
1 Medi-Cal Noncontract Settlement (SCHEDULE 1) Provider NPI 1962407460 Reported
Net Change
Audited Amount Due Provider (State)
$ 1285626
$ (1048374)
$ 237252
2 Subprovider I (SCHEDULE 1-1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
3 Subprovider II (SCHEDULE 1-2) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
4 Medi-Cal Contract Cost (CONTRACT SCH 1) Provider NPI 1962407460 Reported
Net Change
Audited Cost
Audited Amount Due Provider (State)
$
$
$
0
0
0
$ 0
5 Distinct Part Nursing Facility (DPNF SCH 1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
6 Distinct Part Nursing Facility (DPNF SCH 1-1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
7 Adult Subacute (ADULT SUBACUTE SCH 1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
8 Total Medi-Cal Settlement Due Provider (State) - (Lines 1 through 7) $ 237252
9 Total Medi-Cal Cost $ 0
SUMMARY OF FINDINGS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
SETTLEMENT COST
10 Subacute (SUBACUTE SCH 1-1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
11 Rural Health Clinic (RHC SCH 1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
12 Rural Health Clinic (RHC 95-210 SCH 1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
13 Rural Health Clinic (RHC 95-210 SCH 1-1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
14 County Medical Services Program (CMSP SCH 1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
15 Transitional Care (TC SCH 1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
16 Total Other Settlement Due Provider - (Lines 10 through 15) $ 0
17 Total Combined Audited Settlement Due Provider (StateCMSPRHC) - (Line 8 + Line 16) $ 237252
STATE OF CALIFORNIA SCHEDULE 1 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
1 Net Cost of Covered Services Rendered to Medi-Cal Patients (Schedule 3) $ 7914460 $ 7802163
2 Excess Reasonable Cost Over Charges (Schedule 2) $ 0 $ 0
3 Medi-Cal Inpatient Hospital Based Physician Services $ 0 $ NA
4 $ 0 $ 0
5 TOTAL COST-Reimbursable to Provider (Lines 1 through 4) $ 7914460 $ 7802163
6 Interim Payments (Adj 35) $ (6628834) $ (7256881)
7 Balance Due Provider (State) $ 1285626 $ 545282
8 Medi-Cal Overpayments (Adjs 37-38) $ 0 $ (23344)
9 AB 5 and AB 1183 Reduction (Sch A) $ $ (284686)
10 Protested Amount (Adj 2) $ 0 $ 0
11 TOTAL MEDI-CAL SETTLEMENT Due Provider (State) $ 1285626 $ 237252 (To Summary of Findings)
STATE OF CALIFORNIA SCHEDULE A PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT AB 5 and AB 1183 - SUMMARY OF REDUCTIONS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER December 31 2011
Provider No 1962407460
1 10 Reduction to Noncontract Services for 070108 Through 93008 (SCHEDULE A-1) $ 0
2 Reduction to Noncontract Services for 100108 Through 040509 (SCHEDULE A-2) 0
3 10 Reduction to Noncontract Services for 010111 Through 041211 (SCHEDULE A-3) 284686
4 10 Reduction to HFPAs lt 3 Hospitals for 070108 Through 041211 (SCHEDULE A-4) 0
5 10 Reduction to Rural Health Hospitals for 070108 Through 103108 (SCHEDULE A-5) 0
6 10 Reduction to Rural Health Hospitals for 070109 Through 022410 (SCHEDULE A-6) 0
7 Total Noncontract AB 5 AND AB 1183 Reductions $ 284686 (To Schedule 1 Line 9)
STATE OF CALIFORNIA SCHEDULE A-3 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT AB 5 - 10 REDUCTION TO SERVICES FROM APRIL 6 2009 THROUGH April 12 2011 - NONCONTRACT HOSPITALS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER December 31 2011
Provider No 1962407460
Audited Medi-Cal Cost Per Day
1 Medi-Cal Cost of Covered Services (Schedule 3 Line 8) $ 8000826
2 Less Medi-Cal Administrative Day Cost (Schedule 4A Lines 33 and 36)
3 Less Medi-Cal Administrative Ancillary Cost (Schedule A-7)
4 Total Medi-Cal Cost of Covered Services Subject to Reductions (Line 1 - Lines 2 and 3) $ 8000826
5 Total Audited Medi-Cal Days (Schedules 4 4A and 4B excludes Administrative Days) 309425
6 Audited Medi-Cal Cost Per Day (Line 4 Line 5) $ 258571
AB 5 - 10 Cost Reduction For Services From 010111 Through 041211
7 Audited Medi-Cal Days of Service from 010111 Through 041211(excludes Administrative Days) 1101
8 Audited Medi-Cal Cost Per Day For 010111 Through 041211(Line 6 Line 7) $ 2846864
9 AB 5 - 10 Cost Reduction for 010111 Through 041211 (Line 8 10) $ 284686 (To Schedule A Line 3)
0
STATE OF CALIFORNIA SCHEDULE 2 PROGRAM NONCONTRACT
COMPUTATION OF LESSER OF MEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
REASONABLE COST OF MEDI-CAL INPATIENT SERVICES
1 Cost of Covered Services (Schedule 3) $ 8095037 $ 8000826
CHARGES FOR MEDI-CAL INPATIENT SERVICES
2 Inpatient Routine Service Charges (Adj 33) $ 6182850 $ 8491100
3 Inpatient Ancillary Service Charges (Adj 33) $ 20623381 $ 22454058
4 Total Charges - Medi-Cal Inpatient Services $ 26806231 $ 30945158
5 Excess of Customary Charges Over Reasonable Cost (Line 4 minus Line 1) $ 18711194 $ 22944332
6 Excess of Reasonable Cost Over Customary Charges (Line 1 minus Line 4) $ 0 $ 0
(To Schedule 1)
If charges exceed reasonable cost no further calculation necessary for this schedule
STATE OF CALIFORNIA SCHEDULE 3 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL NET COSTS OF COVERED SERVICES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
1 Medi-Cal Inpatient Ancillary Services (Schedule 5) $ 3996748 $ 3799513
2 Medi-Cal Inpatient Routine Services (Schedule 4) $ 4098289 $ 4201313
3 Medi-Cal Inpatient Hospital Based Physician for Intern and Resident Services (Sch ) $ 0 $ 0
4 $ 0 $ 0
5 $ 0 $ 0
6 SUBTOTAL (Sum of Lines 1 through 5) $ 8095037 $ 8000826
7 Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Schedule 7) $ (See Schedule 1) $ 0
8 SUBTOTAL $ 8095037 $ 8000826 (To Schedule 2)
9 Medi-Cal Deductible (Adj 34) $ (19255) $ (18887) 10 Medi-Cal Coinsurance (Adj 34) $ (161322) $ (179776)
11 Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ 7914460 $ 7802163
(To Schedule 1)
STATE OF CALIFORNIA SCHEDULE 4 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED AUDITED
INPATIENT DAYS 1 Total Inpatient Days (include private amp swing-bed) (Adj ) 15592 15592 2 Inpatient Days (include private exclude swing-bed) 15592 15592 3 Private Room Days (exclude swing-bed private room) (Adj ) 0 0 4 Semi-Private Room Days (exclude swing-bed) (Adj ) 15592 15592 5 Medicare NF Swing-Bed Days through Dec 31 (Adj ) 0 0 6 Medicare NF Swing-Bed Days after Dec 31 (Adj ) 0 0 7 Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 0 0 8 Medi-Cal NF Swing-Bed Days after July 31 (Adj ) 0 0 9 Medi-Cal Days (excluding swing-bed) (Adjs 31 36) 229500 270850
SW ING-BED ADJUSTMENT 17 Medicare NF Swing-Bed Rates through Dec 31 (Adj ) $ 000 $ 000 18 Medicare NF Swing-Bed Rates after Dec 31 (Adj ) $ 000 $ 000 19 Medi-Cal NF Swing-Bed Rates through July 31 (Adj ) $ 000 $ 000 20 Medi-Cal NF Swing-Bed Rates after July 31 (Adj ) $ 000 $ 000 21 Total Routine Serv Cost (Sch 8 Line 30 Col 26) $ 22365373 $ 19534607 22 Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17) $ 0 $ 0 23 Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18) $ 0 $ 0 24 Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19) $ 0 $ 0 25 Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20) $ 0 $ 0 26 Total Swing-Bed Cost (Sum of Lines 22 to 25) $ 0 $ 0 27 Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26) $ 22365373 $ 19534607
PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 Gen Inpatient Routine Serv Charges (excl swing-bed charges) $ 0 $ 0 29 Private Room Charges (excluding swing-bed charges) $ 50416207 $ 50416207 30 Semi-Private Room Charges (excluding swing-bed charges) $ (50416207) $ (50416207) 31 Gen Inpatient Routine Service CostCharge Ratio (L 27 divide L 28) $ 0000000 $ 0000000 32 Average Private Room Per Diem Charge (L 29 divide L 3) $ 000 $ 000 33 Average Semi-Private Room Per Diem Charge (L 30 divide L 4) $ (323347) $ (323347) 34 Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33) $ 000 $ 000 35 Average Per Diem Private Room Cost Differential (L 31 x L 34) $ 000 $ 000 36 Private Room Cost Differential Adjustment (L 35 x L 3) $ 0 $ 0 37 Inpatient Rout Cost Net of Swing-Bed amp Prvt Rm (L 27 minus L 36) $ 22365373 $ 19534607
PROGRAM INPATIENT OPERATING COST 38 Adjusted General Inpatient Routine Cost Per Diem (L 37 divide L 2) $ 143441 $ 125286 39 Program General Inpatient Routine Service Cost (L 9 x L 38) $ 3291971 $ 3393371
40 Cost Applicable to Medi-Cal (Sch 4A) $ 806318 $ 807942 41 Cost Applicable to Medi-Cal (Sch 4B) $ 0 $ 0
42 TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 3940 amp 41) $ 4098289 $ 4201313 ( To Schedule 3 )
STATE OF CALIFORNIA SCHEDULE 4A PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE ANDOR NURSERY UNITS REPORTED AUDITED
NURSERY 1 Total Inpatient Routine Cost (Sch 8 Line 43 Col 26)
2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
000
0
$
$
$
00
00000
INTENSIVE CARE UNIT 6 Total Inpatient Routine Cost (Sch 8 Line 31 Col 26)
7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost
9 Medi-Cal Inpatient Days (Adjs 31 36) 10 Cost Applicable to Medi-Cal
$ 50006362059
$ 24286733200
$ 806318
$
$
$
43125232059
20944738575
807942
CORONARY CARE UNIT 11 Total Inpatient Routine Cost (Sch 8 Line 32 Col 26)
12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost 14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
BURN INTENSIVE CARE UNIT 16 Total Inpatient Routine Cost (Sch 8 Line 33 Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
SURGICAL INTENSIVE CARE UNIT 21 Total Inpatient Routine Cost (Sch 8 Line 34 Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
OTHER SPECIAL CARE (SPECIFY) 26 Total Inpatient Routine Cost (Sch 8 Line 35 Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
ADMINISTRATIVE DAYS 31 Per Diem Rate (Adj )32 Medi-Cal Inpatient Days (Adj ) 33 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
ADMINISTRATIVE DAYS 34 Per Diem Rate (Adj )35 Medi-Cal Inpatient Days (Adj ) 36 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
37 Medi-Cal Routine Cost (Sum of Lines 510152025303336) $ 806318 $ 807942 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 4B PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE UNITS REPORTED AUDITED
1 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
6 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost 9 Medi-Cal Inpatient Days (Adj ) 10 Cost Applicable to Medi-Cal
$ 00
$ 0000
$ 0
$
$
$
00
0000 0
11 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
16 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
21 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
26 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
31 Medi-Cal Routine Cost (Sum of Lines 51015202530) $ 0 $ 0 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 5 PROGRAM NONCONTRACT
SCHEDULE OF MEDI-CAL ANCILLARY COSTS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
TOTAL ANCILLARY
COST
TOTAL ANCILLARY CHARGES
(Adj )
RATIO COST TO CHARGES
CHARGES (From Schedule 6)
MEDI-CAL COST
MEDI-CAL
ANCILLARY COST CENTERS 5000 Operating Room $ 3554239 $ 14309479 0248384 $ 2584884 $ 642043 5100 Recovery Room 0 0 0000000 0 0 5300 Anesthesiology 39629 5867250 0006754 879414 5940 5400 Radiology-Diagnostic 2271078 10793343 0210415 794869 167252 5401 Ultra Sound 643680 5098375 0126252 295897 37358 5600 Radioisotope 382848 1732875 0220932 206257 45569 5700 Computed Tomography (CT) Scan 761998 17089310 0044589 1166436 52010 5800 Magnetic Resonance Imaging (MRI) 22902 144113 0158919 0 0 5900 Cardiac Catheterization 0 0 0000000 0 0 6000 Laboratory 4858864 20925490 0232198 2503211 581241 6001 GI Lab 510896 4588397 0111345 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0000000 0 0 6200 W hole Blood amp Packed Red Blood Cells 3056 451924 0006762 176584 1194 6300 Blood Storing Processing amp Trans 0 0 0000000 0 0 6400 Intravenous Therapy 0 0 0000000 0 0 6500 Respiratory Therapy 1638618 10623110 0154250 2225217 343240 6600 Physical Therapy 777505 1187297 0654853 154359 101082 6700 Occupational Therapy 0 0 0000000 0 0 6800 Speech Pathology 0 0 0000000 0 0 6900 Electrocardiology 421192 9169134 0045936 1956860 89890 7000 Electroencephalography 0 0 0000000 0 0 7100 Medical Supplies Charged to Patients 4248079 9775274 0434574 1732396 752854 7200 Implantable Devices Charged to Patients 729822 5181268 0140858 574210 80882 7300 Drugs Charged to Patients 3010434 30786573 0097784 4573271 447193 7400 Renal Dialysis 333141 1165060 0285943 284460 81339 7500 ASC (Non-Distinct Part) 0 0 0000000 0 0 7501 Other Ancillary (specify) 283 41845 0006754 0 0 7700 0 0 0000000 0 0 7800 0 0 0000000 0 0 7900 0 0 0000000 0 0 8000 0 0 0000000 0 0 8100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0 8700 0 0 0000000 0 0 8701 0 0 0000000 0 0 8800 Rural Health Clinic (RHC) 0 0 0000000 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0000000 0 0 9000 Clinic 0 0 0000000 0 0 9100 Emergency 7660663 48511384 0157915 2345733 370426 9200 Observation Beds 0 0 0000000 0 0 9300 Other Outpatient Services (Specify) 0 0 0000000 0 0 9301 0 0 0000000 0 0 9302 0 0 0000000 0 0 9303 0 0 0000000 0 0 9304 0 0 0000000 0 0 9305 0 0 0000000 0 0
TOTAL $ 31868926 $ 197441501 $ 22454058 $ 3799513 (To Schedule 3)
From Schedule 8 Column 26
STATE OF CALIFORNIA SCHEDULE 6 PROGRAM NONCONTRACT
ADJUSTMENTS TO MEDI-CAL CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
ANCILLARY CHARGES REPORTED ADJUSTMENTS
(Adj 32) AUDITED
5000 Operating Room $ 2372682 $ 212202 $ 2584884 5100 Recovery Room 0 5300 Anesthesiology 812663 66751 879414 5400 Radiology-Diagnostic 744425 50444 794869 5401 Ultra Sound 273774 22123 295897 5600 Radioisotope 201256 5001 206257 5700 Computed Tomography (CT) Scan 1104906 61530 1166436 5800 Magnetic Resonance Imaging (MRI) 0 0 5900 Cardiac Catheterization 0 0 6000 Laboratory 2539230 (36019) 2503211 6001 GI Lab 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 6200 W hole Blood amp Packed Red Blood Cells 168194 8390 176584 6300 Blood Storing Processing amp Trans 0 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1944943 280274 2225217 6600 Physical Therapy 140110 14249 154359 6700 Occupational Therapy 0 0 6800 Speech Pathology 0 0 6900 Electrocardiology 1664507 292353 1956860 7000 Electroencephalography 0 0 7100 Medical Supplies Charged to Patients 1472234 260162 1732396 7200 Implantable Devices Charged to Patients 496326 77884 574210 7300 Drugs Charged to Patients 4193928 379343 4573271 7400 Renal Dialysis 266026 18434 284460 7500 ASC (Non-Distinct Part) 0 0 7501 Other Ancillary (specify) 0 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 2228177 117556 2345733 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
TOTAL MEDI-CAL ANCILLARY CHARGES $ 20623381 $ 1830677 $ 22454058 (To Schedule 5)
STATE OF CALIFORNIA SCHEDULE 7 PROGRAM NONCONTRACT
COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED
PHYSICIANS REMUNERATION
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
PROFESSIONAL SERVICE
COST CENTERS REMUNERATION
HBP
(Adj )
TOTAL CHARGES TO ALL PATIENTS
(Adj )
RATIO OF REMUNERATION
TO CHARGES
MEDI-CAL
(Adj )
CHARGES COST MEDI-CAL
5300 Anesthesiology $ 0 $ 0 0000000 $ $ 0 5400 Radiology - Diagnostic 0 0 0000000 0 5500 Radioisotope 0 0 0000000 0 6000 Laboratory 0 0 0000000 0 6900 Electrocardiology 0 0 0000000 0 7000 Electroencephalography 0 0 0000000 0 9100 Emergency 0 0 0000000 0
0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0
TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 2744664 200 Capital Related Costs-Movable Equipment 2187999 0 300 Other Capital Related Costs 0 0 0 301 0 0 0 0 302 0 0 0 0 0 303 0 0 0 0 0 0 304 0 0 0 0 0 0 0 305 0 0 0 0 0 0 0 0 306 0 0 0 0 0 0 0 0 0 307 0 0 0 0 0 0 0 0 0 0 308 0 0 0 0 0 0 0 0 0 0 0 309 0 0 0 0 0 0 0 0 0 0 0 0 400 Employee Benefits 1058934 84358 67249 0 0 0 0 0 0 0 0 0 501 0 0 0 0 0 0 0 0 0 0 0 0 502 0 0 0 0 0 0 0 0 0 0 0 0 503 0 0 0 0 0 0 0 0 0 0 0 0 504 0 0 0 0 0 0 0 0 0 0 0 0 505 0 0 0 0 0 0 0 0 0 0 0 0 506 0 0 0 0 0 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 0 0 0 500 Administrative and General 10629665 247119 196999 0 0 0 0 0 0 0 0 0 600 Maintenance and Repairs 565321 88028 70174 0 0 0 0 0 0 0 0 0 700 Operation of Plant 2017048 317029 252730 0 0 0 0 0 0 0 0 0 800 Laundry and Linen Service 263543 28979 23102 0 0 0 0 0 0 0 0 0 900 Housekeeping 755766 13085 10431 0 0 0 0 0 0 0 0 0
1000 Dietary 807098 83603 66647 0 0 0 0 0 0 0 0 0 1100 Cafeteria 159362 24177 19274 0 0 0 0 0 0 0 0 0 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 1482354 17467 13924 0 0 0 0 0 0 0 0 0 1400 Central Services and Supply 305730 124660 99377 0 0 0 0 0 0 0 0 0 1500 Pharmacy 1132927 24932 19875 0 0 0 0 0 0 0 0 0 1600 Medical Records amp Library 1178942 32900 26228 0 0 0 0 0 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 193276 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9131110 741734 591297 0 0 0 0 0 0 0 0 0
3100 Intensive Care Unit 2477587 130112 103723 0 0 0 0 0 0 0 0 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
ANCILLARY COST CENTERS 5000 Operating Room 1636558 166158 132458 0 0 0 0 0 0 0 0 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 1301021 99078 78983 0 0 0 0 0 0 0 0 0 5401 Ultra Sound 454209 3711 2959 0 0 0 0 0 0 0 0 0 5600 Radioisotope 206030 19816 15797 0 0 0 0 0 0 0 0 0 5700 Computed Tomography (CT) Scan 458725 10002 7974 0 0 0 0 0 0 0 0 0 5800 Magnetic Resonance Imaging (MRI) 16908 0 0 0 0 0 0 0 0 0 0 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 3398341 64417 51352 0 0 0 0 0 0 0 0 0 6001 GI Lab 292049 14678 11701 0 0 0 0 0 0 0 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 3 0 0 0 0 0 0 0 0 0 0 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 1123538 24030 19157 0 0 0 0 0 0 0 0 0 6600 Physical Therapy 241010 97338 77596 0 0 0 0 0 0 0 0 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 266558 2936 2340 0 0 0 0 0 0 0 0 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 2563528 0 0 0 0 0 0 0 0 0 0 0 7200 Implantable Devices Charged to Patients 558092 0 0 0 0 0 0 0 0 0 0 0 7300 Drugs Charged to Patients 972254 0 0 0 0 0 0 0 0 0 0 0 7400 Renal Dialysis 260774 126 100 0 0 0 0 0 0 0 0 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 4126916 138542 110443 0 0 0 0 0 0 0 0 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 5683 4530 0 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 137766 109825 0 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 512225 2202 1755 0 0 0 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 57057440 2744664 2187999 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 0 501 0 0 502 0 0 0 503 0 0 0 0 504 0 0 0 0 0 505 0 0 0 0 0 0 506 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 500 Administrative and General 0 154558 0 0 0 0 0 0 0 0 11228341 600 Maintenance and Repairs 0 0 0 0 0 0 0 0 0 0 723523 177266 700 Operation of Plant 0 22951 0 0 0 0 0 0 0 0 2609759 639403 800 Laundry and Linen Service 0 634 0 0 0 0 0 0 0 0 316257 77484 900 Housekeeping 0 17935 0 0 0 0 0 0 0 0 797216 195322
1000 Dietary 0 12138 0 0 0 0 0 0 0 0 969486 237529 1100 Cafeteria 0 3630 0 0 0 0 0 0 0 0 206442 50579 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 0 51300 0 0 0 0 0 0 0 0 1565046 383443 1400 Central Services and Supply 0 4664 0 0 0 0 0 0 0 0 534431 130938 1500 Pharmacy 0 40906 0 0 0 0 0 0 0 0 1218641 298573 1600 Medical Records amp Library 0 27157 0 0 0 0 0 0 0 0 1265227 309986 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 49131 0 0 0 0 0 0 0 0 1626506 398501 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 193276 47354 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 316959 0 0 0 0 0 0 0 0 10781100 2641419
3100 Intensive Care Unit 0 83801 0 0 0 0 0 0 0 0 2795223 684843 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
ANCILLARY COST CENTERS 5000 Operating Room 0 57734 0 0 0 0 0 0 0 0 1992908 488272 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 0 35520 0 0 0 0 0 0 0 0 1514602 371085 5401 Ultra Sound 0 16650 0 0 0 0 0 0 0 0 477530 116997 5600 Radioisotope 0 4554 0 0 0 0 0 0 0 0 246197 60319 5700 Computed Tomography (CT) Scan 0 17260 0 0 0 0 0 0 0 0 493961 121023 5800 Magnetic Resonance Imaging (MRI) 0 562 0 0 0 0 0 0 0 0 17470 4280 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 104001 0 0 0 0 0 0 0 0 3618110 886454 6001 GI Lab 0 10400 0 0 0 0 0 0 0 0 328829 80565 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3 1 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 33287 0 0 0 0 0 0 0 0 1200012 294009 6600 Physical Therapy 0 0 0 0 0 0 0 0 0 0 415944 101908 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 7758 0 0 0 0 0 0 0 0 279591 68501 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 2563528 628076 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 558092 136735 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 972254 238207 7400 Renal Dialysis 0 0 0 0 0 0 0 0 0 0 261000 63946 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 136296 0 0 0 0 0 0 0 0 4512197 1105509 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 0 0 10213 2502 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 0 0 247590 60661 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 755 0 0 0 0 0 0 0 0 516937 126652 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 1210541 0 0 0 0 0 0 0 0 57057440 11228341
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 122820 800 Laundry and Linen Service 11227 48661 900 Housekeeping 5069 21971 0
1000 Dietary 32389 140383 0 43356 1100 Cafeteria 9366 40597 0 12538 0 1200 Maintenance of Personnel 0 0 0 0 0 0 1300 Nursing Administration 6767 29330 0 9058 0 32774 0 1400 Central Services and Supply 48295 209325 0 64647 0 2815 0 0 1500 Pharmacy 9659 41865 0 12929 0 10368 0 0 0 1600 Medical Records amp Library 12746 55245 0 17062 0 13812 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 287355 1245493 194159 384654 1279497 101907 0 1122397 0 0 282741 0
3100 Intensive Care Unit 50407 218480 44463 67475 122109 22988 0 230707 0 0 57778 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
ANCILLARY COST CENTERS 5000 Operating Room 64371 279006 26097 86167 289 16495 0 179089 0 0 96649 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 39629 0 5400 Radiology-Diagnostic 38384 166369 32393 51381 0 12357 0 11607 0 0 72900 0 5401 Ultra Sound 1438 6232 0 1925 0 5123 0 0 0 0 34435 0 5600 Radioisotope 7677 33274 1304 10276 0 1680 0 10418 0 0 11704 0 5700 Computed Tomography (CT) Scan 3875 16795 0 5187 0 5733 0 0 0 0 115424 0 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 178 0 0 0 0 973 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 24956 108166 597 33406 0 35158 0 10684 0 0 141335 0 6001 GI Lab 5686 24647 1652 7612 0 3106 0 27809 0 0 30991 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3052 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 9310 40351 0 12462 0 10725 0 0 0 0 71751 0 6600 Physical Therapy 37710 163446 0 50478 0 0 0 0 0 0 8019 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 1137 4929 709 1522 0 2871 0 0 0 0 61930 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 990451 0 66024 0 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 34995 0 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 1592035 207938 0 7400 Renal Dialysis 49 211 0 65 0 0 0 0 0 0 7869 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 283 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 53672 232634 152254 71846 21247 41134 0 433708 0 0 327655 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
SUMMARY OF FINDINGS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
SETTLEMENT COST
10 Subacute (SUBACUTE SCH 1-1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
11 Rural Health Clinic (RHC SCH 1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
12 Rural Health Clinic (RHC 95-210 SCH 1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
13 Rural Health Clinic (RHC 95-210 SCH 1-1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
14 County Medical Services Program (CMSP SCH 1) Provider NPI Reported
Net Change
Audited Amount Due Provider (State)
$ 0
$ 0
$ 0
15 Transitional Care (TC SCH 1) Provider NPI Reported
Net Change
Audited Cost Per Day
Audited Amount Due Provider (State)
$
$
$
000
000
000
$ 0
16 Total Other Settlement Due Provider - (Lines 10 through 15) $ 0
17 Total Combined Audited Settlement Due Provider (StateCMSPRHC) - (Line 8 + Line 16) $ 237252
STATE OF CALIFORNIA SCHEDULE 1 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
1 Net Cost of Covered Services Rendered to Medi-Cal Patients (Schedule 3) $ 7914460 $ 7802163
2 Excess Reasonable Cost Over Charges (Schedule 2) $ 0 $ 0
3 Medi-Cal Inpatient Hospital Based Physician Services $ 0 $ NA
4 $ 0 $ 0
5 TOTAL COST-Reimbursable to Provider (Lines 1 through 4) $ 7914460 $ 7802163
6 Interim Payments (Adj 35) $ (6628834) $ (7256881)
7 Balance Due Provider (State) $ 1285626 $ 545282
8 Medi-Cal Overpayments (Adjs 37-38) $ 0 $ (23344)
9 AB 5 and AB 1183 Reduction (Sch A) $ $ (284686)
10 Protested Amount (Adj 2) $ 0 $ 0
11 TOTAL MEDI-CAL SETTLEMENT Due Provider (State) $ 1285626 $ 237252 (To Summary of Findings)
STATE OF CALIFORNIA SCHEDULE A PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT AB 5 and AB 1183 - SUMMARY OF REDUCTIONS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER December 31 2011
Provider No 1962407460
1 10 Reduction to Noncontract Services for 070108 Through 93008 (SCHEDULE A-1) $ 0
2 Reduction to Noncontract Services for 100108 Through 040509 (SCHEDULE A-2) 0
3 10 Reduction to Noncontract Services for 010111 Through 041211 (SCHEDULE A-3) 284686
4 10 Reduction to HFPAs lt 3 Hospitals for 070108 Through 041211 (SCHEDULE A-4) 0
5 10 Reduction to Rural Health Hospitals for 070108 Through 103108 (SCHEDULE A-5) 0
6 10 Reduction to Rural Health Hospitals for 070109 Through 022410 (SCHEDULE A-6) 0
7 Total Noncontract AB 5 AND AB 1183 Reductions $ 284686 (To Schedule 1 Line 9)
STATE OF CALIFORNIA SCHEDULE A-3 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT AB 5 - 10 REDUCTION TO SERVICES FROM APRIL 6 2009 THROUGH April 12 2011 - NONCONTRACT HOSPITALS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER December 31 2011
Provider No 1962407460
Audited Medi-Cal Cost Per Day
1 Medi-Cal Cost of Covered Services (Schedule 3 Line 8) $ 8000826
2 Less Medi-Cal Administrative Day Cost (Schedule 4A Lines 33 and 36)
3 Less Medi-Cal Administrative Ancillary Cost (Schedule A-7)
4 Total Medi-Cal Cost of Covered Services Subject to Reductions (Line 1 - Lines 2 and 3) $ 8000826
5 Total Audited Medi-Cal Days (Schedules 4 4A and 4B excludes Administrative Days) 309425
6 Audited Medi-Cal Cost Per Day (Line 4 Line 5) $ 258571
AB 5 - 10 Cost Reduction For Services From 010111 Through 041211
7 Audited Medi-Cal Days of Service from 010111 Through 041211(excludes Administrative Days) 1101
8 Audited Medi-Cal Cost Per Day For 010111 Through 041211(Line 6 Line 7) $ 2846864
9 AB 5 - 10 Cost Reduction for 010111 Through 041211 (Line 8 10) $ 284686 (To Schedule A Line 3)
0
STATE OF CALIFORNIA SCHEDULE 2 PROGRAM NONCONTRACT
COMPUTATION OF LESSER OF MEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
REASONABLE COST OF MEDI-CAL INPATIENT SERVICES
1 Cost of Covered Services (Schedule 3) $ 8095037 $ 8000826
CHARGES FOR MEDI-CAL INPATIENT SERVICES
2 Inpatient Routine Service Charges (Adj 33) $ 6182850 $ 8491100
3 Inpatient Ancillary Service Charges (Adj 33) $ 20623381 $ 22454058
4 Total Charges - Medi-Cal Inpatient Services $ 26806231 $ 30945158
5 Excess of Customary Charges Over Reasonable Cost (Line 4 minus Line 1) $ 18711194 $ 22944332
6 Excess of Reasonable Cost Over Customary Charges (Line 1 minus Line 4) $ 0 $ 0
(To Schedule 1)
If charges exceed reasonable cost no further calculation necessary for this schedule
STATE OF CALIFORNIA SCHEDULE 3 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL NET COSTS OF COVERED SERVICES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
1 Medi-Cal Inpatient Ancillary Services (Schedule 5) $ 3996748 $ 3799513
2 Medi-Cal Inpatient Routine Services (Schedule 4) $ 4098289 $ 4201313
3 Medi-Cal Inpatient Hospital Based Physician for Intern and Resident Services (Sch ) $ 0 $ 0
4 $ 0 $ 0
5 $ 0 $ 0
6 SUBTOTAL (Sum of Lines 1 through 5) $ 8095037 $ 8000826
7 Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Schedule 7) $ (See Schedule 1) $ 0
8 SUBTOTAL $ 8095037 $ 8000826 (To Schedule 2)
9 Medi-Cal Deductible (Adj 34) $ (19255) $ (18887) 10 Medi-Cal Coinsurance (Adj 34) $ (161322) $ (179776)
11 Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ 7914460 $ 7802163
(To Schedule 1)
STATE OF CALIFORNIA SCHEDULE 4 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED AUDITED
INPATIENT DAYS 1 Total Inpatient Days (include private amp swing-bed) (Adj ) 15592 15592 2 Inpatient Days (include private exclude swing-bed) 15592 15592 3 Private Room Days (exclude swing-bed private room) (Adj ) 0 0 4 Semi-Private Room Days (exclude swing-bed) (Adj ) 15592 15592 5 Medicare NF Swing-Bed Days through Dec 31 (Adj ) 0 0 6 Medicare NF Swing-Bed Days after Dec 31 (Adj ) 0 0 7 Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 0 0 8 Medi-Cal NF Swing-Bed Days after July 31 (Adj ) 0 0 9 Medi-Cal Days (excluding swing-bed) (Adjs 31 36) 229500 270850
SW ING-BED ADJUSTMENT 17 Medicare NF Swing-Bed Rates through Dec 31 (Adj ) $ 000 $ 000 18 Medicare NF Swing-Bed Rates after Dec 31 (Adj ) $ 000 $ 000 19 Medi-Cal NF Swing-Bed Rates through July 31 (Adj ) $ 000 $ 000 20 Medi-Cal NF Swing-Bed Rates after July 31 (Adj ) $ 000 $ 000 21 Total Routine Serv Cost (Sch 8 Line 30 Col 26) $ 22365373 $ 19534607 22 Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17) $ 0 $ 0 23 Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18) $ 0 $ 0 24 Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19) $ 0 $ 0 25 Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20) $ 0 $ 0 26 Total Swing-Bed Cost (Sum of Lines 22 to 25) $ 0 $ 0 27 Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26) $ 22365373 $ 19534607
PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 Gen Inpatient Routine Serv Charges (excl swing-bed charges) $ 0 $ 0 29 Private Room Charges (excluding swing-bed charges) $ 50416207 $ 50416207 30 Semi-Private Room Charges (excluding swing-bed charges) $ (50416207) $ (50416207) 31 Gen Inpatient Routine Service CostCharge Ratio (L 27 divide L 28) $ 0000000 $ 0000000 32 Average Private Room Per Diem Charge (L 29 divide L 3) $ 000 $ 000 33 Average Semi-Private Room Per Diem Charge (L 30 divide L 4) $ (323347) $ (323347) 34 Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33) $ 000 $ 000 35 Average Per Diem Private Room Cost Differential (L 31 x L 34) $ 000 $ 000 36 Private Room Cost Differential Adjustment (L 35 x L 3) $ 0 $ 0 37 Inpatient Rout Cost Net of Swing-Bed amp Prvt Rm (L 27 minus L 36) $ 22365373 $ 19534607
PROGRAM INPATIENT OPERATING COST 38 Adjusted General Inpatient Routine Cost Per Diem (L 37 divide L 2) $ 143441 $ 125286 39 Program General Inpatient Routine Service Cost (L 9 x L 38) $ 3291971 $ 3393371
40 Cost Applicable to Medi-Cal (Sch 4A) $ 806318 $ 807942 41 Cost Applicable to Medi-Cal (Sch 4B) $ 0 $ 0
42 TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 3940 amp 41) $ 4098289 $ 4201313 ( To Schedule 3 )
STATE OF CALIFORNIA SCHEDULE 4A PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE ANDOR NURSERY UNITS REPORTED AUDITED
NURSERY 1 Total Inpatient Routine Cost (Sch 8 Line 43 Col 26)
2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
000
0
$
$
$
00
00000
INTENSIVE CARE UNIT 6 Total Inpatient Routine Cost (Sch 8 Line 31 Col 26)
7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost
9 Medi-Cal Inpatient Days (Adjs 31 36) 10 Cost Applicable to Medi-Cal
$ 50006362059
$ 24286733200
$ 806318
$
$
$
43125232059
20944738575
807942
CORONARY CARE UNIT 11 Total Inpatient Routine Cost (Sch 8 Line 32 Col 26)
12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost 14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
BURN INTENSIVE CARE UNIT 16 Total Inpatient Routine Cost (Sch 8 Line 33 Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
SURGICAL INTENSIVE CARE UNIT 21 Total Inpatient Routine Cost (Sch 8 Line 34 Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
OTHER SPECIAL CARE (SPECIFY) 26 Total Inpatient Routine Cost (Sch 8 Line 35 Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
ADMINISTRATIVE DAYS 31 Per Diem Rate (Adj )32 Medi-Cal Inpatient Days (Adj ) 33 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
ADMINISTRATIVE DAYS 34 Per Diem Rate (Adj )35 Medi-Cal Inpatient Days (Adj ) 36 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
37 Medi-Cal Routine Cost (Sum of Lines 510152025303336) $ 806318 $ 807942 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 4B PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE UNITS REPORTED AUDITED
1 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
6 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost 9 Medi-Cal Inpatient Days (Adj ) 10 Cost Applicable to Medi-Cal
$ 00
$ 0000
$ 0
$
$
$
00
0000 0
11 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
16 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
21 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
26 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
31 Medi-Cal Routine Cost (Sum of Lines 51015202530) $ 0 $ 0 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 5 PROGRAM NONCONTRACT
SCHEDULE OF MEDI-CAL ANCILLARY COSTS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
TOTAL ANCILLARY
COST
TOTAL ANCILLARY CHARGES
(Adj )
RATIO COST TO CHARGES
CHARGES (From Schedule 6)
MEDI-CAL COST
MEDI-CAL
ANCILLARY COST CENTERS 5000 Operating Room $ 3554239 $ 14309479 0248384 $ 2584884 $ 642043 5100 Recovery Room 0 0 0000000 0 0 5300 Anesthesiology 39629 5867250 0006754 879414 5940 5400 Radiology-Diagnostic 2271078 10793343 0210415 794869 167252 5401 Ultra Sound 643680 5098375 0126252 295897 37358 5600 Radioisotope 382848 1732875 0220932 206257 45569 5700 Computed Tomography (CT) Scan 761998 17089310 0044589 1166436 52010 5800 Magnetic Resonance Imaging (MRI) 22902 144113 0158919 0 0 5900 Cardiac Catheterization 0 0 0000000 0 0 6000 Laboratory 4858864 20925490 0232198 2503211 581241 6001 GI Lab 510896 4588397 0111345 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0000000 0 0 6200 W hole Blood amp Packed Red Blood Cells 3056 451924 0006762 176584 1194 6300 Blood Storing Processing amp Trans 0 0 0000000 0 0 6400 Intravenous Therapy 0 0 0000000 0 0 6500 Respiratory Therapy 1638618 10623110 0154250 2225217 343240 6600 Physical Therapy 777505 1187297 0654853 154359 101082 6700 Occupational Therapy 0 0 0000000 0 0 6800 Speech Pathology 0 0 0000000 0 0 6900 Electrocardiology 421192 9169134 0045936 1956860 89890 7000 Electroencephalography 0 0 0000000 0 0 7100 Medical Supplies Charged to Patients 4248079 9775274 0434574 1732396 752854 7200 Implantable Devices Charged to Patients 729822 5181268 0140858 574210 80882 7300 Drugs Charged to Patients 3010434 30786573 0097784 4573271 447193 7400 Renal Dialysis 333141 1165060 0285943 284460 81339 7500 ASC (Non-Distinct Part) 0 0 0000000 0 0 7501 Other Ancillary (specify) 283 41845 0006754 0 0 7700 0 0 0000000 0 0 7800 0 0 0000000 0 0 7900 0 0 0000000 0 0 8000 0 0 0000000 0 0 8100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0 8700 0 0 0000000 0 0 8701 0 0 0000000 0 0 8800 Rural Health Clinic (RHC) 0 0 0000000 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0000000 0 0 9000 Clinic 0 0 0000000 0 0 9100 Emergency 7660663 48511384 0157915 2345733 370426 9200 Observation Beds 0 0 0000000 0 0 9300 Other Outpatient Services (Specify) 0 0 0000000 0 0 9301 0 0 0000000 0 0 9302 0 0 0000000 0 0 9303 0 0 0000000 0 0 9304 0 0 0000000 0 0 9305 0 0 0000000 0 0
TOTAL $ 31868926 $ 197441501 $ 22454058 $ 3799513 (To Schedule 3)
From Schedule 8 Column 26
STATE OF CALIFORNIA SCHEDULE 6 PROGRAM NONCONTRACT
ADJUSTMENTS TO MEDI-CAL CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
ANCILLARY CHARGES REPORTED ADJUSTMENTS
(Adj 32) AUDITED
5000 Operating Room $ 2372682 $ 212202 $ 2584884 5100 Recovery Room 0 5300 Anesthesiology 812663 66751 879414 5400 Radiology-Diagnostic 744425 50444 794869 5401 Ultra Sound 273774 22123 295897 5600 Radioisotope 201256 5001 206257 5700 Computed Tomography (CT) Scan 1104906 61530 1166436 5800 Magnetic Resonance Imaging (MRI) 0 0 5900 Cardiac Catheterization 0 0 6000 Laboratory 2539230 (36019) 2503211 6001 GI Lab 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 6200 W hole Blood amp Packed Red Blood Cells 168194 8390 176584 6300 Blood Storing Processing amp Trans 0 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1944943 280274 2225217 6600 Physical Therapy 140110 14249 154359 6700 Occupational Therapy 0 0 6800 Speech Pathology 0 0 6900 Electrocardiology 1664507 292353 1956860 7000 Electroencephalography 0 0 7100 Medical Supplies Charged to Patients 1472234 260162 1732396 7200 Implantable Devices Charged to Patients 496326 77884 574210 7300 Drugs Charged to Patients 4193928 379343 4573271 7400 Renal Dialysis 266026 18434 284460 7500 ASC (Non-Distinct Part) 0 0 7501 Other Ancillary (specify) 0 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 2228177 117556 2345733 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
TOTAL MEDI-CAL ANCILLARY CHARGES $ 20623381 $ 1830677 $ 22454058 (To Schedule 5)
STATE OF CALIFORNIA SCHEDULE 7 PROGRAM NONCONTRACT
COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED
PHYSICIANS REMUNERATION
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
PROFESSIONAL SERVICE
COST CENTERS REMUNERATION
HBP
(Adj )
TOTAL CHARGES TO ALL PATIENTS
(Adj )
RATIO OF REMUNERATION
TO CHARGES
MEDI-CAL
(Adj )
CHARGES COST MEDI-CAL
5300 Anesthesiology $ 0 $ 0 0000000 $ $ 0 5400 Radiology - Diagnostic 0 0 0000000 0 5500 Radioisotope 0 0 0000000 0 6000 Laboratory 0 0 0000000 0 6900 Electrocardiology 0 0 0000000 0 7000 Electroencephalography 0 0 0000000 0 9100 Emergency 0 0 0000000 0
0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0
TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 2744664 200 Capital Related Costs-Movable Equipment 2187999 0 300 Other Capital Related Costs 0 0 0 301 0 0 0 0 302 0 0 0 0 0 303 0 0 0 0 0 0 304 0 0 0 0 0 0 0 305 0 0 0 0 0 0 0 0 306 0 0 0 0 0 0 0 0 0 307 0 0 0 0 0 0 0 0 0 0 308 0 0 0 0 0 0 0 0 0 0 0 309 0 0 0 0 0 0 0 0 0 0 0 0 400 Employee Benefits 1058934 84358 67249 0 0 0 0 0 0 0 0 0 501 0 0 0 0 0 0 0 0 0 0 0 0 502 0 0 0 0 0 0 0 0 0 0 0 0 503 0 0 0 0 0 0 0 0 0 0 0 0 504 0 0 0 0 0 0 0 0 0 0 0 0 505 0 0 0 0 0 0 0 0 0 0 0 0 506 0 0 0 0 0 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 0 0 0 500 Administrative and General 10629665 247119 196999 0 0 0 0 0 0 0 0 0 600 Maintenance and Repairs 565321 88028 70174 0 0 0 0 0 0 0 0 0 700 Operation of Plant 2017048 317029 252730 0 0 0 0 0 0 0 0 0 800 Laundry and Linen Service 263543 28979 23102 0 0 0 0 0 0 0 0 0 900 Housekeeping 755766 13085 10431 0 0 0 0 0 0 0 0 0
1000 Dietary 807098 83603 66647 0 0 0 0 0 0 0 0 0 1100 Cafeteria 159362 24177 19274 0 0 0 0 0 0 0 0 0 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 1482354 17467 13924 0 0 0 0 0 0 0 0 0 1400 Central Services and Supply 305730 124660 99377 0 0 0 0 0 0 0 0 0 1500 Pharmacy 1132927 24932 19875 0 0 0 0 0 0 0 0 0 1600 Medical Records amp Library 1178942 32900 26228 0 0 0 0 0 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 193276 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9131110 741734 591297 0 0 0 0 0 0 0 0 0
3100 Intensive Care Unit 2477587 130112 103723 0 0 0 0 0 0 0 0 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
ANCILLARY COST CENTERS 5000 Operating Room 1636558 166158 132458 0 0 0 0 0 0 0 0 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 1301021 99078 78983 0 0 0 0 0 0 0 0 0 5401 Ultra Sound 454209 3711 2959 0 0 0 0 0 0 0 0 0 5600 Radioisotope 206030 19816 15797 0 0 0 0 0 0 0 0 0 5700 Computed Tomography (CT) Scan 458725 10002 7974 0 0 0 0 0 0 0 0 0 5800 Magnetic Resonance Imaging (MRI) 16908 0 0 0 0 0 0 0 0 0 0 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 3398341 64417 51352 0 0 0 0 0 0 0 0 0 6001 GI Lab 292049 14678 11701 0 0 0 0 0 0 0 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 3 0 0 0 0 0 0 0 0 0 0 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 1123538 24030 19157 0 0 0 0 0 0 0 0 0 6600 Physical Therapy 241010 97338 77596 0 0 0 0 0 0 0 0 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 266558 2936 2340 0 0 0 0 0 0 0 0 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 2563528 0 0 0 0 0 0 0 0 0 0 0 7200 Implantable Devices Charged to Patients 558092 0 0 0 0 0 0 0 0 0 0 0 7300 Drugs Charged to Patients 972254 0 0 0 0 0 0 0 0 0 0 0 7400 Renal Dialysis 260774 126 100 0 0 0 0 0 0 0 0 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 4126916 138542 110443 0 0 0 0 0 0 0 0 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 5683 4530 0 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 137766 109825 0 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 512225 2202 1755 0 0 0 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 57057440 2744664 2187999 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 0 501 0 0 502 0 0 0 503 0 0 0 0 504 0 0 0 0 0 505 0 0 0 0 0 0 506 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 500 Administrative and General 0 154558 0 0 0 0 0 0 0 0 11228341 600 Maintenance and Repairs 0 0 0 0 0 0 0 0 0 0 723523 177266 700 Operation of Plant 0 22951 0 0 0 0 0 0 0 0 2609759 639403 800 Laundry and Linen Service 0 634 0 0 0 0 0 0 0 0 316257 77484 900 Housekeeping 0 17935 0 0 0 0 0 0 0 0 797216 195322
1000 Dietary 0 12138 0 0 0 0 0 0 0 0 969486 237529 1100 Cafeteria 0 3630 0 0 0 0 0 0 0 0 206442 50579 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 0 51300 0 0 0 0 0 0 0 0 1565046 383443 1400 Central Services and Supply 0 4664 0 0 0 0 0 0 0 0 534431 130938 1500 Pharmacy 0 40906 0 0 0 0 0 0 0 0 1218641 298573 1600 Medical Records amp Library 0 27157 0 0 0 0 0 0 0 0 1265227 309986 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 49131 0 0 0 0 0 0 0 0 1626506 398501 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 193276 47354 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 316959 0 0 0 0 0 0 0 0 10781100 2641419
3100 Intensive Care Unit 0 83801 0 0 0 0 0 0 0 0 2795223 684843 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
ANCILLARY COST CENTERS 5000 Operating Room 0 57734 0 0 0 0 0 0 0 0 1992908 488272 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 0 35520 0 0 0 0 0 0 0 0 1514602 371085 5401 Ultra Sound 0 16650 0 0 0 0 0 0 0 0 477530 116997 5600 Radioisotope 0 4554 0 0 0 0 0 0 0 0 246197 60319 5700 Computed Tomography (CT) Scan 0 17260 0 0 0 0 0 0 0 0 493961 121023 5800 Magnetic Resonance Imaging (MRI) 0 562 0 0 0 0 0 0 0 0 17470 4280 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 104001 0 0 0 0 0 0 0 0 3618110 886454 6001 GI Lab 0 10400 0 0 0 0 0 0 0 0 328829 80565 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3 1 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 33287 0 0 0 0 0 0 0 0 1200012 294009 6600 Physical Therapy 0 0 0 0 0 0 0 0 0 0 415944 101908 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 7758 0 0 0 0 0 0 0 0 279591 68501 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 2563528 628076 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 558092 136735 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 972254 238207 7400 Renal Dialysis 0 0 0 0 0 0 0 0 0 0 261000 63946 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 136296 0 0 0 0 0 0 0 0 4512197 1105509 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 0 0 10213 2502 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 0 0 247590 60661 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 755 0 0 0 0 0 0 0 0 516937 126652 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 1210541 0 0 0 0 0 0 0 0 57057440 11228341
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 122820 800 Laundry and Linen Service 11227 48661 900 Housekeeping 5069 21971 0
1000 Dietary 32389 140383 0 43356 1100 Cafeteria 9366 40597 0 12538 0 1200 Maintenance of Personnel 0 0 0 0 0 0 1300 Nursing Administration 6767 29330 0 9058 0 32774 0 1400 Central Services and Supply 48295 209325 0 64647 0 2815 0 0 1500 Pharmacy 9659 41865 0 12929 0 10368 0 0 0 1600 Medical Records amp Library 12746 55245 0 17062 0 13812 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 287355 1245493 194159 384654 1279497 101907 0 1122397 0 0 282741 0
3100 Intensive Care Unit 50407 218480 44463 67475 122109 22988 0 230707 0 0 57778 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
ANCILLARY COST CENTERS 5000 Operating Room 64371 279006 26097 86167 289 16495 0 179089 0 0 96649 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 39629 0 5400 Radiology-Diagnostic 38384 166369 32393 51381 0 12357 0 11607 0 0 72900 0 5401 Ultra Sound 1438 6232 0 1925 0 5123 0 0 0 0 34435 0 5600 Radioisotope 7677 33274 1304 10276 0 1680 0 10418 0 0 11704 0 5700 Computed Tomography (CT) Scan 3875 16795 0 5187 0 5733 0 0 0 0 115424 0 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 178 0 0 0 0 973 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 24956 108166 597 33406 0 35158 0 10684 0 0 141335 0 6001 GI Lab 5686 24647 1652 7612 0 3106 0 27809 0 0 30991 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3052 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 9310 40351 0 12462 0 10725 0 0 0 0 71751 0 6600 Physical Therapy 37710 163446 0 50478 0 0 0 0 0 0 8019 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 1137 4929 709 1522 0 2871 0 0 0 0 61930 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 990451 0 66024 0 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 34995 0 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 1592035 207938 0 7400 Renal Dialysis 49 211 0 65 0 0 0 0 0 0 7869 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 283 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 53672 232634 152254 71846 21247 41134 0 433708 0 0 327655 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA SCHEDULE 1 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
1 Net Cost of Covered Services Rendered to Medi-Cal Patients (Schedule 3) $ 7914460 $ 7802163
2 Excess Reasonable Cost Over Charges (Schedule 2) $ 0 $ 0
3 Medi-Cal Inpatient Hospital Based Physician Services $ 0 $ NA
4 $ 0 $ 0
5 TOTAL COST-Reimbursable to Provider (Lines 1 through 4) $ 7914460 $ 7802163
6 Interim Payments (Adj 35) $ (6628834) $ (7256881)
7 Balance Due Provider (State) $ 1285626 $ 545282
8 Medi-Cal Overpayments (Adjs 37-38) $ 0 $ (23344)
9 AB 5 and AB 1183 Reduction (Sch A) $ $ (284686)
10 Protested Amount (Adj 2) $ 0 $ 0
11 TOTAL MEDI-CAL SETTLEMENT Due Provider (State) $ 1285626 $ 237252 (To Summary of Findings)
STATE OF CALIFORNIA SCHEDULE A PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT AB 5 and AB 1183 - SUMMARY OF REDUCTIONS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER December 31 2011
Provider No 1962407460
1 10 Reduction to Noncontract Services for 070108 Through 93008 (SCHEDULE A-1) $ 0
2 Reduction to Noncontract Services for 100108 Through 040509 (SCHEDULE A-2) 0
3 10 Reduction to Noncontract Services for 010111 Through 041211 (SCHEDULE A-3) 284686
4 10 Reduction to HFPAs lt 3 Hospitals for 070108 Through 041211 (SCHEDULE A-4) 0
5 10 Reduction to Rural Health Hospitals for 070108 Through 103108 (SCHEDULE A-5) 0
6 10 Reduction to Rural Health Hospitals for 070109 Through 022410 (SCHEDULE A-6) 0
7 Total Noncontract AB 5 AND AB 1183 Reductions $ 284686 (To Schedule 1 Line 9)
STATE OF CALIFORNIA SCHEDULE A-3 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT AB 5 - 10 REDUCTION TO SERVICES FROM APRIL 6 2009 THROUGH April 12 2011 - NONCONTRACT HOSPITALS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER December 31 2011
Provider No 1962407460
Audited Medi-Cal Cost Per Day
1 Medi-Cal Cost of Covered Services (Schedule 3 Line 8) $ 8000826
2 Less Medi-Cal Administrative Day Cost (Schedule 4A Lines 33 and 36)
3 Less Medi-Cal Administrative Ancillary Cost (Schedule A-7)
4 Total Medi-Cal Cost of Covered Services Subject to Reductions (Line 1 - Lines 2 and 3) $ 8000826
5 Total Audited Medi-Cal Days (Schedules 4 4A and 4B excludes Administrative Days) 309425
6 Audited Medi-Cal Cost Per Day (Line 4 Line 5) $ 258571
AB 5 - 10 Cost Reduction For Services From 010111 Through 041211
7 Audited Medi-Cal Days of Service from 010111 Through 041211(excludes Administrative Days) 1101
8 Audited Medi-Cal Cost Per Day For 010111 Through 041211(Line 6 Line 7) $ 2846864
9 AB 5 - 10 Cost Reduction for 010111 Through 041211 (Line 8 10) $ 284686 (To Schedule A Line 3)
0
STATE OF CALIFORNIA SCHEDULE 2 PROGRAM NONCONTRACT
COMPUTATION OF LESSER OF MEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
REASONABLE COST OF MEDI-CAL INPATIENT SERVICES
1 Cost of Covered Services (Schedule 3) $ 8095037 $ 8000826
CHARGES FOR MEDI-CAL INPATIENT SERVICES
2 Inpatient Routine Service Charges (Adj 33) $ 6182850 $ 8491100
3 Inpatient Ancillary Service Charges (Adj 33) $ 20623381 $ 22454058
4 Total Charges - Medi-Cal Inpatient Services $ 26806231 $ 30945158
5 Excess of Customary Charges Over Reasonable Cost (Line 4 minus Line 1) $ 18711194 $ 22944332
6 Excess of Reasonable Cost Over Customary Charges (Line 1 minus Line 4) $ 0 $ 0
(To Schedule 1)
If charges exceed reasonable cost no further calculation necessary for this schedule
STATE OF CALIFORNIA SCHEDULE 3 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL NET COSTS OF COVERED SERVICES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
1 Medi-Cal Inpatient Ancillary Services (Schedule 5) $ 3996748 $ 3799513
2 Medi-Cal Inpatient Routine Services (Schedule 4) $ 4098289 $ 4201313
3 Medi-Cal Inpatient Hospital Based Physician for Intern and Resident Services (Sch ) $ 0 $ 0
4 $ 0 $ 0
5 $ 0 $ 0
6 SUBTOTAL (Sum of Lines 1 through 5) $ 8095037 $ 8000826
7 Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Schedule 7) $ (See Schedule 1) $ 0
8 SUBTOTAL $ 8095037 $ 8000826 (To Schedule 2)
9 Medi-Cal Deductible (Adj 34) $ (19255) $ (18887) 10 Medi-Cal Coinsurance (Adj 34) $ (161322) $ (179776)
11 Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ 7914460 $ 7802163
(To Schedule 1)
STATE OF CALIFORNIA SCHEDULE 4 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED AUDITED
INPATIENT DAYS 1 Total Inpatient Days (include private amp swing-bed) (Adj ) 15592 15592 2 Inpatient Days (include private exclude swing-bed) 15592 15592 3 Private Room Days (exclude swing-bed private room) (Adj ) 0 0 4 Semi-Private Room Days (exclude swing-bed) (Adj ) 15592 15592 5 Medicare NF Swing-Bed Days through Dec 31 (Adj ) 0 0 6 Medicare NF Swing-Bed Days after Dec 31 (Adj ) 0 0 7 Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 0 0 8 Medi-Cal NF Swing-Bed Days after July 31 (Adj ) 0 0 9 Medi-Cal Days (excluding swing-bed) (Adjs 31 36) 229500 270850
SW ING-BED ADJUSTMENT 17 Medicare NF Swing-Bed Rates through Dec 31 (Adj ) $ 000 $ 000 18 Medicare NF Swing-Bed Rates after Dec 31 (Adj ) $ 000 $ 000 19 Medi-Cal NF Swing-Bed Rates through July 31 (Adj ) $ 000 $ 000 20 Medi-Cal NF Swing-Bed Rates after July 31 (Adj ) $ 000 $ 000 21 Total Routine Serv Cost (Sch 8 Line 30 Col 26) $ 22365373 $ 19534607 22 Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17) $ 0 $ 0 23 Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18) $ 0 $ 0 24 Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19) $ 0 $ 0 25 Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20) $ 0 $ 0 26 Total Swing-Bed Cost (Sum of Lines 22 to 25) $ 0 $ 0 27 Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26) $ 22365373 $ 19534607
PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 Gen Inpatient Routine Serv Charges (excl swing-bed charges) $ 0 $ 0 29 Private Room Charges (excluding swing-bed charges) $ 50416207 $ 50416207 30 Semi-Private Room Charges (excluding swing-bed charges) $ (50416207) $ (50416207) 31 Gen Inpatient Routine Service CostCharge Ratio (L 27 divide L 28) $ 0000000 $ 0000000 32 Average Private Room Per Diem Charge (L 29 divide L 3) $ 000 $ 000 33 Average Semi-Private Room Per Diem Charge (L 30 divide L 4) $ (323347) $ (323347) 34 Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33) $ 000 $ 000 35 Average Per Diem Private Room Cost Differential (L 31 x L 34) $ 000 $ 000 36 Private Room Cost Differential Adjustment (L 35 x L 3) $ 0 $ 0 37 Inpatient Rout Cost Net of Swing-Bed amp Prvt Rm (L 27 minus L 36) $ 22365373 $ 19534607
PROGRAM INPATIENT OPERATING COST 38 Adjusted General Inpatient Routine Cost Per Diem (L 37 divide L 2) $ 143441 $ 125286 39 Program General Inpatient Routine Service Cost (L 9 x L 38) $ 3291971 $ 3393371
40 Cost Applicable to Medi-Cal (Sch 4A) $ 806318 $ 807942 41 Cost Applicable to Medi-Cal (Sch 4B) $ 0 $ 0
42 TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 3940 amp 41) $ 4098289 $ 4201313 ( To Schedule 3 )
STATE OF CALIFORNIA SCHEDULE 4A PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE ANDOR NURSERY UNITS REPORTED AUDITED
NURSERY 1 Total Inpatient Routine Cost (Sch 8 Line 43 Col 26)
2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
000
0
$
$
$
00
00000
INTENSIVE CARE UNIT 6 Total Inpatient Routine Cost (Sch 8 Line 31 Col 26)
7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost
9 Medi-Cal Inpatient Days (Adjs 31 36) 10 Cost Applicable to Medi-Cal
$ 50006362059
$ 24286733200
$ 806318
$
$
$
43125232059
20944738575
807942
CORONARY CARE UNIT 11 Total Inpatient Routine Cost (Sch 8 Line 32 Col 26)
12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost 14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
BURN INTENSIVE CARE UNIT 16 Total Inpatient Routine Cost (Sch 8 Line 33 Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
SURGICAL INTENSIVE CARE UNIT 21 Total Inpatient Routine Cost (Sch 8 Line 34 Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
OTHER SPECIAL CARE (SPECIFY) 26 Total Inpatient Routine Cost (Sch 8 Line 35 Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
ADMINISTRATIVE DAYS 31 Per Diem Rate (Adj )32 Medi-Cal Inpatient Days (Adj ) 33 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
ADMINISTRATIVE DAYS 34 Per Diem Rate (Adj )35 Medi-Cal Inpatient Days (Adj ) 36 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
37 Medi-Cal Routine Cost (Sum of Lines 510152025303336) $ 806318 $ 807942 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 4B PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE UNITS REPORTED AUDITED
1 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
6 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost 9 Medi-Cal Inpatient Days (Adj ) 10 Cost Applicable to Medi-Cal
$ 00
$ 0000
$ 0
$
$
$
00
0000 0
11 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
16 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
21 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
26 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
31 Medi-Cal Routine Cost (Sum of Lines 51015202530) $ 0 $ 0 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 5 PROGRAM NONCONTRACT
SCHEDULE OF MEDI-CAL ANCILLARY COSTS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
TOTAL ANCILLARY
COST
TOTAL ANCILLARY CHARGES
(Adj )
RATIO COST TO CHARGES
CHARGES (From Schedule 6)
MEDI-CAL COST
MEDI-CAL
ANCILLARY COST CENTERS 5000 Operating Room $ 3554239 $ 14309479 0248384 $ 2584884 $ 642043 5100 Recovery Room 0 0 0000000 0 0 5300 Anesthesiology 39629 5867250 0006754 879414 5940 5400 Radiology-Diagnostic 2271078 10793343 0210415 794869 167252 5401 Ultra Sound 643680 5098375 0126252 295897 37358 5600 Radioisotope 382848 1732875 0220932 206257 45569 5700 Computed Tomography (CT) Scan 761998 17089310 0044589 1166436 52010 5800 Magnetic Resonance Imaging (MRI) 22902 144113 0158919 0 0 5900 Cardiac Catheterization 0 0 0000000 0 0 6000 Laboratory 4858864 20925490 0232198 2503211 581241 6001 GI Lab 510896 4588397 0111345 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0000000 0 0 6200 W hole Blood amp Packed Red Blood Cells 3056 451924 0006762 176584 1194 6300 Blood Storing Processing amp Trans 0 0 0000000 0 0 6400 Intravenous Therapy 0 0 0000000 0 0 6500 Respiratory Therapy 1638618 10623110 0154250 2225217 343240 6600 Physical Therapy 777505 1187297 0654853 154359 101082 6700 Occupational Therapy 0 0 0000000 0 0 6800 Speech Pathology 0 0 0000000 0 0 6900 Electrocardiology 421192 9169134 0045936 1956860 89890 7000 Electroencephalography 0 0 0000000 0 0 7100 Medical Supplies Charged to Patients 4248079 9775274 0434574 1732396 752854 7200 Implantable Devices Charged to Patients 729822 5181268 0140858 574210 80882 7300 Drugs Charged to Patients 3010434 30786573 0097784 4573271 447193 7400 Renal Dialysis 333141 1165060 0285943 284460 81339 7500 ASC (Non-Distinct Part) 0 0 0000000 0 0 7501 Other Ancillary (specify) 283 41845 0006754 0 0 7700 0 0 0000000 0 0 7800 0 0 0000000 0 0 7900 0 0 0000000 0 0 8000 0 0 0000000 0 0 8100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0 8700 0 0 0000000 0 0 8701 0 0 0000000 0 0 8800 Rural Health Clinic (RHC) 0 0 0000000 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0000000 0 0 9000 Clinic 0 0 0000000 0 0 9100 Emergency 7660663 48511384 0157915 2345733 370426 9200 Observation Beds 0 0 0000000 0 0 9300 Other Outpatient Services (Specify) 0 0 0000000 0 0 9301 0 0 0000000 0 0 9302 0 0 0000000 0 0 9303 0 0 0000000 0 0 9304 0 0 0000000 0 0 9305 0 0 0000000 0 0
TOTAL $ 31868926 $ 197441501 $ 22454058 $ 3799513 (To Schedule 3)
From Schedule 8 Column 26
STATE OF CALIFORNIA SCHEDULE 6 PROGRAM NONCONTRACT
ADJUSTMENTS TO MEDI-CAL CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
ANCILLARY CHARGES REPORTED ADJUSTMENTS
(Adj 32) AUDITED
5000 Operating Room $ 2372682 $ 212202 $ 2584884 5100 Recovery Room 0 5300 Anesthesiology 812663 66751 879414 5400 Radiology-Diagnostic 744425 50444 794869 5401 Ultra Sound 273774 22123 295897 5600 Radioisotope 201256 5001 206257 5700 Computed Tomography (CT) Scan 1104906 61530 1166436 5800 Magnetic Resonance Imaging (MRI) 0 0 5900 Cardiac Catheterization 0 0 6000 Laboratory 2539230 (36019) 2503211 6001 GI Lab 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 6200 W hole Blood amp Packed Red Blood Cells 168194 8390 176584 6300 Blood Storing Processing amp Trans 0 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1944943 280274 2225217 6600 Physical Therapy 140110 14249 154359 6700 Occupational Therapy 0 0 6800 Speech Pathology 0 0 6900 Electrocardiology 1664507 292353 1956860 7000 Electroencephalography 0 0 7100 Medical Supplies Charged to Patients 1472234 260162 1732396 7200 Implantable Devices Charged to Patients 496326 77884 574210 7300 Drugs Charged to Patients 4193928 379343 4573271 7400 Renal Dialysis 266026 18434 284460 7500 ASC (Non-Distinct Part) 0 0 7501 Other Ancillary (specify) 0 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 2228177 117556 2345733 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
TOTAL MEDI-CAL ANCILLARY CHARGES $ 20623381 $ 1830677 $ 22454058 (To Schedule 5)
STATE OF CALIFORNIA SCHEDULE 7 PROGRAM NONCONTRACT
COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED
PHYSICIANS REMUNERATION
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
PROFESSIONAL SERVICE
COST CENTERS REMUNERATION
HBP
(Adj )
TOTAL CHARGES TO ALL PATIENTS
(Adj )
RATIO OF REMUNERATION
TO CHARGES
MEDI-CAL
(Adj )
CHARGES COST MEDI-CAL
5300 Anesthesiology $ 0 $ 0 0000000 $ $ 0 5400 Radiology - Diagnostic 0 0 0000000 0 5500 Radioisotope 0 0 0000000 0 6000 Laboratory 0 0 0000000 0 6900 Electrocardiology 0 0 0000000 0 7000 Electroencephalography 0 0 0000000 0 9100 Emergency 0 0 0000000 0
0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0
TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 2744664 200 Capital Related Costs-Movable Equipment 2187999 0 300 Other Capital Related Costs 0 0 0 301 0 0 0 0 302 0 0 0 0 0 303 0 0 0 0 0 0 304 0 0 0 0 0 0 0 305 0 0 0 0 0 0 0 0 306 0 0 0 0 0 0 0 0 0 307 0 0 0 0 0 0 0 0 0 0 308 0 0 0 0 0 0 0 0 0 0 0 309 0 0 0 0 0 0 0 0 0 0 0 0 400 Employee Benefits 1058934 84358 67249 0 0 0 0 0 0 0 0 0 501 0 0 0 0 0 0 0 0 0 0 0 0 502 0 0 0 0 0 0 0 0 0 0 0 0 503 0 0 0 0 0 0 0 0 0 0 0 0 504 0 0 0 0 0 0 0 0 0 0 0 0 505 0 0 0 0 0 0 0 0 0 0 0 0 506 0 0 0 0 0 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 0 0 0 500 Administrative and General 10629665 247119 196999 0 0 0 0 0 0 0 0 0 600 Maintenance and Repairs 565321 88028 70174 0 0 0 0 0 0 0 0 0 700 Operation of Plant 2017048 317029 252730 0 0 0 0 0 0 0 0 0 800 Laundry and Linen Service 263543 28979 23102 0 0 0 0 0 0 0 0 0 900 Housekeeping 755766 13085 10431 0 0 0 0 0 0 0 0 0
1000 Dietary 807098 83603 66647 0 0 0 0 0 0 0 0 0 1100 Cafeteria 159362 24177 19274 0 0 0 0 0 0 0 0 0 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 1482354 17467 13924 0 0 0 0 0 0 0 0 0 1400 Central Services and Supply 305730 124660 99377 0 0 0 0 0 0 0 0 0 1500 Pharmacy 1132927 24932 19875 0 0 0 0 0 0 0 0 0 1600 Medical Records amp Library 1178942 32900 26228 0 0 0 0 0 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 193276 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9131110 741734 591297 0 0 0 0 0 0 0 0 0
3100 Intensive Care Unit 2477587 130112 103723 0 0 0 0 0 0 0 0 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
ANCILLARY COST CENTERS 5000 Operating Room 1636558 166158 132458 0 0 0 0 0 0 0 0 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 1301021 99078 78983 0 0 0 0 0 0 0 0 0 5401 Ultra Sound 454209 3711 2959 0 0 0 0 0 0 0 0 0 5600 Radioisotope 206030 19816 15797 0 0 0 0 0 0 0 0 0 5700 Computed Tomography (CT) Scan 458725 10002 7974 0 0 0 0 0 0 0 0 0 5800 Magnetic Resonance Imaging (MRI) 16908 0 0 0 0 0 0 0 0 0 0 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 3398341 64417 51352 0 0 0 0 0 0 0 0 0 6001 GI Lab 292049 14678 11701 0 0 0 0 0 0 0 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 3 0 0 0 0 0 0 0 0 0 0 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 1123538 24030 19157 0 0 0 0 0 0 0 0 0 6600 Physical Therapy 241010 97338 77596 0 0 0 0 0 0 0 0 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 266558 2936 2340 0 0 0 0 0 0 0 0 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 2563528 0 0 0 0 0 0 0 0 0 0 0 7200 Implantable Devices Charged to Patients 558092 0 0 0 0 0 0 0 0 0 0 0 7300 Drugs Charged to Patients 972254 0 0 0 0 0 0 0 0 0 0 0 7400 Renal Dialysis 260774 126 100 0 0 0 0 0 0 0 0 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 4126916 138542 110443 0 0 0 0 0 0 0 0 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 5683 4530 0 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 137766 109825 0 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 512225 2202 1755 0 0 0 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 57057440 2744664 2187999 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 0 501 0 0 502 0 0 0 503 0 0 0 0 504 0 0 0 0 0 505 0 0 0 0 0 0 506 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 500 Administrative and General 0 154558 0 0 0 0 0 0 0 0 11228341 600 Maintenance and Repairs 0 0 0 0 0 0 0 0 0 0 723523 177266 700 Operation of Plant 0 22951 0 0 0 0 0 0 0 0 2609759 639403 800 Laundry and Linen Service 0 634 0 0 0 0 0 0 0 0 316257 77484 900 Housekeeping 0 17935 0 0 0 0 0 0 0 0 797216 195322
1000 Dietary 0 12138 0 0 0 0 0 0 0 0 969486 237529 1100 Cafeteria 0 3630 0 0 0 0 0 0 0 0 206442 50579 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 0 51300 0 0 0 0 0 0 0 0 1565046 383443 1400 Central Services and Supply 0 4664 0 0 0 0 0 0 0 0 534431 130938 1500 Pharmacy 0 40906 0 0 0 0 0 0 0 0 1218641 298573 1600 Medical Records amp Library 0 27157 0 0 0 0 0 0 0 0 1265227 309986 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 49131 0 0 0 0 0 0 0 0 1626506 398501 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 193276 47354 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 316959 0 0 0 0 0 0 0 0 10781100 2641419
3100 Intensive Care Unit 0 83801 0 0 0 0 0 0 0 0 2795223 684843 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
ANCILLARY COST CENTERS 5000 Operating Room 0 57734 0 0 0 0 0 0 0 0 1992908 488272 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 0 35520 0 0 0 0 0 0 0 0 1514602 371085 5401 Ultra Sound 0 16650 0 0 0 0 0 0 0 0 477530 116997 5600 Radioisotope 0 4554 0 0 0 0 0 0 0 0 246197 60319 5700 Computed Tomography (CT) Scan 0 17260 0 0 0 0 0 0 0 0 493961 121023 5800 Magnetic Resonance Imaging (MRI) 0 562 0 0 0 0 0 0 0 0 17470 4280 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 104001 0 0 0 0 0 0 0 0 3618110 886454 6001 GI Lab 0 10400 0 0 0 0 0 0 0 0 328829 80565 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3 1 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 33287 0 0 0 0 0 0 0 0 1200012 294009 6600 Physical Therapy 0 0 0 0 0 0 0 0 0 0 415944 101908 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 7758 0 0 0 0 0 0 0 0 279591 68501 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 2563528 628076 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 558092 136735 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 972254 238207 7400 Renal Dialysis 0 0 0 0 0 0 0 0 0 0 261000 63946 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 136296 0 0 0 0 0 0 0 0 4512197 1105509 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 0 0 10213 2502 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 0 0 247590 60661 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 755 0 0 0 0 0 0 0 0 516937 126652 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 1210541 0 0 0 0 0 0 0 0 57057440 11228341
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 122820 800 Laundry and Linen Service 11227 48661 900 Housekeeping 5069 21971 0
1000 Dietary 32389 140383 0 43356 1100 Cafeteria 9366 40597 0 12538 0 1200 Maintenance of Personnel 0 0 0 0 0 0 1300 Nursing Administration 6767 29330 0 9058 0 32774 0 1400 Central Services and Supply 48295 209325 0 64647 0 2815 0 0 1500 Pharmacy 9659 41865 0 12929 0 10368 0 0 0 1600 Medical Records amp Library 12746 55245 0 17062 0 13812 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 287355 1245493 194159 384654 1279497 101907 0 1122397 0 0 282741 0
3100 Intensive Care Unit 50407 218480 44463 67475 122109 22988 0 230707 0 0 57778 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
ANCILLARY COST CENTERS 5000 Operating Room 64371 279006 26097 86167 289 16495 0 179089 0 0 96649 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 39629 0 5400 Radiology-Diagnostic 38384 166369 32393 51381 0 12357 0 11607 0 0 72900 0 5401 Ultra Sound 1438 6232 0 1925 0 5123 0 0 0 0 34435 0 5600 Radioisotope 7677 33274 1304 10276 0 1680 0 10418 0 0 11704 0 5700 Computed Tomography (CT) Scan 3875 16795 0 5187 0 5733 0 0 0 0 115424 0 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 178 0 0 0 0 973 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 24956 108166 597 33406 0 35158 0 10684 0 0 141335 0 6001 GI Lab 5686 24647 1652 7612 0 3106 0 27809 0 0 30991 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3052 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 9310 40351 0 12462 0 10725 0 0 0 0 71751 0 6600 Physical Therapy 37710 163446 0 50478 0 0 0 0 0 0 8019 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 1137 4929 709 1522 0 2871 0 0 0 0 61930 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 990451 0 66024 0 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 34995 0 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 1592035 207938 0 7400 Renal Dialysis 49 211 0 65 0 0 0 0 0 0 7869 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 283 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 53672 232634 152254 71846 21247 41134 0 433708 0 0 327655 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA SCHEDULE A PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT AB 5 and AB 1183 - SUMMARY OF REDUCTIONS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER December 31 2011
Provider No 1962407460
1 10 Reduction to Noncontract Services for 070108 Through 93008 (SCHEDULE A-1) $ 0
2 Reduction to Noncontract Services for 100108 Through 040509 (SCHEDULE A-2) 0
3 10 Reduction to Noncontract Services for 010111 Through 041211 (SCHEDULE A-3) 284686
4 10 Reduction to HFPAs lt 3 Hospitals for 070108 Through 041211 (SCHEDULE A-4) 0
5 10 Reduction to Rural Health Hospitals for 070108 Through 103108 (SCHEDULE A-5) 0
6 10 Reduction to Rural Health Hospitals for 070109 Through 022410 (SCHEDULE A-6) 0
7 Total Noncontract AB 5 AND AB 1183 Reductions $ 284686 (To Schedule 1 Line 9)
STATE OF CALIFORNIA SCHEDULE A-3 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT AB 5 - 10 REDUCTION TO SERVICES FROM APRIL 6 2009 THROUGH April 12 2011 - NONCONTRACT HOSPITALS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER December 31 2011
Provider No 1962407460
Audited Medi-Cal Cost Per Day
1 Medi-Cal Cost of Covered Services (Schedule 3 Line 8) $ 8000826
2 Less Medi-Cal Administrative Day Cost (Schedule 4A Lines 33 and 36)
3 Less Medi-Cal Administrative Ancillary Cost (Schedule A-7)
4 Total Medi-Cal Cost of Covered Services Subject to Reductions (Line 1 - Lines 2 and 3) $ 8000826
5 Total Audited Medi-Cal Days (Schedules 4 4A and 4B excludes Administrative Days) 309425
6 Audited Medi-Cal Cost Per Day (Line 4 Line 5) $ 258571
AB 5 - 10 Cost Reduction For Services From 010111 Through 041211
7 Audited Medi-Cal Days of Service from 010111 Through 041211(excludes Administrative Days) 1101
8 Audited Medi-Cal Cost Per Day For 010111 Through 041211(Line 6 Line 7) $ 2846864
9 AB 5 - 10 Cost Reduction for 010111 Through 041211 (Line 8 10) $ 284686 (To Schedule A Line 3)
0
STATE OF CALIFORNIA SCHEDULE 2 PROGRAM NONCONTRACT
COMPUTATION OF LESSER OF MEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
REASONABLE COST OF MEDI-CAL INPATIENT SERVICES
1 Cost of Covered Services (Schedule 3) $ 8095037 $ 8000826
CHARGES FOR MEDI-CAL INPATIENT SERVICES
2 Inpatient Routine Service Charges (Adj 33) $ 6182850 $ 8491100
3 Inpatient Ancillary Service Charges (Adj 33) $ 20623381 $ 22454058
4 Total Charges - Medi-Cal Inpatient Services $ 26806231 $ 30945158
5 Excess of Customary Charges Over Reasonable Cost (Line 4 minus Line 1) $ 18711194 $ 22944332
6 Excess of Reasonable Cost Over Customary Charges (Line 1 minus Line 4) $ 0 $ 0
(To Schedule 1)
If charges exceed reasonable cost no further calculation necessary for this schedule
STATE OF CALIFORNIA SCHEDULE 3 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL NET COSTS OF COVERED SERVICES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
1 Medi-Cal Inpatient Ancillary Services (Schedule 5) $ 3996748 $ 3799513
2 Medi-Cal Inpatient Routine Services (Schedule 4) $ 4098289 $ 4201313
3 Medi-Cal Inpatient Hospital Based Physician for Intern and Resident Services (Sch ) $ 0 $ 0
4 $ 0 $ 0
5 $ 0 $ 0
6 SUBTOTAL (Sum of Lines 1 through 5) $ 8095037 $ 8000826
7 Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Schedule 7) $ (See Schedule 1) $ 0
8 SUBTOTAL $ 8095037 $ 8000826 (To Schedule 2)
9 Medi-Cal Deductible (Adj 34) $ (19255) $ (18887) 10 Medi-Cal Coinsurance (Adj 34) $ (161322) $ (179776)
11 Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ 7914460 $ 7802163
(To Schedule 1)
STATE OF CALIFORNIA SCHEDULE 4 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED AUDITED
INPATIENT DAYS 1 Total Inpatient Days (include private amp swing-bed) (Adj ) 15592 15592 2 Inpatient Days (include private exclude swing-bed) 15592 15592 3 Private Room Days (exclude swing-bed private room) (Adj ) 0 0 4 Semi-Private Room Days (exclude swing-bed) (Adj ) 15592 15592 5 Medicare NF Swing-Bed Days through Dec 31 (Adj ) 0 0 6 Medicare NF Swing-Bed Days after Dec 31 (Adj ) 0 0 7 Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 0 0 8 Medi-Cal NF Swing-Bed Days after July 31 (Adj ) 0 0 9 Medi-Cal Days (excluding swing-bed) (Adjs 31 36) 229500 270850
SW ING-BED ADJUSTMENT 17 Medicare NF Swing-Bed Rates through Dec 31 (Adj ) $ 000 $ 000 18 Medicare NF Swing-Bed Rates after Dec 31 (Adj ) $ 000 $ 000 19 Medi-Cal NF Swing-Bed Rates through July 31 (Adj ) $ 000 $ 000 20 Medi-Cal NF Swing-Bed Rates after July 31 (Adj ) $ 000 $ 000 21 Total Routine Serv Cost (Sch 8 Line 30 Col 26) $ 22365373 $ 19534607 22 Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17) $ 0 $ 0 23 Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18) $ 0 $ 0 24 Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19) $ 0 $ 0 25 Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20) $ 0 $ 0 26 Total Swing-Bed Cost (Sum of Lines 22 to 25) $ 0 $ 0 27 Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26) $ 22365373 $ 19534607
PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 Gen Inpatient Routine Serv Charges (excl swing-bed charges) $ 0 $ 0 29 Private Room Charges (excluding swing-bed charges) $ 50416207 $ 50416207 30 Semi-Private Room Charges (excluding swing-bed charges) $ (50416207) $ (50416207) 31 Gen Inpatient Routine Service CostCharge Ratio (L 27 divide L 28) $ 0000000 $ 0000000 32 Average Private Room Per Diem Charge (L 29 divide L 3) $ 000 $ 000 33 Average Semi-Private Room Per Diem Charge (L 30 divide L 4) $ (323347) $ (323347) 34 Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33) $ 000 $ 000 35 Average Per Diem Private Room Cost Differential (L 31 x L 34) $ 000 $ 000 36 Private Room Cost Differential Adjustment (L 35 x L 3) $ 0 $ 0 37 Inpatient Rout Cost Net of Swing-Bed amp Prvt Rm (L 27 minus L 36) $ 22365373 $ 19534607
PROGRAM INPATIENT OPERATING COST 38 Adjusted General Inpatient Routine Cost Per Diem (L 37 divide L 2) $ 143441 $ 125286 39 Program General Inpatient Routine Service Cost (L 9 x L 38) $ 3291971 $ 3393371
40 Cost Applicable to Medi-Cal (Sch 4A) $ 806318 $ 807942 41 Cost Applicable to Medi-Cal (Sch 4B) $ 0 $ 0
42 TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 3940 amp 41) $ 4098289 $ 4201313 ( To Schedule 3 )
STATE OF CALIFORNIA SCHEDULE 4A PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE ANDOR NURSERY UNITS REPORTED AUDITED
NURSERY 1 Total Inpatient Routine Cost (Sch 8 Line 43 Col 26)
2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
000
0
$
$
$
00
00000
INTENSIVE CARE UNIT 6 Total Inpatient Routine Cost (Sch 8 Line 31 Col 26)
7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost
9 Medi-Cal Inpatient Days (Adjs 31 36) 10 Cost Applicable to Medi-Cal
$ 50006362059
$ 24286733200
$ 806318
$
$
$
43125232059
20944738575
807942
CORONARY CARE UNIT 11 Total Inpatient Routine Cost (Sch 8 Line 32 Col 26)
12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost 14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
BURN INTENSIVE CARE UNIT 16 Total Inpatient Routine Cost (Sch 8 Line 33 Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
SURGICAL INTENSIVE CARE UNIT 21 Total Inpatient Routine Cost (Sch 8 Line 34 Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
OTHER SPECIAL CARE (SPECIFY) 26 Total Inpatient Routine Cost (Sch 8 Line 35 Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
ADMINISTRATIVE DAYS 31 Per Diem Rate (Adj )32 Medi-Cal Inpatient Days (Adj ) 33 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
ADMINISTRATIVE DAYS 34 Per Diem Rate (Adj )35 Medi-Cal Inpatient Days (Adj ) 36 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
37 Medi-Cal Routine Cost (Sum of Lines 510152025303336) $ 806318 $ 807942 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 4B PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE UNITS REPORTED AUDITED
1 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
6 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost 9 Medi-Cal Inpatient Days (Adj ) 10 Cost Applicable to Medi-Cal
$ 00
$ 0000
$ 0
$
$
$
00
0000 0
11 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
16 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
21 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
26 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
31 Medi-Cal Routine Cost (Sum of Lines 51015202530) $ 0 $ 0 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 5 PROGRAM NONCONTRACT
SCHEDULE OF MEDI-CAL ANCILLARY COSTS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
TOTAL ANCILLARY
COST
TOTAL ANCILLARY CHARGES
(Adj )
RATIO COST TO CHARGES
CHARGES (From Schedule 6)
MEDI-CAL COST
MEDI-CAL
ANCILLARY COST CENTERS 5000 Operating Room $ 3554239 $ 14309479 0248384 $ 2584884 $ 642043 5100 Recovery Room 0 0 0000000 0 0 5300 Anesthesiology 39629 5867250 0006754 879414 5940 5400 Radiology-Diagnostic 2271078 10793343 0210415 794869 167252 5401 Ultra Sound 643680 5098375 0126252 295897 37358 5600 Radioisotope 382848 1732875 0220932 206257 45569 5700 Computed Tomography (CT) Scan 761998 17089310 0044589 1166436 52010 5800 Magnetic Resonance Imaging (MRI) 22902 144113 0158919 0 0 5900 Cardiac Catheterization 0 0 0000000 0 0 6000 Laboratory 4858864 20925490 0232198 2503211 581241 6001 GI Lab 510896 4588397 0111345 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0000000 0 0 6200 W hole Blood amp Packed Red Blood Cells 3056 451924 0006762 176584 1194 6300 Blood Storing Processing amp Trans 0 0 0000000 0 0 6400 Intravenous Therapy 0 0 0000000 0 0 6500 Respiratory Therapy 1638618 10623110 0154250 2225217 343240 6600 Physical Therapy 777505 1187297 0654853 154359 101082 6700 Occupational Therapy 0 0 0000000 0 0 6800 Speech Pathology 0 0 0000000 0 0 6900 Electrocardiology 421192 9169134 0045936 1956860 89890 7000 Electroencephalography 0 0 0000000 0 0 7100 Medical Supplies Charged to Patients 4248079 9775274 0434574 1732396 752854 7200 Implantable Devices Charged to Patients 729822 5181268 0140858 574210 80882 7300 Drugs Charged to Patients 3010434 30786573 0097784 4573271 447193 7400 Renal Dialysis 333141 1165060 0285943 284460 81339 7500 ASC (Non-Distinct Part) 0 0 0000000 0 0 7501 Other Ancillary (specify) 283 41845 0006754 0 0 7700 0 0 0000000 0 0 7800 0 0 0000000 0 0 7900 0 0 0000000 0 0 8000 0 0 0000000 0 0 8100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0 8700 0 0 0000000 0 0 8701 0 0 0000000 0 0 8800 Rural Health Clinic (RHC) 0 0 0000000 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0000000 0 0 9000 Clinic 0 0 0000000 0 0 9100 Emergency 7660663 48511384 0157915 2345733 370426 9200 Observation Beds 0 0 0000000 0 0 9300 Other Outpatient Services (Specify) 0 0 0000000 0 0 9301 0 0 0000000 0 0 9302 0 0 0000000 0 0 9303 0 0 0000000 0 0 9304 0 0 0000000 0 0 9305 0 0 0000000 0 0
TOTAL $ 31868926 $ 197441501 $ 22454058 $ 3799513 (To Schedule 3)
From Schedule 8 Column 26
STATE OF CALIFORNIA SCHEDULE 6 PROGRAM NONCONTRACT
ADJUSTMENTS TO MEDI-CAL CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
ANCILLARY CHARGES REPORTED ADJUSTMENTS
(Adj 32) AUDITED
5000 Operating Room $ 2372682 $ 212202 $ 2584884 5100 Recovery Room 0 5300 Anesthesiology 812663 66751 879414 5400 Radiology-Diagnostic 744425 50444 794869 5401 Ultra Sound 273774 22123 295897 5600 Radioisotope 201256 5001 206257 5700 Computed Tomography (CT) Scan 1104906 61530 1166436 5800 Magnetic Resonance Imaging (MRI) 0 0 5900 Cardiac Catheterization 0 0 6000 Laboratory 2539230 (36019) 2503211 6001 GI Lab 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 6200 W hole Blood amp Packed Red Blood Cells 168194 8390 176584 6300 Blood Storing Processing amp Trans 0 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1944943 280274 2225217 6600 Physical Therapy 140110 14249 154359 6700 Occupational Therapy 0 0 6800 Speech Pathology 0 0 6900 Electrocardiology 1664507 292353 1956860 7000 Electroencephalography 0 0 7100 Medical Supplies Charged to Patients 1472234 260162 1732396 7200 Implantable Devices Charged to Patients 496326 77884 574210 7300 Drugs Charged to Patients 4193928 379343 4573271 7400 Renal Dialysis 266026 18434 284460 7500 ASC (Non-Distinct Part) 0 0 7501 Other Ancillary (specify) 0 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 2228177 117556 2345733 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
TOTAL MEDI-CAL ANCILLARY CHARGES $ 20623381 $ 1830677 $ 22454058 (To Schedule 5)
STATE OF CALIFORNIA SCHEDULE 7 PROGRAM NONCONTRACT
COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED
PHYSICIANS REMUNERATION
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
PROFESSIONAL SERVICE
COST CENTERS REMUNERATION
HBP
(Adj )
TOTAL CHARGES TO ALL PATIENTS
(Adj )
RATIO OF REMUNERATION
TO CHARGES
MEDI-CAL
(Adj )
CHARGES COST MEDI-CAL
5300 Anesthesiology $ 0 $ 0 0000000 $ $ 0 5400 Radiology - Diagnostic 0 0 0000000 0 5500 Radioisotope 0 0 0000000 0 6000 Laboratory 0 0 0000000 0 6900 Electrocardiology 0 0 0000000 0 7000 Electroencephalography 0 0 0000000 0 9100 Emergency 0 0 0000000 0
0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0
TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 2744664 200 Capital Related Costs-Movable Equipment 2187999 0 300 Other Capital Related Costs 0 0 0 301 0 0 0 0 302 0 0 0 0 0 303 0 0 0 0 0 0 304 0 0 0 0 0 0 0 305 0 0 0 0 0 0 0 0 306 0 0 0 0 0 0 0 0 0 307 0 0 0 0 0 0 0 0 0 0 308 0 0 0 0 0 0 0 0 0 0 0 309 0 0 0 0 0 0 0 0 0 0 0 0 400 Employee Benefits 1058934 84358 67249 0 0 0 0 0 0 0 0 0 501 0 0 0 0 0 0 0 0 0 0 0 0 502 0 0 0 0 0 0 0 0 0 0 0 0 503 0 0 0 0 0 0 0 0 0 0 0 0 504 0 0 0 0 0 0 0 0 0 0 0 0 505 0 0 0 0 0 0 0 0 0 0 0 0 506 0 0 0 0 0 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 0 0 0 500 Administrative and General 10629665 247119 196999 0 0 0 0 0 0 0 0 0 600 Maintenance and Repairs 565321 88028 70174 0 0 0 0 0 0 0 0 0 700 Operation of Plant 2017048 317029 252730 0 0 0 0 0 0 0 0 0 800 Laundry and Linen Service 263543 28979 23102 0 0 0 0 0 0 0 0 0 900 Housekeeping 755766 13085 10431 0 0 0 0 0 0 0 0 0
1000 Dietary 807098 83603 66647 0 0 0 0 0 0 0 0 0 1100 Cafeteria 159362 24177 19274 0 0 0 0 0 0 0 0 0 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 1482354 17467 13924 0 0 0 0 0 0 0 0 0 1400 Central Services and Supply 305730 124660 99377 0 0 0 0 0 0 0 0 0 1500 Pharmacy 1132927 24932 19875 0 0 0 0 0 0 0 0 0 1600 Medical Records amp Library 1178942 32900 26228 0 0 0 0 0 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 193276 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9131110 741734 591297 0 0 0 0 0 0 0 0 0
3100 Intensive Care Unit 2477587 130112 103723 0 0 0 0 0 0 0 0 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
ANCILLARY COST CENTERS 5000 Operating Room 1636558 166158 132458 0 0 0 0 0 0 0 0 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 1301021 99078 78983 0 0 0 0 0 0 0 0 0 5401 Ultra Sound 454209 3711 2959 0 0 0 0 0 0 0 0 0 5600 Radioisotope 206030 19816 15797 0 0 0 0 0 0 0 0 0 5700 Computed Tomography (CT) Scan 458725 10002 7974 0 0 0 0 0 0 0 0 0 5800 Magnetic Resonance Imaging (MRI) 16908 0 0 0 0 0 0 0 0 0 0 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 3398341 64417 51352 0 0 0 0 0 0 0 0 0 6001 GI Lab 292049 14678 11701 0 0 0 0 0 0 0 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 3 0 0 0 0 0 0 0 0 0 0 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 1123538 24030 19157 0 0 0 0 0 0 0 0 0 6600 Physical Therapy 241010 97338 77596 0 0 0 0 0 0 0 0 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 266558 2936 2340 0 0 0 0 0 0 0 0 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 2563528 0 0 0 0 0 0 0 0 0 0 0 7200 Implantable Devices Charged to Patients 558092 0 0 0 0 0 0 0 0 0 0 0 7300 Drugs Charged to Patients 972254 0 0 0 0 0 0 0 0 0 0 0 7400 Renal Dialysis 260774 126 100 0 0 0 0 0 0 0 0 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 4126916 138542 110443 0 0 0 0 0 0 0 0 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 5683 4530 0 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 137766 109825 0 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 512225 2202 1755 0 0 0 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 57057440 2744664 2187999 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 0 501 0 0 502 0 0 0 503 0 0 0 0 504 0 0 0 0 0 505 0 0 0 0 0 0 506 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 500 Administrative and General 0 154558 0 0 0 0 0 0 0 0 11228341 600 Maintenance and Repairs 0 0 0 0 0 0 0 0 0 0 723523 177266 700 Operation of Plant 0 22951 0 0 0 0 0 0 0 0 2609759 639403 800 Laundry and Linen Service 0 634 0 0 0 0 0 0 0 0 316257 77484 900 Housekeeping 0 17935 0 0 0 0 0 0 0 0 797216 195322
1000 Dietary 0 12138 0 0 0 0 0 0 0 0 969486 237529 1100 Cafeteria 0 3630 0 0 0 0 0 0 0 0 206442 50579 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 0 51300 0 0 0 0 0 0 0 0 1565046 383443 1400 Central Services and Supply 0 4664 0 0 0 0 0 0 0 0 534431 130938 1500 Pharmacy 0 40906 0 0 0 0 0 0 0 0 1218641 298573 1600 Medical Records amp Library 0 27157 0 0 0 0 0 0 0 0 1265227 309986 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 49131 0 0 0 0 0 0 0 0 1626506 398501 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 193276 47354 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 316959 0 0 0 0 0 0 0 0 10781100 2641419
3100 Intensive Care Unit 0 83801 0 0 0 0 0 0 0 0 2795223 684843 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
ANCILLARY COST CENTERS 5000 Operating Room 0 57734 0 0 0 0 0 0 0 0 1992908 488272 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 0 35520 0 0 0 0 0 0 0 0 1514602 371085 5401 Ultra Sound 0 16650 0 0 0 0 0 0 0 0 477530 116997 5600 Radioisotope 0 4554 0 0 0 0 0 0 0 0 246197 60319 5700 Computed Tomography (CT) Scan 0 17260 0 0 0 0 0 0 0 0 493961 121023 5800 Magnetic Resonance Imaging (MRI) 0 562 0 0 0 0 0 0 0 0 17470 4280 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 104001 0 0 0 0 0 0 0 0 3618110 886454 6001 GI Lab 0 10400 0 0 0 0 0 0 0 0 328829 80565 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3 1 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 33287 0 0 0 0 0 0 0 0 1200012 294009 6600 Physical Therapy 0 0 0 0 0 0 0 0 0 0 415944 101908 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 7758 0 0 0 0 0 0 0 0 279591 68501 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 2563528 628076 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 558092 136735 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 972254 238207 7400 Renal Dialysis 0 0 0 0 0 0 0 0 0 0 261000 63946 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 136296 0 0 0 0 0 0 0 0 4512197 1105509 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 0 0 10213 2502 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 0 0 247590 60661 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 755 0 0 0 0 0 0 0 0 516937 126652 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 1210541 0 0 0 0 0 0 0 0 57057440 11228341
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 122820 800 Laundry and Linen Service 11227 48661 900 Housekeeping 5069 21971 0
1000 Dietary 32389 140383 0 43356 1100 Cafeteria 9366 40597 0 12538 0 1200 Maintenance of Personnel 0 0 0 0 0 0 1300 Nursing Administration 6767 29330 0 9058 0 32774 0 1400 Central Services and Supply 48295 209325 0 64647 0 2815 0 0 1500 Pharmacy 9659 41865 0 12929 0 10368 0 0 0 1600 Medical Records amp Library 12746 55245 0 17062 0 13812 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 287355 1245493 194159 384654 1279497 101907 0 1122397 0 0 282741 0
3100 Intensive Care Unit 50407 218480 44463 67475 122109 22988 0 230707 0 0 57778 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
ANCILLARY COST CENTERS 5000 Operating Room 64371 279006 26097 86167 289 16495 0 179089 0 0 96649 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 39629 0 5400 Radiology-Diagnostic 38384 166369 32393 51381 0 12357 0 11607 0 0 72900 0 5401 Ultra Sound 1438 6232 0 1925 0 5123 0 0 0 0 34435 0 5600 Radioisotope 7677 33274 1304 10276 0 1680 0 10418 0 0 11704 0 5700 Computed Tomography (CT) Scan 3875 16795 0 5187 0 5733 0 0 0 0 115424 0 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 178 0 0 0 0 973 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 24956 108166 597 33406 0 35158 0 10684 0 0 141335 0 6001 GI Lab 5686 24647 1652 7612 0 3106 0 27809 0 0 30991 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3052 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 9310 40351 0 12462 0 10725 0 0 0 0 71751 0 6600 Physical Therapy 37710 163446 0 50478 0 0 0 0 0 0 8019 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 1137 4929 709 1522 0 2871 0 0 0 0 61930 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 990451 0 66024 0 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 34995 0 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 1592035 207938 0 7400 Renal Dialysis 49 211 0 65 0 0 0 0 0 0 7869 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 283 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 53672 232634 152254 71846 21247 41134 0 433708 0 0 327655 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA SCHEDULE A-3 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL REIMBURSEMENT SETTLEMENT AB 5 - 10 REDUCTION TO SERVICES FROM APRIL 6 2009 THROUGH April 12 2011 - NONCONTRACT HOSPITALS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER December 31 2011
Provider No 1962407460
Audited Medi-Cal Cost Per Day
1 Medi-Cal Cost of Covered Services (Schedule 3 Line 8) $ 8000826
2 Less Medi-Cal Administrative Day Cost (Schedule 4A Lines 33 and 36)
3 Less Medi-Cal Administrative Ancillary Cost (Schedule A-7)
4 Total Medi-Cal Cost of Covered Services Subject to Reductions (Line 1 - Lines 2 and 3) $ 8000826
5 Total Audited Medi-Cal Days (Schedules 4 4A and 4B excludes Administrative Days) 309425
6 Audited Medi-Cal Cost Per Day (Line 4 Line 5) $ 258571
AB 5 - 10 Cost Reduction For Services From 010111 Through 041211
7 Audited Medi-Cal Days of Service from 010111 Through 041211(excludes Administrative Days) 1101
8 Audited Medi-Cal Cost Per Day For 010111 Through 041211(Line 6 Line 7) $ 2846864
9 AB 5 - 10 Cost Reduction for 010111 Through 041211 (Line 8 10) $ 284686 (To Schedule A Line 3)
0
STATE OF CALIFORNIA SCHEDULE 2 PROGRAM NONCONTRACT
COMPUTATION OF LESSER OF MEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
REASONABLE COST OF MEDI-CAL INPATIENT SERVICES
1 Cost of Covered Services (Schedule 3) $ 8095037 $ 8000826
CHARGES FOR MEDI-CAL INPATIENT SERVICES
2 Inpatient Routine Service Charges (Adj 33) $ 6182850 $ 8491100
3 Inpatient Ancillary Service Charges (Adj 33) $ 20623381 $ 22454058
4 Total Charges - Medi-Cal Inpatient Services $ 26806231 $ 30945158
5 Excess of Customary Charges Over Reasonable Cost (Line 4 minus Line 1) $ 18711194 $ 22944332
6 Excess of Reasonable Cost Over Customary Charges (Line 1 minus Line 4) $ 0 $ 0
(To Schedule 1)
If charges exceed reasonable cost no further calculation necessary for this schedule
STATE OF CALIFORNIA SCHEDULE 3 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL NET COSTS OF COVERED SERVICES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
1 Medi-Cal Inpatient Ancillary Services (Schedule 5) $ 3996748 $ 3799513
2 Medi-Cal Inpatient Routine Services (Schedule 4) $ 4098289 $ 4201313
3 Medi-Cal Inpatient Hospital Based Physician for Intern and Resident Services (Sch ) $ 0 $ 0
4 $ 0 $ 0
5 $ 0 $ 0
6 SUBTOTAL (Sum of Lines 1 through 5) $ 8095037 $ 8000826
7 Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Schedule 7) $ (See Schedule 1) $ 0
8 SUBTOTAL $ 8095037 $ 8000826 (To Schedule 2)
9 Medi-Cal Deductible (Adj 34) $ (19255) $ (18887) 10 Medi-Cal Coinsurance (Adj 34) $ (161322) $ (179776)
11 Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ 7914460 $ 7802163
(To Schedule 1)
STATE OF CALIFORNIA SCHEDULE 4 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED AUDITED
INPATIENT DAYS 1 Total Inpatient Days (include private amp swing-bed) (Adj ) 15592 15592 2 Inpatient Days (include private exclude swing-bed) 15592 15592 3 Private Room Days (exclude swing-bed private room) (Adj ) 0 0 4 Semi-Private Room Days (exclude swing-bed) (Adj ) 15592 15592 5 Medicare NF Swing-Bed Days through Dec 31 (Adj ) 0 0 6 Medicare NF Swing-Bed Days after Dec 31 (Adj ) 0 0 7 Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 0 0 8 Medi-Cal NF Swing-Bed Days after July 31 (Adj ) 0 0 9 Medi-Cal Days (excluding swing-bed) (Adjs 31 36) 229500 270850
SW ING-BED ADJUSTMENT 17 Medicare NF Swing-Bed Rates through Dec 31 (Adj ) $ 000 $ 000 18 Medicare NF Swing-Bed Rates after Dec 31 (Adj ) $ 000 $ 000 19 Medi-Cal NF Swing-Bed Rates through July 31 (Adj ) $ 000 $ 000 20 Medi-Cal NF Swing-Bed Rates after July 31 (Adj ) $ 000 $ 000 21 Total Routine Serv Cost (Sch 8 Line 30 Col 26) $ 22365373 $ 19534607 22 Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17) $ 0 $ 0 23 Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18) $ 0 $ 0 24 Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19) $ 0 $ 0 25 Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20) $ 0 $ 0 26 Total Swing-Bed Cost (Sum of Lines 22 to 25) $ 0 $ 0 27 Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26) $ 22365373 $ 19534607
PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 Gen Inpatient Routine Serv Charges (excl swing-bed charges) $ 0 $ 0 29 Private Room Charges (excluding swing-bed charges) $ 50416207 $ 50416207 30 Semi-Private Room Charges (excluding swing-bed charges) $ (50416207) $ (50416207) 31 Gen Inpatient Routine Service CostCharge Ratio (L 27 divide L 28) $ 0000000 $ 0000000 32 Average Private Room Per Diem Charge (L 29 divide L 3) $ 000 $ 000 33 Average Semi-Private Room Per Diem Charge (L 30 divide L 4) $ (323347) $ (323347) 34 Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33) $ 000 $ 000 35 Average Per Diem Private Room Cost Differential (L 31 x L 34) $ 000 $ 000 36 Private Room Cost Differential Adjustment (L 35 x L 3) $ 0 $ 0 37 Inpatient Rout Cost Net of Swing-Bed amp Prvt Rm (L 27 minus L 36) $ 22365373 $ 19534607
PROGRAM INPATIENT OPERATING COST 38 Adjusted General Inpatient Routine Cost Per Diem (L 37 divide L 2) $ 143441 $ 125286 39 Program General Inpatient Routine Service Cost (L 9 x L 38) $ 3291971 $ 3393371
40 Cost Applicable to Medi-Cal (Sch 4A) $ 806318 $ 807942 41 Cost Applicable to Medi-Cal (Sch 4B) $ 0 $ 0
42 TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 3940 amp 41) $ 4098289 $ 4201313 ( To Schedule 3 )
STATE OF CALIFORNIA SCHEDULE 4A PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE ANDOR NURSERY UNITS REPORTED AUDITED
NURSERY 1 Total Inpatient Routine Cost (Sch 8 Line 43 Col 26)
2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
000
0
$
$
$
00
00000
INTENSIVE CARE UNIT 6 Total Inpatient Routine Cost (Sch 8 Line 31 Col 26)
7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost
9 Medi-Cal Inpatient Days (Adjs 31 36) 10 Cost Applicable to Medi-Cal
$ 50006362059
$ 24286733200
$ 806318
$
$
$
43125232059
20944738575
807942
CORONARY CARE UNIT 11 Total Inpatient Routine Cost (Sch 8 Line 32 Col 26)
12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost 14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
BURN INTENSIVE CARE UNIT 16 Total Inpatient Routine Cost (Sch 8 Line 33 Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
SURGICAL INTENSIVE CARE UNIT 21 Total Inpatient Routine Cost (Sch 8 Line 34 Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
OTHER SPECIAL CARE (SPECIFY) 26 Total Inpatient Routine Cost (Sch 8 Line 35 Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
ADMINISTRATIVE DAYS 31 Per Diem Rate (Adj )32 Medi-Cal Inpatient Days (Adj ) 33 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
ADMINISTRATIVE DAYS 34 Per Diem Rate (Adj )35 Medi-Cal Inpatient Days (Adj ) 36 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
37 Medi-Cal Routine Cost (Sum of Lines 510152025303336) $ 806318 $ 807942 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 4B PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE UNITS REPORTED AUDITED
1 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
6 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost 9 Medi-Cal Inpatient Days (Adj ) 10 Cost Applicable to Medi-Cal
$ 00
$ 0000
$ 0
$
$
$
00
0000 0
11 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
16 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
21 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
26 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
31 Medi-Cal Routine Cost (Sum of Lines 51015202530) $ 0 $ 0 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 5 PROGRAM NONCONTRACT
SCHEDULE OF MEDI-CAL ANCILLARY COSTS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
TOTAL ANCILLARY
COST
TOTAL ANCILLARY CHARGES
(Adj )
RATIO COST TO CHARGES
CHARGES (From Schedule 6)
MEDI-CAL COST
MEDI-CAL
ANCILLARY COST CENTERS 5000 Operating Room $ 3554239 $ 14309479 0248384 $ 2584884 $ 642043 5100 Recovery Room 0 0 0000000 0 0 5300 Anesthesiology 39629 5867250 0006754 879414 5940 5400 Radiology-Diagnostic 2271078 10793343 0210415 794869 167252 5401 Ultra Sound 643680 5098375 0126252 295897 37358 5600 Radioisotope 382848 1732875 0220932 206257 45569 5700 Computed Tomography (CT) Scan 761998 17089310 0044589 1166436 52010 5800 Magnetic Resonance Imaging (MRI) 22902 144113 0158919 0 0 5900 Cardiac Catheterization 0 0 0000000 0 0 6000 Laboratory 4858864 20925490 0232198 2503211 581241 6001 GI Lab 510896 4588397 0111345 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0000000 0 0 6200 W hole Blood amp Packed Red Blood Cells 3056 451924 0006762 176584 1194 6300 Blood Storing Processing amp Trans 0 0 0000000 0 0 6400 Intravenous Therapy 0 0 0000000 0 0 6500 Respiratory Therapy 1638618 10623110 0154250 2225217 343240 6600 Physical Therapy 777505 1187297 0654853 154359 101082 6700 Occupational Therapy 0 0 0000000 0 0 6800 Speech Pathology 0 0 0000000 0 0 6900 Electrocardiology 421192 9169134 0045936 1956860 89890 7000 Electroencephalography 0 0 0000000 0 0 7100 Medical Supplies Charged to Patients 4248079 9775274 0434574 1732396 752854 7200 Implantable Devices Charged to Patients 729822 5181268 0140858 574210 80882 7300 Drugs Charged to Patients 3010434 30786573 0097784 4573271 447193 7400 Renal Dialysis 333141 1165060 0285943 284460 81339 7500 ASC (Non-Distinct Part) 0 0 0000000 0 0 7501 Other Ancillary (specify) 283 41845 0006754 0 0 7700 0 0 0000000 0 0 7800 0 0 0000000 0 0 7900 0 0 0000000 0 0 8000 0 0 0000000 0 0 8100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0 8700 0 0 0000000 0 0 8701 0 0 0000000 0 0 8800 Rural Health Clinic (RHC) 0 0 0000000 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0000000 0 0 9000 Clinic 0 0 0000000 0 0 9100 Emergency 7660663 48511384 0157915 2345733 370426 9200 Observation Beds 0 0 0000000 0 0 9300 Other Outpatient Services (Specify) 0 0 0000000 0 0 9301 0 0 0000000 0 0 9302 0 0 0000000 0 0 9303 0 0 0000000 0 0 9304 0 0 0000000 0 0 9305 0 0 0000000 0 0
TOTAL $ 31868926 $ 197441501 $ 22454058 $ 3799513 (To Schedule 3)
From Schedule 8 Column 26
STATE OF CALIFORNIA SCHEDULE 6 PROGRAM NONCONTRACT
ADJUSTMENTS TO MEDI-CAL CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
ANCILLARY CHARGES REPORTED ADJUSTMENTS
(Adj 32) AUDITED
5000 Operating Room $ 2372682 $ 212202 $ 2584884 5100 Recovery Room 0 5300 Anesthesiology 812663 66751 879414 5400 Radiology-Diagnostic 744425 50444 794869 5401 Ultra Sound 273774 22123 295897 5600 Radioisotope 201256 5001 206257 5700 Computed Tomography (CT) Scan 1104906 61530 1166436 5800 Magnetic Resonance Imaging (MRI) 0 0 5900 Cardiac Catheterization 0 0 6000 Laboratory 2539230 (36019) 2503211 6001 GI Lab 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 6200 W hole Blood amp Packed Red Blood Cells 168194 8390 176584 6300 Blood Storing Processing amp Trans 0 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1944943 280274 2225217 6600 Physical Therapy 140110 14249 154359 6700 Occupational Therapy 0 0 6800 Speech Pathology 0 0 6900 Electrocardiology 1664507 292353 1956860 7000 Electroencephalography 0 0 7100 Medical Supplies Charged to Patients 1472234 260162 1732396 7200 Implantable Devices Charged to Patients 496326 77884 574210 7300 Drugs Charged to Patients 4193928 379343 4573271 7400 Renal Dialysis 266026 18434 284460 7500 ASC (Non-Distinct Part) 0 0 7501 Other Ancillary (specify) 0 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 2228177 117556 2345733 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
TOTAL MEDI-CAL ANCILLARY CHARGES $ 20623381 $ 1830677 $ 22454058 (To Schedule 5)
STATE OF CALIFORNIA SCHEDULE 7 PROGRAM NONCONTRACT
COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED
PHYSICIANS REMUNERATION
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
PROFESSIONAL SERVICE
COST CENTERS REMUNERATION
HBP
(Adj )
TOTAL CHARGES TO ALL PATIENTS
(Adj )
RATIO OF REMUNERATION
TO CHARGES
MEDI-CAL
(Adj )
CHARGES COST MEDI-CAL
5300 Anesthesiology $ 0 $ 0 0000000 $ $ 0 5400 Radiology - Diagnostic 0 0 0000000 0 5500 Radioisotope 0 0 0000000 0 6000 Laboratory 0 0 0000000 0 6900 Electrocardiology 0 0 0000000 0 7000 Electroencephalography 0 0 0000000 0 9100 Emergency 0 0 0000000 0
0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0
TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 2744664 200 Capital Related Costs-Movable Equipment 2187999 0 300 Other Capital Related Costs 0 0 0 301 0 0 0 0 302 0 0 0 0 0 303 0 0 0 0 0 0 304 0 0 0 0 0 0 0 305 0 0 0 0 0 0 0 0 306 0 0 0 0 0 0 0 0 0 307 0 0 0 0 0 0 0 0 0 0 308 0 0 0 0 0 0 0 0 0 0 0 309 0 0 0 0 0 0 0 0 0 0 0 0 400 Employee Benefits 1058934 84358 67249 0 0 0 0 0 0 0 0 0 501 0 0 0 0 0 0 0 0 0 0 0 0 502 0 0 0 0 0 0 0 0 0 0 0 0 503 0 0 0 0 0 0 0 0 0 0 0 0 504 0 0 0 0 0 0 0 0 0 0 0 0 505 0 0 0 0 0 0 0 0 0 0 0 0 506 0 0 0 0 0 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 0 0 0 500 Administrative and General 10629665 247119 196999 0 0 0 0 0 0 0 0 0 600 Maintenance and Repairs 565321 88028 70174 0 0 0 0 0 0 0 0 0 700 Operation of Plant 2017048 317029 252730 0 0 0 0 0 0 0 0 0 800 Laundry and Linen Service 263543 28979 23102 0 0 0 0 0 0 0 0 0 900 Housekeeping 755766 13085 10431 0 0 0 0 0 0 0 0 0
1000 Dietary 807098 83603 66647 0 0 0 0 0 0 0 0 0 1100 Cafeteria 159362 24177 19274 0 0 0 0 0 0 0 0 0 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 1482354 17467 13924 0 0 0 0 0 0 0 0 0 1400 Central Services and Supply 305730 124660 99377 0 0 0 0 0 0 0 0 0 1500 Pharmacy 1132927 24932 19875 0 0 0 0 0 0 0 0 0 1600 Medical Records amp Library 1178942 32900 26228 0 0 0 0 0 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 193276 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9131110 741734 591297 0 0 0 0 0 0 0 0 0
3100 Intensive Care Unit 2477587 130112 103723 0 0 0 0 0 0 0 0 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
ANCILLARY COST CENTERS 5000 Operating Room 1636558 166158 132458 0 0 0 0 0 0 0 0 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 1301021 99078 78983 0 0 0 0 0 0 0 0 0 5401 Ultra Sound 454209 3711 2959 0 0 0 0 0 0 0 0 0 5600 Radioisotope 206030 19816 15797 0 0 0 0 0 0 0 0 0 5700 Computed Tomography (CT) Scan 458725 10002 7974 0 0 0 0 0 0 0 0 0 5800 Magnetic Resonance Imaging (MRI) 16908 0 0 0 0 0 0 0 0 0 0 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 3398341 64417 51352 0 0 0 0 0 0 0 0 0 6001 GI Lab 292049 14678 11701 0 0 0 0 0 0 0 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 3 0 0 0 0 0 0 0 0 0 0 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 1123538 24030 19157 0 0 0 0 0 0 0 0 0 6600 Physical Therapy 241010 97338 77596 0 0 0 0 0 0 0 0 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 266558 2936 2340 0 0 0 0 0 0 0 0 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 2563528 0 0 0 0 0 0 0 0 0 0 0 7200 Implantable Devices Charged to Patients 558092 0 0 0 0 0 0 0 0 0 0 0 7300 Drugs Charged to Patients 972254 0 0 0 0 0 0 0 0 0 0 0 7400 Renal Dialysis 260774 126 100 0 0 0 0 0 0 0 0 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 4126916 138542 110443 0 0 0 0 0 0 0 0 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 5683 4530 0 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 137766 109825 0 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 512225 2202 1755 0 0 0 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 57057440 2744664 2187999 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 0 501 0 0 502 0 0 0 503 0 0 0 0 504 0 0 0 0 0 505 0 0 0 0 0 0 506 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 500 Administrative and General 0 154558 0 0 0 0 0 0 0 0 11228341 600 Maintenance and Repairs 0 0 0 0 0 0 0 0 0 0 723523 177266 700 Operation of Plant 0 22951 0 0 0 0 0 0 0 0 2609759 639403 800 Laundry and Linen Service 0 634 0 0 0 0 0 0 0 0 316257 77484 900 Housekeeping 0 17935 0 0 0 0 0 0 0 0 797216 195322
1000 Dietary 0 12138 0 0 0 0 0 0 0 0 969486 237529 1100 Cafeteria 0 3630 0 0 0 0 0 0 0 0 206442 50579 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 0 51300 0 0 0 0 0 0 0 0 1565046 383443 1400 Central Services and Supply 0 4664 0 0 0 0 0 0 0 0 534431 130938 1500 Pharmacy 0 40906 0 0 0 0 0 0 0 0 1218641 298573 1600 Medical Records amp Library 0 27157 0 0 0 0 0 0 0 0 1265227 309986 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 49131 0 0 0 0 0 0 0 0 1626506 398501 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 193276 47354 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 316959 0 0 0 0 0 0 0 0 10781100 2641419
3100 Intensive Care Unit 0 83801 0 0 0 0 0 0 0 0 2795223 684843 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
ANCILLARY COST CENTERS 5000 Operating Room 0 57734 0 0 0 0 0 0 0 0 1992908 488272 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 0 35520 0 0 0 0 0 0 0 0 1514602 371085 5401 Ultra Sound 0 16650 0 0 0 0 0 0 0 0 477530 116997 5600 Radioisotope 0 4554 0 0 0 0 0 0 0 0 246197 60319 5700 Computed Tomography (CT) Scan 0 17260 0 0 0 0 0 0 0 0 493961 121023 5800 Magnetic Resonance Imaging (MRI) 0 562 0 0 0 0 0 0 0 0 17470 4280 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 104001 0 0 0 0 0 0 0 0 3618110 886454 6001 GI Lab 0 10400 0 0 0 0 0 0 0 0 328829 80565 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3 1 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 33287 0 0 0 0 0 0 0 0 1200012 294009 6600 Physical Therapy 0 0 0 0 0 0 0 0 0 0 415944 101908 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 7758 0 0 0 0 0 0 0 0 279591 68501 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 2563528 628076 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 558092 136735 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 972254 238207 7400 Renal Dialysis 0 0 0 0 0 0 0 0 0 0 261000 63946 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 136296 0 0 0 0 0 0 0 0 4512197 1105509 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 0 0 10213 2502 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 0 0 247590 60661 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 755 0 0 0 0 0 0 0 0 516937 126652 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 1210541 0 0 0 0 0 0 0 0 57057440 11228341
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 122820 800 Laundry and Linen Service 11227 48661 900 Housekeeping 5069 21971 0
1000 Dietary 32389 140383 0 43356 1100 Cafeteria 9366 40597 0 12538 0 1200 Maintenance of Personnel 0 0 0 0 0 0 1300 Nursing Administration 6767 29330 0 9058 0 32774 0 1400 Central Services and Supply 48295 209325 0 64647 0 2815 0 0 1500 Pharmacy 9659 41865 0 12929 0 10368 0 0 0 1600 Medical Records amp Library 12746 55245 0 17062 0 13812 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 287355 1245493 194159 384654 1279497 101907 0 1122397 0 0 282741 0
3100 Intensive Care Unit 50407 218480 44463 67475 122109 22988 0 230707 0 0 57778 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
ANCILLARY COST CENTERS 5000 Operating Room 64371 279006 26097 86167 289 16495 0 179089 0 0 96649 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 39629 0 5400 Radiology-Diagnostic 38384 166369 32393 51381 0 12357 0 11607 0 0 72900 0 5401 Ultra Sound 1438 6232 0 1925 0 5123 0 0 0 0 34435 0 5600 Radioisotope 7677 33274 1304 10276 0 1680 0 10418 0 0 11704 0 5700 Computed Tomography (CT) Scan 3875 16795 0 5187 0 5733 0 0 0 0 115424 0 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 178 0 0 0 0 973 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 24956 108166 597 33406 0 35158 0 10684 0 0 141335 0 6001 GI Lab 5686 24647 1652 7612 0 3106 0 27809 0 0 30991 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3052 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 9310 40351 0 12462 0 10725 0 0 0 0 71751 0 6600 Physical Therapy 37710 163446 0 50478 0 0 0 0 0 0 8019 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 1137 4929 709 1522 0 2871 0 0 0 0 61930 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 990451 0 66024 0 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 34995 0 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 1592035 207938 0 7400 Renal Dialysis 49 211 0 65 0 0 0 0 0 0 7869 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 283 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 53672 232634 152254 71846 21247 41134 0 433708 0 0 327655 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA SCHEDULE 2 PROGRAM NONCONTRACT
COMPUTATION OF LESSER OF MEDI-CAL REASONABLE COST OR CUSTOMARY CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
REASONABLE COST OF MEDI-CAL INPATIENT SERVICES
1 Cost of Covered Services (Schedule 3) $ 8095037 $ 8000826
CHARGES FOR MEDI-CAL INPATIENT SERVICES
2 Inpatient Routine Service Charges (Adj 33) $ 6182850 $ 8491100
3 Inpatient Ancillary Service Charges (Adj 33) $ 20623381 $ 22454058
4 Total Charges - Medi-Cal Inpatient Services $ 26806231 $ 30945158
5 Excess of Customary Charges Over Reasonable Cost (Line 4 minus Line 1) $ 18711194 $ 22944332
6 Excess of Reasonable Cost Over Customary Charges (Line 1 minus Line 4) $ 0 $ 0
(To Schedule 1)
If charges exceed reasonable cost no further calculation necessary for this schedule
STATE OF CALIFORNIA SCHEDULE 3 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL NET COSTS OF COVERED SERVICES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
1 Medi-Cal Inpatient Ancillary Services (Schedule 5) $ 3996748 $ 3799513
2 Medi-Cal Inpatient Routine Services (Schedule 4) $ 4098289 $ 4201313
3 Medi-Cal Inpatient Hospital Based Physician for Intern and Resident Services (Sch ) $ 0 $ 0
4 $ 0 $ 0
5 $ 0 $ 0
6 SUBTOTAL (Sum of Lines 1 through 5) $ 8095037 $ 8000826
7 Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Schedule 7) $ (See Schedule 1) $ 0
8 SUBTOTAL $ 8095037 $ 8000826 (To Schedule 2)
9 Medi-Cal Deductible (Adj 34) $ (19255) $ (18887) 10 Medi-Cal Coinsurance (Adj 34) $ (161322) $ (179776)
11 Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ 7914460 $ 7802163
(To Schedule 1)
STATE OF CALIFORNIA SCHEDULE 4 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED AUDITED
INPATIENT DAYS 1 Total Inpatient Days (include private amp swing-bed) (Adj ) 15592 15592 2 Inpatient Days (include private exclude swing-bed) 15592 15592 3 Private Room Days (exclude swing-bed private room) (Adj ) 0 0 4 Semi-Private Room Days (exclude swing-bed) (Adj ) 15592 15592 5 Medicare NF Swing-Bed Days through Dec 31 (Adj ) 0 0 6 Medicare NF Swing-Bed Days after Dec 31 (Adj ) 0 0 7 Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 0 0 8 Medi-Cal NF Swing-Bed Days after July 31 (Adj ) 0 0 9 Medi-Cal Days (excluding swing-bed) (Adjs 31 36) 229500 270850
SW ING-BED ADJUSTMENT 17 Medicare NF Swing-Bed Rates through Dec 31 (Adj ) $ 000 $ 000 18 Medicare NF Swing-Bed Rates after Dec 31 (Adj ) $ 000 $ 000 19 Medi-Cal NF Swing-Bed Rates through July 31 (Adj ) $ 000 $ 000 20 Medi-Cal NF Swing-Bed Rates after July 31 (Adj ) $ 000 $ 000 21 Total Routine Serv Cost (Sch 8 Line 30 Col 26) $ 22365373 $ 19534607 22 Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17) $ 0 $ 0 23 Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18) $ 0 $ 0 24 Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19) $ 0 $ 0 25 Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20) $ 0 $ 0 26 Total Swing-Bed Cost (Sum of Lines 22 to 25) $ 0 $ 0 27 Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26) $ 22365373 $ 19534607
PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 Gen Inpatient Routine Serv Charges (excl swing-bed charges) $ 0 $ 0 29 Private Room Charges (excluding swing-bed charges) $ 50416207 $ 50416207 30 Semi-Private Room Charges (excluding swing-bed charges) $ (50416207) $ (50416207) 31 Gen Inpatient Routine Service CostCharge Ratio (L 27 divide L 28) $ 0000000 $ 0000000 32 Average Private Room Per Diem Charge (L 29 divide L 3) $ 000 $ 000 33 Average Semi-Private Room Per Diem Charge (L 30 divide L 4) $ (323347) $ (323347) 34 Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33) $ 000 $ 000 35 Average Per Diem Private Room Cost Differential (L 31 x L 34) $ 000 $ 000 36 Private Room Cost Differential Adjustment (L 35 x L 3) $ 0 $ 0 37 Inpatient Rout Cost Net of Swing-Bed amp Prvt Rm (L 27 minus L 36) $ 22365373 $ 19534607
PROGRAM INPATIENT OPERATING COST 38 Adjusted General Inpatient Routine Cost Per Diem (L 37 divide L 2) $ 143441 $ 125286 39 Program General Inpatient Routine Service Cost (L 9 x L 38) $ 3291971 $ 3393371
40 Cost Applicable to Medi-Cal (Sch 4A) $ 806318 $ 807942 41 Cost Applicable to Medi-Cal (Sch 4B) $ 0 $ 0
42 TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 3940 amp 41) $ 4098289 $ 4201313 ( To Schedule 3 )
STATE OF CALIFORNIA SCHEDULE 4A PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE ANDOR NURSERY UNITS REPORTED AUDITED
NURSERY 1 Total Inpatient Routine Cost (Sch 8 Line 43 Col 26)
2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
000
0
$
$
$
00
00000
INTENSIVE CARE UNIT 6 Total Inpatient Routine Cost (Sch 8 Line 31 Col 26)
7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost
9 Medi-Cal Inpatient Days (Adjs 31 36) 10 Cost Applicable to Medi-Cal
$ 50006362059
$ 24286733200
$ 806318
$
$
$
43125232059
20944738575
807942
CORONARY CARE UNIT 11 Total Inpatient Routine Cost (Sch 8 Line 32 Col 26)
12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost 14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
BURN INTENSIVE CARE UNIT 16 Total Inpatient Routine Cost (Sch 8 Line 33 Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
SURGICAL INTENSIVE CARE UNIT 21 Total Inpatient Routine Cost (Sch 8 Line 34 Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
OTHER SPECIAL CARE (SPECIFY) 26 Total Inpatient Routine Cost (Sch 8 Line 35 Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
ADMINISTRATIVE DAYS 31 Per Diem Rate (Adj )32 Medi-Cal Inpatient Days (Adj ) 33 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
ADMINISTRATIVE DAYS 34 Per Diem Rate (Adj )35 Medi-Cal Inpatient Days (Adj ) 36 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
37 Medi-Cal Routine Cost (Sum of Lines 510152025303336) $ 806318 $ 807942 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 4B PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE UNITS REPORTED AUDITED
1 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
6 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost 9 Medi-Cal Inpatient Days (Adj ) 10 Cost Applicable to Medi-Cal
$ 00
$ 0000
$ 0
$
$
$
00
0000 0
11 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
16 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
21 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
26 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
31 Medi-Cal Routine Cost (Sum of Lines 51015202530) $ 0 $ 0 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 5 PROGRAM NONCONTRACT
SCHEDULE OF MEDI-CAL ANCILLARY COSTS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
TOTAL ANCILLARY
COST
TOTAL ANCILLARY CHARGES
(Adj )
RATIO COST TO CHARGES
CHARGES (From Schedule 6)
MEDI-CAL COST
MEDI-CAL
ANCILLARY COST CENTERS 5000 Operating Room $ 3554239 $ 14309479 0248384 $ 2584884 $ 642043 5100 Recovery Room 0 0 0000000 0 0 5300 Anesthesiology 39629 5867250 0006754 879414 5940 5400 Radiology-Diagnostic 2271078 10793343 0210415 794869 167252 5401 Ultra Sound 643680 5098375 0126252 295897 37358 5600 Radioisotope 382848 1732875 0220932 206257 45569 5700 Computed Tomography (CT) Scan 761998 17089310 0044589 1166436 52010 5800 Magnetic Resonance Imaging (MRI) 22902 144113 0158919 0 0 5900 Cardiac Catheterization 0 0 0000000 0 0 6000 Laboratory 4858864 20925490 0232198 2503211 581241 6001 GI Lab 510896 4588397 0111345 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0000000 0 0 6200 W hole Blood amp Packed Red Blood Cells 3056 451924 0006762 176584 1194 6300 Blood Storing Processing amp Trans 0 0 0000000 0 0 6400 Intravenous Therapy 0 0 0000000 0 0 6500 Respiratory Therapy 1638618 10623110 0154250 2225217 343240 6600 Physical Therapy 777505 1187297 0654853 154359 101082 6700 Occupational Therapy 0 0 0000000 0 0 6800 Speech Pathology 0 0 0000000 0 0 6900 Electrocardiology 421192 9169134 0045936 1956860 89890 7000 Electroencephalography 0 0 0000000 0 0 7100 Medical Supplies Charged to Patients 4248079 9775274 0434574 1732396 752854 7200 Implantable Devices Charged to Patients 729822 5181268 0140858 574210 80882 7300 Drugs Charged to Patients 3010434 30786573 0097784 4573271 447193 7400 Renal Dialysis 333141 1165060 0285943 284460 81339 7500 ASC (Non-Distinct Part) 0 0 0000000 0 0 7501 Other Ancillary (specify) 283 41845 0006754 0 0 7700 0 0 0000000 0 0 7800 0 0 0000000 0 0 7900 0 0 0000000 0 0 8000 0 0 0000000 0 0 8100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0 8700 0 0 0000000 0 0 8701 0 0 0000000 0 0 8800 Rural Health Clinic (RHC) 0 0 0000000 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0000000 0 0 9000 Clinic 0 0 0000000 0 0 9100 Emergency 7660663 48511384 0157915 2345733 370426 9200 Observation Beds 0 0 0000000 0 0 9300 Other Outpatient Services (Specify) 0 0 0000000 0 0 9301 0 0 0000000 0 0 9302 0 0 0000000 0 0 9303 0 0 0000000 0 0 9304 0 0 0000000 0 0 9305 0 0 0000000 0 0
TOTAL $ 31868926 $ 197441501 $ 22454058 $ 3799513 (To Schedule 3)
From Schedule 8 Column 26
STATE OF CALIFORNIA SCHEDULE 6 PROGRAM NONCONTRACT
ADJUSTMENTS TO MEDI-CAL CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
ANCILLARY CHARGES REPORTED ADJUSTMENTS
(Adj 32) AUDITED
5000 Operating Room $ 2372682 $ 212202 $ 2584884 5100 Recovery Room 0 5300 Anesthesiology 812663 66751 879414 5400 Radiology-Diagnostic 744425 50444 794869 5401 Ultra Sound 273774 22123 295897 5600 Radioisotope 201256 5001 206257 5700 Computed Tomography (CT) Scan 1104906 61530 1166436 5800 Magnetic Resonance Imaging (MRI) 0 0 5900 Cardiac Catheterization 0 0 6000 Laboratory 2539230 (36019) 2503211 6001 GI Lab 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 6200 W hole Blood amp Packed Red Blood Cells 168194 8390 176584 6300 Blood Storing Processing amp Trans 0 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1944943 280274 2225217 6600 Physical Therapy 140110 14249 154359 6700 Occupational Therapy 0 0 6800 Speech Pathology 0 0 6900 Electrocardiology 1664507 292353 1956860 7000 Electroencephalography 0 0 7100 Medical Supplies Charged to Patients 1472234 260162 1732396 7200 Implantable Devices Charged to Patients 496326 77884 574210 7300 Drugs Charged to Patients 4193928 379343 4573271 7400 Renal Dialysis 266026 18434 284460 7500 ASC (Non-Distinct Part) 0 0 7501 Other Ancillary (specify) 0 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 2228177 117556 2345733 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
TOTAL MEDI-CAL ANCILLARY CHARGES $ 20623381 $ 1830677 $ 22454058 (To Schedule 5)
STATE OF CALIFORNIA SCHEDULE 7 PROGRAM NONCONTRACT
COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED
PHYSICIANS REMUNERATION
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
PROFESSIONAL SERVICE
COST CENTERS REMUNERATION
HBP
(Adj )
TOTAL CHARGES TO ALL PATIENTS
(Adj )
RATIO OF REMUNERATION
TO CHARGES
MEDI-CAL
(Adj )
CHARGES COST MEDI-CAL
5300 Anesthesiology $ 0 $ 0 0000000 $ $ 0 5400 Radiology - Diagnostic 0 0 0000000 0 5500 Radioisotope 0 0 0000000 0 6000 Laboratory 0 0 0000000 0 6900 Electrocardiology 0 0 0000000 0 7000 Electroencephalography 0 0 0000000 0 9100 Emergency 0 0 0000000 0
0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0
TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 2744664 200 Capital Related Costs-Movable Equipment 2187999 0 300 Other Capital Related Costs 0 0 0 301 0 0 0 0 302 0 0 0 0 0 303 0 0 0 0 0 0 304 0 0 0 0 0 0 0 305 0 0 0 0 0 0 0 0 306 0 0 0 0 0 0 0 0 0 307 0 0 0 0 0 0 0 0 0 0 308 0 0 0 0 0 0 0 0 0 0 0 309 0 0 0 0 0 0 0 0 0 0 0 0 400 Employee Benefits 1058934 84358 67249 0 0 0 0 0 0 0 0 0 501 0 0 0 0 0 0 0 0 0 0 0 0 502 0 0 0 0 0 0 0 0 0 0 0 0 503 0 0 0 0 0 0 0 0 0 0 0 0 504 0 0 0 0 0 0 0 0 0 0 0 0 505 0 0 0 0 0 0 0 0 0 0 0 0 506 0 0 0 0 0 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 0 0 0 500 Administrative and General 10629665 247119 196999 0 0 0 0 0 0 0 0 0 600 Maintenance and Repairs 565321 88028 70174 0 0 0 0 0 0 0 0 0 700 Operation of Plant 2017048 317029 252730 0 0 0 0 0 0 0 0 0 800 Laundry and Linen Service 263543 28979 23102 0 0 0 0 0 0 0 0 0 900 Housekeeping 755766 13085 10431 0 0 0 0 0 0 0 0 0
1000 Dietary 807098 83603 66647 0 0 0 0 0 0 0 0 0 1100 Cafeteria 159362 24177 19274 0 0 0 0 0 0 0 0 0 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 1482354 17467 13924 0 0 0 0 0 0 0 0 0 1400 Central Services and Supply 305730 124660 99377 0 0 0 0 0 0 0 0 0 1500 Pharmacy 1132927 24932 19875 0 0 0 0 0 0 0 0 0 1600 Medical Records amp Library 1178942 32900 26228 0 0 0 0 0 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 193276 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9131110 741734 591297 0 0 0 0 0 0 0 0 0
3100 Intensive Care Unit 2477587 130112 103723 0 0 0 0 0 0 0 0 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
ANCILLARY COST CENTERS 5000 Operating Room 1636558 166158 132458 0 0 0 0 0 0 0 0 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 1301021 99078 78983 0 0 0 0 0 0 0 0 0 5401 Ultra Sound 454209 3711 2959 0 0 0 0 0 0 0 0 0 5600 Radioisotope 206030 19816 15797 0 0 0 0 0 0 0 0 0 5700 Computed Tomography (CT) Scan 458725 10002 7974 0 0 0 0 0 0 0 0 0 5800 Magnetic Resonance Imaging (MRI) 16908 0 0 0 0 0 0 0 0 0 0 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 3398341 64417 51352 0 0 0 0 0 0 0 0 0 6001 GI Lab 292049 14678 11701 0 0 0 0 0 0 0 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 3 0 0 0 0 0 0 0 0 0 0 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 1123538 24030 19157 0 0 0 0 0 0 0 0 0 6600 Physical Therapy 241010 97338 77596 0 0 0 0 0 0 0 0 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 266558 2936 2340 0 0 0 0 0 0 0 0 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 2563528 0 0 0 0 0 0 0 0 0 0 0 7200 Implantable Devices Charged to Patients 558092 0 0 0 0 0 0 0 0 0 0 0 7300 Drugs Charged to Patients 972254 0 0 0 0 0 0 0 0 0 0 0 7400 Renal Dialysis 260774 126 100 0 0 0 0 0 0 0 0 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 4126916 138542 110443 0 0 0 0 0 0 0 0 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 5683 4530 0 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 137766 109825 0 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 512225 2202 1755 0 0 0 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 57057440 2744664 2187999 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 0 501 0 0 502 0 0 0 503 0 0 0 0 504 0 0 0 0 0 505 0 0 0 0 0 0 506 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 500 Administrative and General 0 154558 0 0 0 0 0 0 0 0 11228341 600 Maintenance and Repairs 0 0 0 0 0 0 0 0 0 0 723523 177266 700 Operation of Plant 0 22951 0 0 0 0 0 0 0 0 2609759 639403 800 Laundry and Linen Service 0 634 0 0 0 0 0 0 0 0 316257 77484 900 Housekeeping 0 17935 0 0 0 0 0 0 0 0 797216 195322
1000 Dietary 0 12138 0 0 0 0 0 0 0 0 969486 237529 1100 Cafeteria 0 3630 0 0 0 0 0 0 0 0 206442 50579 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 0 51300 0 0 0 0 0 0 0 0 1565046 383443 1400 Central Services and Supply 0 4664 0 0 0 0 0 0 0 0 534431 130938 1500 Pharmacy 0 40906 0 0 0 0 0 0 0 0 1218641 298573 1600 Medical Records amp Library 0 27157 0 0 0 0 0 0 0 0 1265227 309986 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 49131 0 0 0 0 0 0 0 0 1626506 398501 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 193276 47354 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 316959 0 0 0 0 0 0 0 0 10781100 2641419
3100 Intensive Care Unit 0 83801 0 0 0 0 0 0 0 0 2795223 684843 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
ANCILLARY COST CENTERS 5000 Operating Room 0 57734 0 0 0 0 0 0 0 0 1992908 488272 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 0 35520 0 0 0 0 0 0 0 0 1514602 371085 5401 Ultra Sound 0 16650 0 0 0 0 0 0 0 0 477530 116997 5600 Radioisotope 0 4554 0 0 0 0 0 0 0 0 246197 60319 5700 Computed Tomography (CT) Scan 0 17260 0 0 0 0 0 0 0 0 493961 121023 5800 Magnetic Resonance Imaging (MRI) 0 562 0 0 0 0 0 0 0 0 17470 4280 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 104001 0 0 0 0 0 0 0 0 3618110 886454 6001 GI Lab 0 10400 0 0 0 0 0 0 0 0 328829 80565 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3 1 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 33287 0 0 0 0 0 0 0 0 1200012 294009 6600 Physical Therapy 0 0 0 0 0 0 0 0 0 0 415944 101908 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 7758 0 0 0 0 0 0 0 0 279591 68501 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 2563528 628076 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 558092 136735 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 972254 238207 7400 Renal Dialysis 0 0 0 0 0 0 0 0 0 0 261000 63946 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 136296 0 0 0 0 0 0 0 0 4512197 1105509 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 0 0 10213 2502 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 0 0 247590 60661 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 755 0 0 0 0 0 0 0 0 516937 126652 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 1210541 0 0 0 0 0 0 0 0 57057440 11228341
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 122820 800 Laundry and Linen Service 11227 48661 900 Housekeeping 5069 21971 0
1000 Dietary 32389 140383 0 43356 1100 Cafeteria 9366 40597 0 12538 0 1200 Maintenance of Personnel 0 0 0 0 0 0 1300 Nursing Administration 6767 29330 0 9058 0 32774 0 1400 Central Services and Supply 48295 209325 0 64647 0 2815 0 0 1500 Pharmacy 9659 41865 0 12929 0 10368 0 0 0 1600 Medical Records amp Library 12746 55245 0 17062 0 13812 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 287355 1245493 194159 384654 1279497 101907 0 1122397 0 0 282741 0
3100 Intensive Care Unit 50407 218480 44463 67475 122109 22988 0 230707 0 0 57778 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
ANCILLARY COST CENTERS 5000 Operating Room 64371 279006 26097 86167 289 16495 0 179089 0 0 96649 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 39629 0 5400 Radiology-Diagnostic 38384 166369 32393 51381 0 12357 0 11607 0 0 72900 0 5401 Ultra Sound 1438 6232 0 1925 0 5123 0 0 0 0 34435 0 5600 Radioisotope 7677 33274 1304 10276 0 1680 0 10418 0 0 11704 0 5700 Computed Tomography (CT) Scan 3875 16795 0 5187 0 5733 0 0 0 0 115424 0 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 178 0 0 0 0 973 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 24956 108166 597 33406 0 35158 0 10684 0 0 141335 0 6001 GI Lab 5686 24647 1652 7612 0 3106 0 27809 0 0 30991 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3052 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 9310 40351 0 12462 0 10725 0 0 0 0 71751 0 6600 Physical Therapy 37710 163446 0 50478 0 0 0 0 0 0 8019 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 1137 4929 709 1522 0 2871 0 0 0 0 61930 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 990451 0 66024 0 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 34995 0 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 1592035 207938 0 7400 Renal Dialysis 49 211 0 65 0 0 0 0 0 0 7869 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 283 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 53672 232634 152254 71846 21247 41134 0 433708 0 0 327655 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA SCHEDULE 3 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL NET COSTS OF COVERED SERVICES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
REPORTED AUDITED
1 Medi-Cal Inpatient Ancillary Services (Schedule 5) $ 3996748 $ 3799513
2 Medi-Cal Inpatient Routine Services (Schedule 4) $ 4098289 $ 4201313
3 Medi-Cal Inpatient Hospital Based Physician for Intern and Resident Services (Sch ) $ 0 $ 0
4 $ 0 $ 0
5 $ 0 $ 0
6 SUBTOTAL (Sum of Lines 1 through 5) $ 8095037 $ 8000826
7 Medi-Cal Inpatient Hospital Based Physician for Acute Care Services (Schedule 7) $ (See Schedule 1) $ 0
8 SUBTOTAL $ 8095037 $ 8000826 (To Schedule 2)
9 Medi-Cal Deductible (Adj 34) $ (19255) $ (18887) 10 Medi-Cal Coinsurance (Adj 34) $ (161322) $ (179776)
11 Net Cost of Covered Services Rendered to Medi-Cal Inpatients $ 7914460 $ 7802163
(To Schedule 1)
STATE OF CALIFORNIA SCHEDULE 4 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED AUDITED
INPATIENT DAYS 1 Total Inpatient Days (include private amp swing-bed) (Adj ) 15592 15592 2 Inpatient Days (include private exclude swing-bed) 15592 15592 3 Private Room Days (exclude swing-bed private room) (Adj ) 0 0 4 Semi-Private Room Days (exclude swing-bed) (Adj ) 15592 15592 5 Medicare NF Swing-Bed Days through Dec 31 (Adj ) 0 0 6 Medicare NF Swing-Bed Days after Dec 31 (Adj ) 0 0 7 Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 0 0 8 Medi-Cal NF Swing-Bed Days after July 31 (Adj ) 0 0 9 Medi-Cal Days (excluding swing-bed) (Adjs 31 36) 229500 270850
SW ING-BED ADJUSTMENT 17 Medicare NF Swing-Bed Rates through Dec 31 (Adj ) $ 000 $ 000 18 Medicare NF Swing-Bed Rates after Dec 31 (Adj ) $ 000 $ 000 19 Medi-Cal NF Swing-Bed Rates through July 31 (Adj ) $ 000 $ 000 20 Medi-Cal NF Swing-Bed Rates after July 31 (Adj ) $ 000 $ 000 21 Total Routine Serv Cost (Sch 8 Line 30 Col 26) $ 22365373 $ 19534607 22 Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17) $ 0 $ 0 23 Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18) $ 0 $ 0 24 Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19) $ 0 $ 0 25 Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20) $ 0 $ 0 26 Total Swing-Bed Cost (Sum of Lines 22 to 25) $ 0 $ 0 27 Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26) $ 22365373 $ 19534607
PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 Gen Inpatient Routine Serv Charges (excl swing-bed charges) $ 0 $ 0 29 Private Room Charges (excluding swing-bed charges) $ 50416207 $ 50416207 30 Semi-Private Room Charges (excluding swing-bed charges) $ (50416207) $ (50416207) 31 Gen Inpatient Routine Service CostCharge Ratio (L 27 divide L 28) $ 0000000 $ 0000000 32 Average Private Room Per Diem Charge (L 29 divide L 3) $ 000 $ 000 33 Average Semi-Private Room Per Diem Charge (L 30 divide L 4) $ (323347) $ (323347) 34 Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33) $ 000 $ 000 35 Average Per Diem Private Room Cost Differential (L 31 x L 34) $ 000 $ 000 36 Private Room Cost Differential Adjustment (L 35 x L 3) $ 0 $ 0 37 Inpatient Rout Cost Net of Swing-Bed amp Prvt Rm (L 27 minus L 36) $ 22365373 $ 19534607
PROGRAM INPATIENT OPERATING COST 38 Adjusted General Inpatient Routine Cost Per Diem (L 37 divide L 2) $ 143441 $ 125286 39 Program General Inpatient Routine Service Cost (L 9 x L 38) $ 3291971 $ 3393371
40 Cost Applicable to Medi-Cal (Sch 4A) $ 806318 $ 807942 41 Cost Applicable to Medi-Cal (Sch 4B) $ 0 $ 0
42 TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 3940 amp 41) $ 4098289 $ 4201313 ( To Schedule 3 )
STATE OF CALIFORNIA SCHEDULE 4A PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE ANDOR NURSERY UNITS REPORTED AUDITED
NURSERY 1 Total Inpatient Routine Cost (Sch 8 Line 43 Col 26)
2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
000
0
$
$
$
00
00000
INTENSIVE CARE UNIT 6 Total Inpatient Routine Cost (Sch 8 Line 31 Col 26)
7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost
9 Medi-Cal Inpatient Days (Adjs 31 36) 10 Cost Applicable to Medi-Cal
$ 50006362059
$ 24286733200
$ 806318
$
$
$
43125232059
20944738575
807942
CORONARY CARE UNIT 11 Total Inpatient Routine Cost (Sch 8 Line 32 Col 26)
12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost 14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
BURN INTENSIVE CARE UNIT 16 Total Inpatient Routine Cost (Sch 8 Line 33 Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
SURGICAL INTENSIVE CARE UNIT 21 Total Inpatient Routine Cost (Sch 8 Line 34 Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
OTHER SPECIAL CARE (SPECIFY) 26 Total Inpatient Routine Cost (Sch 8 Line 35 Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
ADMINISTRATIVE DAYS 31 Per Diem Rate (Adj )32 Medi-Cal Inpatient Days (Adj ) 33 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
ADMINISTRATIVE DAYS 34 Per Diem Rate (Adj )35 Medi-Cal Inpatient Days (Adj ) 36 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
37 Medi-Cal Routine Cost (Sum of Lines 510152025303336) $ 806318 $ 807942 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 4B PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE UNITS REPORTED AUDITED
1 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
6 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost 9 Medi-Cal Inpatient Days (Adj ) 10 Cost Applicable to Medi-Cal
$ 00
$ 0000
$ 0
$
$
$
00
0000 0
11 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
16 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
21 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
26 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
31 Medi-Cal Routine Cost (Sum of Lines 51015202530) $ 0 $ 0 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 5 PROGRAM NONCONTRACT
SCHEDULE OF MEDI-CAL ANCILLARY COSTS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
TOTAL ANCILLARY
COST
TOTAL ANCILLARY CHARGES
(Adj )
RATIO COST TO CHARGES
CHARGES (From Schedule 6)
MEDI-CAL COST
MEDI-CAL
ANCILLARY COST CENTERS 5000 Operating Room $ 3554239 $ 14309479 0248384 $ 2584884 $ 642043 5100 Recovery Room 0 0 0000000 0 0 5300 Anesthesiology 39629 5867250 0006754 879414 5940 5400 Radiology-Diagnostic 2271078 10793343 0210415 794869 167252 5401 Ultra Sound 643680 5098375 0126252 295897 37358 5600 Radioisotope 382848 1732875 0220932 206257 45569 5700 Computed Tomography (CT) Scan 761998 17089310 0044589 1166436 52010 5800 Magnetic Resonance Imaging (MRI) 22902 144113 0158919 0 0 5900 Cardiac Catheterization 0 0 0000000 0 0 6000 Laboratory 4858864 20925490 0232198 2503211 581241 6001 GI Lab 510896 4588397 0111345 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0000000 0 0 6200 W hole Blood amp Packed Red Blood Cells 3056 451924 0006762 176584 1194 6300 Blood Storing Processing amp Trans 0 0 0000000 0 0 6400 Intravenous Therapy 0 0 0000000 0 0 6500 Respiratory Therapy 1638618 10623110 0154250 2225217 343240 6600 Physical Therapy 777505 1187297 0654853 154359 101082 6700 Occupational Therapy 0 0 0000000 0 0 6800 Speech Pathology 0 0 0000000 0 0 6900 Electrocardiology 421192 9169134 0045936 1956860 89890 7000 Electroencephalography 0 0 0000000 0 0 7100 Medical Supplies Charged to Patients 4248079 9775274 0434574 1732396 752854 7200 Implantable Devices Charged to Patients 729822 5181268 0140858 574210 80882 7300 Drugs Charged to Patients 3010434 30786573 0097784 4573271 447193 7400 Renal Dialysis 333141 1165060 0285943 284460 81339 7500 ASC (Non-Distinct Part) 0 0 0000000 0 0 7501 Other Ancillary (specify) 283 41845 0006754 0 0 7700 0 0 0000000 0 0 7800 0 0 0000000 0 0 7900 0 0 0000000 0 0 8000 0 0 0000000 0 0 8100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0 8700 0 0 0000000 0 0 8701 0 0 0000000 0 0 8800 Rural Health Clinic (RHC) 0 0 0000000 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0000000 0 0 9000 Clinic 0 0 0000000 0 0 9100 Emergency 7660663 48511384 0157915 2345733 370426 9200 Observation Beds 0 0 0000000 0 0 9300 Other Outpatient Services (Specify) 0 0 0000000 0 0 9301 0 0 0000000 0 0 9302 0 0 0000000 0 0 9303 0 0 0000000 0 0 9304 0 0 0000000 0 0 9305 0 0 0000000 0 0
TOTAL $ 31868926 $ 197441501 $ 22454058 $ 3799513 (To Schedule 3)
From Schedule 8 Column 26
STATE OF CALIFORNIA SCHEDULE 6 PROGRAM NONCONTRACT
ADJUSTMENTS TO MEDI-CAL CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
ANCILLARY CHARGES REPORTED ADJUSTMENTS
(Adj 32) AUDITED
5000 Operating Room $ 2372682 $ 212202 $ 2584884 5100 Recovery Room 0 5300 Anesthesiology 812663 66751 879414 5400 Radiology-Diagnostic 744425 50444 794869 5401 Ultra Sound 273774 22123 295897 5600 Radioisotope 201256 5001 206257 5700 Computed Tomography (CT) Scan 1104906 61530 1166436 5800 Magnetic Resonance Imaging (MRI) 0 0 5900 Cardiac Catheterization 0 0 6000 Laboratory 2539230 (36019) 2503211 6001 GI Lab 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 6200 W hole Blood amp Packed Red Blood Cells 168194 8390 176584 6300 Blood Storing Processing amp Trans 0 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1944943 280274 2225217 6600 Physical Therapy 140110 14249 154359 6700 Occupational Therapy 0 0 6800 Speech Pathology 0 0 6900 Electrocardiology 1664507 292353 1956860 7000 Electroencephalography 0 0 7100 Medical Supplies Charged to Patients 1472234 260162 1732396 7200 Implantable Devices Charged to Patients 496326 77884 574210 7300 Drugs Charged to Patients 4193928 379343 4573271 7400 Renal Dialysis 266026 18434 284460 7500 ASC (Non-Distinct Part) 0 0 7501 Other Ancillary (specify) 0 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 2228177 117556 2345733 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
TOTAL MEDI-CAL ANCILLARY CHARGES $ 20623381 $ 1830677 $ 22454058 (To Schedule 5)
STATE OF CALIFORNIA SCHEDULE 7 PROGRAM NONCONTRACT
COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED
PHYSICIANS REMUNERATION
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
PROFESSIONAL SERVICE
COST CENTERS REMUNERATION
HBP
(Adj )
TOTAL CHARGES TO ALL PATIENTS
(Adj )
RATIO OF REMUNERATION
TO CHARGES
MEDI-CAL
(Adj )
CHARGES COST MEDI-CAL
5300 Anesthesiology $ 0 $ 0 0000000 $ $ 0 5400 Radiology - Diagnostic 0 0 0000000 0 5500 Radioisotope 0 0 0000000 0 6000 Laboratory 0 0 0000000 0 6900 Electrocardiology 0 0 0000000 0 7000 Electroencephalography 0 0 0000000 0 9100 Emergency 0 0 0000000 0
0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0
TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 2744664 200 Capital Related Costs-Movable Equipment 2187999 0 300 Other Capital Related Costs 0 0 0 301 0 0 0 0 302 0 0 0 0 0 303 0 0 0 0 0 0 304 0 0 0 0 0 0 0 305 0 0 0 0 0 0 0 0 306 0 0 0 0 0 0 0 0 0 307 0 0 0 0 0 0 0 0 0 0 308 0 0 0 0 0 0 0 0 0 0 0 309 0 0 0 0 0 0 0 0 0 0 0 0 400 Employee Benefits 1058934 84358 67249 0 0 0 0 0 0 0 0 0 501 0 0 0 0 0 0 0 0 0 0 0 0 502 0 0 0 0 0 0 0 0 0 0 0 0 503 0 0 0 0 0 0 0 0 0 0 0 0 504 0 0 0 0 0 0 0 0 0 0 0 0 505 0 0 0 0 0 0 0 0 0 0 0 0 506 0 0 0 0 0 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 0 0 0 500 Administrative and General 10629665 247119 196999 0 0 0 0 0 0 0 0 0 600 Maintenance and Repairs 565321 88028 70174 0 0 0 0 0 0 0 0 0 700 Operation of Plant 2017048 317029 252730 0 0 0 0 0 0 0 0 0 800 Laundry and Linen Service 263543 28979 23102 0 0 0 0 0 0 0 0 0 900 Housekeeping 755766 13085 10431 0 0 0 0 0 0 0 0 0
1000 Dietary 807098 83603 66647 0 0 0 0 0 0 0 0 0 1100 Cafeteria 159362 24177 19274 0 0 0 0 0 0 0 0 0 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 1482354 17467 13924 0 0 0 0 0 0 0 0 0 1400 Central Services and Supply 305730 124660 99377 0 0 0 0 0 0 0 0 0 1500 Pharmacy 1132927 24932 19875 0 0 0 0 0 0 0 0 0 1600 Medical Records amp Library 1178942 32900 26228 0 0 0 0 0 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 193276 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9131110 741734 591297 0 0 0 0 0 0 0 0 0
3100 Intensive Care Unit 2477587 130112 103723 0 0 0 0 0 0 0 0 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
ANCILLARY COST CENTERS 5000 Operating Room 1636558 166158 132458 0 0 0 0 0 0 0 0 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 1301021 99078 78983 0 0 0 0 0 0 0 0 0 5401 Ultra Sound 454209 3711 2959 0 0 0 0 0 0 0 0 0 5600 Radioisotope 206030 19816 15797 0 0 0 0 0 0 0 0 0 5700 Computed Tomography (CT) Scan 458725 10002 7974 0 0 0 0 0 0 0 0 0 5800 Magnetic Resonance Imaging (MRI) 16908 0 0 0 0 0 0 0 0 0 0 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 3398341 64417 51352 0 0 0 0 0 0 0 0 0 6001 GI Lab 292049 14678 11701 0 0 0 0 0 0 0 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 3 0 0 0 0 0 0 0 0 0 0 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 1123538 24030 19157 0 0 0 0 0 0 0 0 0 6600 Physical Therapy 241010 97338 77596 0 0 0 0 0 0 0 0 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 266558 2936 2340 0 0 0 0 0 0 0 0 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 2563528 0 0 0 0 0 0 0 0 0 0 0 7200 Implantable Devices Charged to Patients 558092 0 0 0 0 0 0 0 0 0 0 0 7300 Drugs Charged to Patients 972254 0 0 0 0 0 0 0 0 0 0 0 7400 Renal Dialysis 260774 126 100 0 0 0 0 0 0 0 0 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 4126916 138542 110443 0 0 0 0 0 0 0 0 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 5683 4530 0 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 137766 109825 0 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 512225 2202 1755 0 0 0 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 57057440 2744664 2187999 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 0 501 0 0 502 0 0 0 503 0 0 0 0 504 0 0 0 0 0 505 0 0 0 0 0 0 506 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 500 Administrative and General 0 154558 0 0 0 0 0 0 0 0 11228341 600 Maintenance and Repairs 0 0 0 0 0 0 0 0 0 0 723523 177266 700 Operation of Plant 0 22951 0 0 0 0 0 0 0 0 2609759 639403 800 Laundry and Linen Service 0 634 0 0 0 0 0 0 0 0 316257 77484 900 Housekeeping 0 17935 0 0 0 0 0 0 0 0 797216 195322
1000 Dietary 0 12138 0 0 0 0 0 0 0 0 969486 237529 1100 Cafeteria 0 3630 0 0 0 0 0 0 0 0 206442 50579 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 0 51300 0 0 0 0 0 0 0 0 1565046 383443 1400 Central Services and Supply 0 4664 0 0 0 0 0 0 0 0 534431 130938 1500 Pharmacy 0 40906 0 0 0 0 0 0 0 0 1218641 298573 1600 Medical Records amp Library 0 27157 0 0 0 0 0 0 0 0 1265227 309986 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 49131 0 0 0 0 0 0 0 0 1626506 398501 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 193276 47354 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 316959 0 0 0 0 0 0 0 0 10781100 2641419
3100 Intensive Care Unit 0 83801 0 0 0 0 0 0 0 0 2795223 684843 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
ANCILLARY COST CENTERS 5000 Operating Room 0 57734 0 0 0 0 0 0 0 0 1992908 488272 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 0 35520 0 0 0 0 0 0 0 0 1514602 371085 5401 Ultra Sound 0 16650 0 0 0 0 0 0 0 0 477530 116997 5600 Radioisotope 0 4554 0 0 0 0 0 0 0 0 246197 60319 5700 Computed Tomography (CT) Scan 0 17260 0 0 0 0 0 0 0 0 493961 121023 5800 Magnetic Resonance Imaging (MRI) 0 562 0 0 0 0 0 0 0 0 17470 4280 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 104001 0 0 0 0 0 0 0 0 3618110 886454 6001 GI Lab 0 10400 0 0 0 0 0 0 0 0 328829 80565 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3 1 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 33287 0 0 0 0 0 0 0 0 1200012 294009 6600 Physical Therapy 0 0 0 0 0 0 0 0 0 0 415944 101908 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 7758 0 0 0 0 0 0 0 0 279591 68501 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 2563528 628076 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 558092 136735 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 972254 238207 7400 Renal Dialysis 0 0 0 0 0 0 0 0 0 0 261000 63946 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 136296 0 0 0 0 0 0 0 0 4512197 1105509 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 0 0 10213 2502 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 0 0 247590 60661 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 755 0 0 0 0 0 0 0 0 516937 126652 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 1210541 0 0 0 0 0 0 0 0 57057440 11228341
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 122820 800 Laundry and Linen Service 11227 48661 900 Housekeeping 5069 21971 0
1000 Dietary 32389 140383 0 43356 1100 Cafeteria 9366 40597 0 12538 0 1200 Maintenance of Personnel 0 0 0 0 0 0 1300 Nursing Administration 6767 29330 0 9058 0 32774 0 1400 Central Services and Supply 48295 209325 0 64647 0 2815 0 0 1500 Pharmacy 9659 41865 0 12929 0 10368 0 0 0 1600 Medical Records amp Library 12746 55245 0 17062 0 13812 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 287355 1245493 194159 384654 1279497 101907 0 1122397 0 0 282741 0
3100 Intensive Care Unit 50407 218480 44463 67475 122109 22988 0 230707 0 0 57778 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
ANCILLARY COST CENTERS 5000 Operating Room 64371 279006 26097 86167 289 16495 0 179089 0 0 96649 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 39629 0 5400 Radiology-Diagnostic 38384 166369 32393 51381 0 12357 0 11607 0 0 72900 0 5401 Ultra Sound 1438 6232 0 1925 0 5123 0 0 0 0 34435 0 5600 Radioisotope 7677 33274 1304 10276 0 1680 0 10418 0 0 11704 0 5700 Computed Tomography (CT) Scan 3875 16795 0 5187 0 5733 0 0 0 0 115424 0 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 178 0 0 0 0 973 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 24956 108166 597 33406 0 35158 0 10684 0 0 141335 0 6001 GI Lab 5686 24647 1652 7612 0 3106 0 27809 0 0 30991 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3052 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 9310 40351 0 12462 0 10725 0 0 0 0 71751 0 6600 Physical Therapy 37710 163446 0 50478 0 0 0 0 0 0 8019 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 1137 4929 709 1522 0 2871 0 0 0 0 61930 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 990451 0 66024 0 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 34995 0 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 1592035 207938 0 7400 Renal Dialysis 49 211 0 65 0 0 0 0 0 0 7869 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 283 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 53672 232634 152254 71846 21247 41134 0 433708 0 0 327655 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA SCHEDULE 4 PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
GENERAL SERVICE UNIT NET OF SWING-BED COSTS REPORTED AUDITED
INPATIENT DAYS 1 Total Inpatient Days (include private amp swing-bed) (Adj ) 15592 15592 2 Inpatient Days (include private exclude swing-bed) 15592 15592 3 Private Room Days (exclude swing-bed private room) (Adj ) 0 0 4 Semi-Private Room Days (exclude swing-bed) (Adj ) 15592 15592 5 Medicare NF Swing-Bed Days through Dec 31 (Adj ) 0 0 6 Medicare NF Swing-Bed Days after Dec 31 (Adj ) 0 0 7 Medi-Cal NF Swing-Bed Days through July 31 (Adj ) 0 0 8 Medi-Cal NF Swing-Bed Days after July 31 (Adj ) 0 0 9 Medi-Cal Days (excluding swing-bed) (Adjs 31 36) 229500 270850
SW ING-BED ADJUSTMENT 17 Medicare NF Swing-Bed Rates through Dec 31 (Adj ) $ 000 $ 000 18 Medicare NF Swing-Bed Rates after Dec 31 (Adj ) $ 000 $ 000 19 Medi-Cal NF Swing-Bed Rates through July 31 (Adj ) $ 000 $ 000 20 Medi-Cal NF Swing-Bed Rates after July 31 (Adj ) $ 000 $ 000 21 Total Routine Serv Cost (Sch 8 Line 30 Col 26) $ 22365373 $ 19534607 22 Medicare NF Swing-Bed Cost through Dec 31 (L 5 x L 17) $ 0 $ 0 23 Medicare NF Swing-Bed Cost after Dec 31 (L 6 x L 18) $ 0 $ 0 24 Medi-Cal NF Swing-Bed Cost through July 31 (L 7 x L 19) $ 0 $ 0 25 Medi-Cal NF Swing-Bed Cost after July 31 (L 8 x L 20) $ 0 $ 0 26 Total Swing-Bed Cost (Sum of Lines 22 to 25) $ 0 $ 0 27 Inpatient Routine Cost Net of Swing-Bed (L 21 minus L 26) $ 22365373 $ 19534607
PRIVATE ROOM DIFFERENTIAL ADJUSTMENT 28 Gen Inpatient Routine Serv Charges (excl swing-bed charges) $ 0 $ 0 29 Private Room Charges (excluding swing-bed charges) $ 50416207 $ 50416207 30 Semi-Private Room Charges (excluding swing-bed charges) $ (50416207) $ (50416207) 31 Gen Inpatient Routine Service CostCharge Ratio (L 27 divide L 28) $ 0000000 $ 0000000 32 Average Private Room Per Diem Charge (L 29 divide L 3) $ 000 $ 000 33 Average Semi-Private Room Per Diem Charge (L 30 divide L 4) $ (323347) $ (323347) 34 Avg Per Diem Prvt Room Charge Differential (L 32 minus L 33) $ 000 $ 000 35 Average Per Diem Private Room Cost Differential (L 31 x L 34) $ 000 $ 000 36 Private Room Cost Differential Adjustment (L 35 x L 3) $ 0 $ 0 37 Inpatient Rout Cost Net of Swing-Bed amp Prvt Rm (L 27 minus L 36) $ 22365373 $ 19534607
PROGRAM INPATIENT OPERATING COST 38 Adjusted General Inpatient Routine Cost Per Diem (L 37 divide L 2) $ 143441 $ 125286 39 Program General Inpatient Routine Service Cost (L 9 x L 38) $ 3291971 $ 3393371
40 Cost Applicable to Medi-Cal (Sch 4A) $ 806318 $ 807942 41 Cost Applicable to Medi-Cal (Sch 4B) $ 0 $ 0
42 TOTAL MEDI-CAL ROUTINE COST (Sum of Lines 3940 amp 41) $ 4098289 $ 4201313 ( To Schedule 3 )
STATE OF CALIFORNIA SCHEDULE 4A PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE ANDOR NURSERY UNITS REPORTED AUDITED
NURSERY 1 Total Inpatient Routine Cost (Sch 8 Line 43 Col 26)
2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
000
0
$
$
$
00
00000
INTENSIVE CARE UNIT 6 Total Inpatient Routine Cost (Sch 8 Line 31 Col 26)
7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost
9 Medi-Cal Inpatient Days (Adjs 31 36) 10 Cost Applicable to Medi-Cal
$ 50006362059
$ 24286733200
$ 806318
$
$
$
43125232059
20944738575
807942
CORONARY CARE UNIT 11 Total Inpatient Routine Cost (Sch 8 Line 32 Col 26)
12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost 14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
BURN INTENSIVE CARE UNIT 16 Total Inpatient Routine Cost (Sch 8 Line 33 Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
SURGICAL INTENSIVE CARE UNIT 21 Total Inpatient Routine Cost (Sch 8 Line 34 Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
OTHER SPECIAL CARE (SPECIFY) 26 Total Inpatient Routine Cost (Sch 8 Line 35 Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
ADMINISTRATIVE DAYS 31 Per Diem Rate (Adj )32 Medi-Cal Inpatient Days (Adj ) 33 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
ADMINISTRATIVE DAYS 34 Per Diem Rate (Adj )35 Medi-Cal Inpatient Days (Adj ) 36 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
37 Medi-Cal Routine Cost (Sum of Lines 510152025303336) $ 806318 $ 807942 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 4B PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE UNITS REPORTED AUDITED
1 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
6 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost 9 Medi-Cal Inpatient Days (Adj ) 10 Cost Applicable to Medi-Cal
$ 00
$ 0000
$ 0
$
$
$
00
0000 0
11 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
16 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
21 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
26 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
31 Medi-Cal Routine Cost (Sum of Lines 51015202530) $ 0 $ 0 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 5 PROGRAM NONCONTRACT
SCHEDULE OF MEDI-CAL ANCILLARY COSTS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
TOTAL ANCILLARY
COST
TOTAL ANCILLARY CHARGES
(Adj )
RATIO COST TO CHARGES
CHARGES (From Schedule 6)
MEDI-CAL COST
MEDI-CAL
ANCILLARY COST CENTERS 5000 Operating Room $ 3554239 $ 14309479 0248384 $ 2584884 $ 642043 5100 Recovery Room 0 0 0000000 0 0 5300 Anesthesiology 39629 5867250 0006754 879414 5940 5400 Radiology-Diagnostic 2271078 10793343 0210415 794869 167252 5401 Ultra Sound 643680 5098375 0126252 295897 37358 5600 Radioisotope 382848 1732875 0220932 206257 45569 5700 Computed Tomography (CT) Scan 761998 17089310 0044589 1166436 52010 5800 Magnetic Resonance Imaging (MRI) 22902 144113 0158919 0 0 5900 Cardiac Catheterization 0 0 0000000 0 0 6000 Laboratory 4858864 20925490 0232198 2503211 581241 6001 GI Lab 510896 4588397 0111345 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0000000 0 0 6200 W hole Blood amp Packed Red Blood Cells 3056 451924 0006762 176584 1194 6300 Blood Storing Processing amp Trans 0 0 0000000 0 0 6400 Intravenous Therapy 0 0 0000000 0 0 6500 Respiratory Therapy 1638618 10623110 0154250 2225217 343240 6600 Physical Therapy 777505 1187297 0654853 154359 101082 6700 Occupational Therapy 0 0 0000000 0 0 6800 Speech Pathology 0 0 0000000 0 0 6900 Electrocardiology 421192 9169134 0045936 1956860 89890 7000 Electroencephalography 0 0 0000000 0 0 7100 Medical Supplies Charged to Patients 4248079 9775274 0434574 1732396 752854 7200 Implantable Devices Charged to Patients 729822 5181268 0140858 574210 80882 7300 Drugs Charged to Patients 3010434 30786573 0097784 4573271 447193 7400 Renal Dialysis 333141 1165060 0285943 284460 81339 7500 ASC (Non-Distinct Part) 0 0 0000000 0 0 7501 Other Ancillary (specify) 283 41845 0006754 0 0 7700 0 0 0000000 0 0 7800 0 0 0000000 0 0 7900 0 0 0000000 0 0 8000 0 0 0000000 0 0 8100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0 8700 0 0 0000000 0 0 8701 0 0 0000000 0 0 8800 Rural Health Clinic (RHC) 0 0 0000000 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0000000 0 0 9000 Clinic 0 0 0000000 0 0 9100 Emergency 7660663 48511384 0157915 2345733 370426 9200 Observation Beds 0 0 0000000 0 0 9300 Other Outpatient Services (Specify) 0 0 0000000 0 0 9301 0 0 0000000 0 0 9302 0 0 0000000 0 0 9303 0 0 0000000 0 0 9304 0 0 0000000 0 0 9305 0 0 0000000 0 0
TOTAL $ 31868926 $ 197441501 $ 22454058 $ 3799513 (To Schedule 3)
From Schedule 8 Column 26
STATE OF CALIFORNIA SCHEDULE 6 PROGRAM NONCONTRACT
ADJUSTMENTS TO MEDI-CAL CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
ANCILLARY CHARGES REPORTED ADJUSTMENTS
(Adj 32) AUDITED
5000 Operating Room $ 2372682 $ 212202 $ 2584884 5100 Recovery Room 0 5300 Anesthesiology 812663 66751 879414 5400 Radiology-Diagnostic 744425 50444 794869 5401 Ultra Sound 273774 22123 295897 5600 Radioisotope 201256 5001 206257 5700 Computed Tomography (CT) Scan 1104906 61530 1166436 5800 Magnetic Resonance Imaging (MRI) 0 0 5900 Cardiac Catheterization 0 0 6000 Laboratory 2539230 (36019) 2503211 6001 GI Lab 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 6200 W hole Blood amp Packed Red Blood Cells 168194 8390 176584 6300 Blood Storing Processing amp Trans 0 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1944943 280274 2225217 6600 Physical Therapy 140110 14249 154359 6700 Occupational Therapy 0 0 6800 Speech Pathology 0 0 6900 Electrocardiology 1664507 292353 1956860 7000 Electroencephalography 0 0 7100 Medical Supplies Charged to Patients 1472234 260162 1732396 7200 Implantable Devices Charged to Patients 496326 77884 574210 7300 Drugs Charged to Patients 4193928 379343 4573271 7400 Renal Dialysis 266026 18434 284460 7500 ASC (Non-Distinct Part) 0 0 7501 Other Ancillary (specify) 0 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 2228177 117556 2345733 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
TOTAL MEDI-CAL ANCILLARY CHARGES $ 20623381 $ 1830677 $ 22454058 (To Schedule 5)
STATE OF CALIFORNIA SCHEDULE 7 PROGRAM NONCONTRACT
COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED
PHYSICIANS REMUNERATION
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
PROFESSIONAL SERVICE
COST CENTERS REMUNERATION
HBP
(Adj )
TOTAL CHARGES TO ALL PATIENTS
(Adj )
RATIO OF REMUNERATION
TO CHARGES
MEDI-CAL
(Adj )
CHARGES COST MEDI-CAL
5300 Anesthesiology $ 0 $ 0 0000000 $ $ 0 5400 Radiology - Diagnostic 0 0 0000000 0 5500 Radioisotope 0 0 0000000 0 6000 Laboratory 0 0 0000000 0 6900 Electrocardiology 0 0 0000000 0 7000 Electroencephalography 0 0 0000000 0 9100 Emergency 0 0 0000000 0
0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0
TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 2744664 200 Capital Related Costs-Movable Equipment 2187999 0 300 Other Capital Related Costs 0 0 0 301 0 0 0 0 302 0 0 0 0 0 303 0 0 0 0 0 0 304 0 0 0 0 0 0 0 305 0 0 0 0 0 0 0 0 306 0 0 0 0 0 0 0 0 0 307 0 0 0 0 0 0 0 0 0 0 308 0 0 0 0 0 0 0 0 0 0 0 309 0 0 0 0 0 0 0 0 0 0 0 0 400 Employee Benefits 1058934 84358 67249 0 0 0 0 0 0 0 0 0 501 0 0 0 0 0 0 0 0 0 0 0 0 502 0 0 0 0 0 0 0 0 0 0 0 0 503 0 0 0 0 0 0 0 0 0 0 0 0 504 0 0 0 0 0 0 0 0 0 0 0 0 505 0 0 0 0 0 0 0 0 0 0 0 0 506 0 0 0 0 0 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 0 0 0 500 Administrative and General 10629665 247119 196999 0 0 0 0 0 0 0 0 0 600 Maintenance and Repairs 565321 88028 70174 0 0 0 0 0 0 0 0 0 700 Operation of Plant 2017048 317029 252730 0 0 0 0 0 0 0 0 0 800 Laundry and Linen Service 263543 28979 23102 0 0 0 0 0 0 0 0 0 900 Housekeeping 755766 13085 10431 0 0 0 0 0 0 0 0 0
1000 Dietary 807098 83603 66647 0 0 0 0 0 0 0 0 0 1100 Cafeteria 159362 24177 19274 0 0 0 0 0 0 0 0 0 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 1482354 17467 13924 0 0 0 0 0 0 0 0 0 1400 Central Services and Supply 305730 124660 99377 0 0 0 0 0 0 0 0 0 1500 Pharmacy 1132927 24932 19875 0 0 0 0 0 0 0 0 0 1600 Medical Records amp Library 1178942 32900 26228 0 0 0 0 0 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 193276 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9131110 741734 591297 0 0 0 0 0 0 0 0 0
3100 Intensive Care Unit 2477587 130112 103723 0 0 0 0 0 0 0 0 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
ANCILLARY COST CENTERS 5000 Operating Room 1636558 166158 132458 0 0 0 0 0 0 0 0 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 1301021 99078 78983 0 0 0 0 0 0 0 0 0 5401 Ultra Sound 454209 3711 2959 0 0 0 0 0 0 0 0 0 5600 Radioisotope 206030 19816 15797 0 0 0 0 0 0 0 0 0 5700 Computed Tomography (CT) Scan 458725 10002 7974 0 0 0 0 0 0 0 0 0 5800 Magnetic Resonance Imaging (MRI) 16908 0 0 0 0 0 0 0 0 0 0 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 3398341 64417 51352 0 0 0 0 0 0 0 0 0 6001 GI Lab 292049 14678 11701 0 0 0 0 0 0 0 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 3 0 0 0 0 0 0 0 0 0 0 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 1123538 24030 19157 0 0 0 0 0 0 0 0 0 6600 Physical Therapy 241010 97338 77596 0 0 0 0 0 0 0 0 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 266558 2936 2340 0 0 0 0 0 0 0 0 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 2563528 0 0 0 0 0 0 0 0 0 0 0 7200 Implantable Devices Charged to Patients 558092 0 0 0 0 0 0 0 0 0 0 0 7300 Drugs Charged to Patients 972254 0 0 0 0 0 0 0 0 0 0 0 7400 Renal Dialysis 260774 126 100 0 0 0 0 0 0 0 0 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 4126916 138542 110443 0 0 0 0 0 0 0 0 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 5683 4530 0 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 137766 109825 0 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 512225 2202 1755 0 0 0 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 57057440 2744664 2187999 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 0 501 0 0 502 0 0 0 503 0 0 0 0 504 0 0 0 0 0 505 0 0 0 0 0 0 506 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 500 Administrative and General 0 154558 0 0 0 0 0 0 0 0 11228341 600 Maintenance and Repairs 0 0 0 0 0 0 0 0 0 0 723523 177266 700 Operation of Plant 0 22951 0 0 0 0 0 0 0 0 2609759 639403 800 Laundry and Linen Service 0 634 0 0 0 0 0 0 0 0 316257 77484 900 Housekeeping 0 17935 0 0 0 0 0 0 0 0 797216 195322
1000 Dietary 0 12138 0 0 0 0 0 0 0 0 969486 237529 1100 Cafeteria 0 3630 0 0 0 0 0 0 0 0 206442 50579 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 0 51300 0 0 0 0 0 0 0 0 1565046 383443 1400 Central Services and Supply 0 4664 0 0 0 0 0 0 0 0 534431 130938 1500 Pharmacy 0 40906 0 0 0 0 0 0 0 0 1218641 298573 1600 Medical Records amp Library 0 27157 0 0 0 0 0 0 0 0 1265227 309986 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 49131 0 0 0 0 0 0 0 0 1626506 398501 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 193276 47354 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 316959 0 0 0 0 0 0 0 0 10781100 2641419
3100 Intensive Care Unit 0 83801 0 0 0 0 0 0 0 0 2795223 684843 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
ANCILLARY COST CENTERS 5000 Operating Room 0 57734 0 0 0 0 0 0 0 0 1992908 488272 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 0 35520 0 0 0 0 0 0 0 0 1514602 371085 5401 Ultra Sound 0 16650 0 0 0 0 0 0 0 0 477530 116997 5600 Radioisotope 0 4554 0 0 0 0 0 0 0 0 246197 60319 5700 Computed Tomography (CT) Scan 0 17260 0 0 0 0 0 0 0 0 493961 121023 5800 Magnetic Resonance Imaging (MRI) 0 562 0 0 0 0 0 0 0 0 17470 4280 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 104001 0 0 0 0 0 0 0 0 3618110 886454 6001 GI Lab 0 10400 0 0 0 0 0 0 0 0 328829 80565 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3 1 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 33287 0 0 0 0 0 0 0 0 1200012 294009 6600 Physical Therapy 0 0 0 0 0 0 0 0 0 0 415944 101908 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 7758 0 0 0 0 0 0 0 0 279591 68501 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 2563528 628076 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 558092 136735 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 972254 238207 7400 Renal Dialysis 0 0 0 0 0 0 0 0 0 0 261000 63946 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 136296 0 0 0 0 0 0 0 0 4512197 1105509 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 0 0 10213 2502 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 0 0 247590 60661 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 755 0 0 0 0 0 0 0 0 516937 126652 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 1210541 0 0 0 0 0 0 0 0 57057440 11228341
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 122820 800 Laundry and Linen Service 11227 48661 900 Housekeeping 5069 21971 0
1000 Dietary 32389 140383 0 43356 1100 Cafeteria 9366 40597 0 12538 0 1200 Maintenance of Personnel 0 0 0 0 0 0 1300 Nursing Administration 6767 29330 0 9058 0 32774 0 1400 Central Services and Supply 48295 209325 0 64647 0 2815 0 0 1500 Pharmacy 9659 41865 0 12929 0 10368 0 0 0 1600 Medical Records amp Library 12746 55245 0 17062 0 13812 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 287355 1245493 194159 384654 1279497 101907 0 1122397 0 0 282741 0
3100 Intensive Care Unit 50407 218480 44463 67475 122109 22988 0 230707 0 0 57778 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
ANCILLARY COST CENTERS 5000 Operating Room 64371 279006 26097 86167 289 16495 0 179089 0 0 96649 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 39629 0 5400 Radiology-Diagnostic 38384 166369 32393 51381 0 12357 0 11607 0 0 72900 0 5401 Ultra Sound 1438 6232 0 1925 0 5123 0 0 0 0 34435 0 5600 Radioisotope 7677 33274 1304 10276 0 1680 0 10418 0 0 11704 0 5700 Computed Tomography (CT) Scan 3875 16795 0 5187 0 5733 0 0 0 0 115424 0 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 178 0 0 0 0 973 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 24956 108166 597 33406 0 35158 0 10684 0 0 141335 0 6001 GI Lab 5686 24647 1652 7612 0 3106 0 27809 0 0 30991 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3052 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 9310 40351 0 12462 0 10725 0 0 0 0 71751 0 6600 Physical Therapy 37710 163446 0 50478 0 0 0 0 0 0 8019 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 1137 4929 709 1522 0 2871 0 0 0 0 61930 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 990451 0 66024 0 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 34995 0 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 1592035 207938 0 7400 Renal Dialysis 49 211 0 65 0 0 0 0 0 0 7869 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 283 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 53672 232634 152254 71846 21247 41134 0 433708 0 0 327655 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA SCHEDULE 4A PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE ANDOR NURSERY UNITS REPORTED AUDITED
NURSERY 1 Total Inpatient Routine Cost (Sch 8 Line 43 Col 26)
2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
000
0
$
$
$
00
00000
INTENSIVE CARE UNIT 6 Total Inpatient Routine Cost (Sch 8 Line 31 Col 26)
7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost
9 Medi-Cal Inpatient Days (Adjs 31 36) 10 Cost Applicable to Medi-Cal
$ 50006362059
$ 24286733200
$ 806318
$
$
$
43125232059
20944738575
807942
CORONARY CARE UNIT 11 Total Inpatient Routine Cost (Sch 8 Line 32 Col 26)
12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost 14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
BURN INTENSIVE CARE UNIT 16 Total Inpatient Routine Cost (Sch 8 Line 33 Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
SURGICAL INTENSIVE CARE UNIT 21 Total Inpatient Routine Cost (Sch 8 Line 34 Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
OTHER SPECIAL CARE (SPECIFY) 26 Total Inpatient Routine Cost (Sch 8 Line 35 Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
ADMINISTRATIVE DAYS 31 Per Diem Rate (Adj )32 Medi-Cal Inpatient Days (Adj ) 33 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
ADMINISTRATIVE DAYS 34 Per Diem Rate (Adj )35 Medi-Cal Inpatient Days (Adj ) 36 Cost Applicable to Medi-Cal
$
$
0000 0
$
$
000 0 0
37 Medi-Cal Routine Cost (Sum of Lines 510152025303336) $ 806318 $ 807942 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 4B PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE UNITS REPORTED AUDITED
1 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
6 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost 9 Medi-Cal Inpatient Days (Adj ) 10 Cost Applicable to Medi-Cal
$ 00
$ 0000
$ 0
$
$
$
00
0000 0
11 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
16 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
21 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
26 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
31 Medi-Cal Routine Cost (Sum of Lines 51015202530) $ 0 $ 0 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 5 PROGRAM NONCONTRACT
SCHEDULE OF MEDI-CAL ANCILLARY COSTS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
TOTAL ANCILLARY
COST
TOTAL ANCILLARY CHARGES
(Adj )
RATIO COST TO CHARGES
CHARGES (From Schedule 6)
MEDI-CAL COST
MEDI-CAL
ANCILLARY COST CENTERS 5000 Operating Room $ 3554239 $ 14309479 0248384 $ 2584884 $ 642043 5100 Recovery Room 0 0 0000000 0 0 5300 Anesthesiology 39629 5867250 0006754 879414 5940 5400 Radiology-Diagnostic 2271078 10793343 0210415 794869 167252 5401 Ultra Sound 643680 5098375 0126252 295897 37358 5600 Radioisotope 382848 1732875 0220932 206257 45569 5700 Computed Tomography (CT) Scan 761998 17089310 0044589 1166436 52010 5800 Magnetic Resonance Imaging (MRI) 22902 144113 0158919 0 0 5900 Cardiac Catheterization 0 0 0000000 0 0 6000 Laboratory 4858864 20925490 0232198 2503211 581241 6001 GI Lab 510896 4588397 0111345 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0000000 0 0 6200 W hole Blood amp Packed Red Blood Cells 3056 451924 0006762 176584 1194 6300 Blood Storing Processing amp Trans 0 0 0000000 0 0 6400 Intravenous Therapy 0 0 0000000 0 0 6500 Respiratory Therapy 1638618 10623110 0154250 2225217 343240 6600 Physical Therapy 777505 1187297 0654853 154359 101082 6700 Occupational Therapy 0 0 0000000 0 0 6800 Speech Pathology 0 0 0000000 0 0 6900 Electrocardiology 421192 9169134 0045936 1956860 89890 7000 Electroencephalography 0 0 0000000 0 0 7100 Medical Supplies Charged to Patients 4248079 9775274 0434574 1732396 752854 7200 Implantable Devices Charged to Patients 729822 5181268 0140858 574210 80882 7300 Drugs Charged to Patients 3010434 30786573 0097784 4573271 447193 7400 Renal Dialysis 333141 1165060 0285943 284460 81339 7500 ASC (Non-Distinct Part) 0 0 0000000 0 0 7501 Other Ancillary (specify) 283 41845 0006754 0 0 7700 0 0 0000000 0 0 7800 0 0 0000000 0 0 7900 0 0 0000000 0 0 8000 0 0 0000000 0 0 8100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0 8700 0 0 0000000 0 0 8701 0 0 0000000 0 0 8800 Rural Health Clinic (RHC) 0 0 0000000 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0000000 0 0 9000 Clinic 0 0 0000000 0 0 9100 Emergency 7660663 48511384 0157915 2345733 370426 9200 Observation Beds 0 0 0000000 0 0 9300 Other Outpatient Services (Specify) 0 0 0000000 0 0 9301 0 0 0000000 0 0 9302 0 0 0000000 0 0 9303 0 0 0000000 0 0 9304 0 0 0000000 0 0 9305 0 0 0000000 0 0
TOTAL $ 31868926 $ 197441501 $ 22454058 $ 3799513 (To Schedule 3)
From Schedule 8 Column 26
STATE OF CALIFORNIA SCHEDULE 6 PROGRAM NONCONTRACT
ADJUSTMENTS TO MEDI-CAL CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
ANCILLARY CHARGES REPORTED ADJUSTMENTS
(Adj 32) AUDITED
5000 Operating Room $ 2372682 $ 212202 $ 2584884 5100 Recovery Room 0 5300 Anesthesiology 812663 66751 879414 5400 Radiology-Diagnostic 744425 50444 794869 5401 Ultra Sound 273774 22123 295897 5600 Radioisotope 201256 5001 206257 5700 Computed Tomography (CT) Scan 1104906 61530 1166436 5800 Magnetic Resonance Imaging (MRI) 0 0 5900 Cardiac Catheterization 0 0 6000 Laboratory 2539230 (36019) 2503211 6001 GI Lab 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 6200 W hole Blood amp Packed Red Blood Cells 168194 8390 176584 6300 Blood Storing Processing amp Trans 0 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1944943 280274 2225217 6600 Physical Therapy 140110 14249 154359 6700 Occupational Therapy 0 0 6800 Speech Pathology 0 0 6900 Electrocardiology 1664507 292353 1956860 7000 Electroencephalography 0 0 7100 Medical Supplies Charged to Patients 1472234 260162 1732396 7200 Implantable Devices Charged to Patients 496326 77884 574210 7300 Drugs Charged to Patients 4193928 379343 4573271 7400 Renal Dialysis 266026 18434 284460 7500 ASC (Non-Distinct Part) 0 0 7501 Other Ancillary (specify) 0 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 2228177 117556 2345733 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
TOTAL MEDI-CAL ANCILLARY CHARGES $ 20623381 $ 1830677 $ 22454058 (To Schedule 5)
STATE OF CALIFORNIA SCHEDULE 7 PROGRAM NONCONTRACT
COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED
PHYSICIANS REMUNERATION
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
PROFESSIONAL SERVICE
COST CENTERS REMUNERATION
HBP
(Adj )
TOTAL CHARGES TO ALL PATIENTS
(Adj )
RATIO OF REMUNERATION
TO CHARGES
MEDI-CAL
(Adj )
CHARGES COST MEDI-CAL
5300 Anesthesiology $ 0 $ 0 0000000 $ $ 0 5400 Radiology - Diagnostic 0 0 0000000 0 5500 Radioisotope 0 0 0000000 0 6000 Laboratory 0 0 0000000 0 6900 Electrocardiology 0 0 0000000 0 7000 Electroencephalography 0 0 0000000 0 9100 Emergency 0 0 0000000 0
0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0
TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 2744664 200 Capital Related Costs-Movable Equipment 2187999 0 300 Other Capital Related Costs 0 0 0 301 0 0 0 0 302 0 0 0 0 0 303 0 0 0 0 0 0 304 0 0 0 0 0 0 0 305 0 0 0 0 0 0 0 0 306 0 0 0 0 0 0 0 0 0 307 0 0 0 0 0 0 0 0 0 0 308 0 0 0 0 0 0 0 0 0 0 0 309 0 0 0 0 0 0 0 0 0 0 0 0 400 Employee Benefits 1058934 84358 67249 0 0 0 0 0 0 0 0 0 501 0 0 0 0 0 0 0 0 0 0 0 0 502 0 0 0 0 0 0 0 0 0 0 0 0 503 0 0 0 0 0 0 0 0 0 0 0 0 504 0 0 0 0 0 0 0 0 0 0 0 0 505 0 0 0 0 0 0 0 0 0 0 0 0 506 0 0 0 0 0 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 0 0 0 500 Administrative and General 10629665 247119 196999 0 0 0 0 0 0 0 0 0 600 Maintenance and Repairs 565321 88028 70174 0 0 0 0 0 0 0 0 0 700 Operation of Plant 2017048 317029 252730 0 0 0 0 0 0 0 0 0 800 Laundry and Linen Service 263543 28979 23102 0 0 0 0 0 0 0 0 0 900 Housekeeping 755766 13085 10431 0 0 0 0 0 0 0 0 0
1000 Dietary 807098 83603 66647 0 0 0 0 0 0 0 0 0 1100 Cafeteria 159362 24177 19274 0 0 0 0 0 0 0 0 0 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 1482354 17467 13924 0 0 0 0 0 0 0 0 0 1400 Central Services and Supply 305730 124660 99377 0 0 0 0 0 0 0 0 0 1500 Pharmacy 1132927 24932 19875 0 0 0 0 0 0 0 0 0 1600 Medical Records amp Library 1178942 32900 26228 0 0 0 0 0 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 193276 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9131110 741734 591297 0 0 0 0 0 0 0 0 0
3100 Intensive Care Unit 2477587 130112 103723 0 0 0 0 0 0 0 0 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
ANCILLARY COST CENTERS 5000 Operating Room 1636558 166158 132458 0 0 0 0 0 0 0 0 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 1301021 99078 78983 0 0 0 0 0 0 0 0 0 5401 Ultra Sound 454209 3711 2959 0 0 0 0 0 0 0 0 0 5600 Radioisotope 206030 19816 15797 0 0 0 0 0 0 0 0 0 5700 Computed Tomography (CT) Scan 458725 10002 7974 0 0 0 0 0 0 0 0 0 5800 Magnetic Resonance Imaging (MRI) 16908 0 0 0 0 0 0 0 0 0 0 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 3398341 64417 51352 0 0 0 0 0 0 0 0 0 6001 GI Lab 292049 14678 11701 0 0 0 0 0 0 0 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 3 0 0 0 0 0 0 0 0 0 0 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 1123538 24030 19157 0 0 0 0 0 0 0 0 0 6600 Physical Therapy 241010 97338 77596 0 0 0 0 0 0 0 0 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 266558 2936 2340 0 0 0 0 0 0 0 0 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 2563528 0 0 0 0 0 0 0 0 0 0 0 7200 Implantable Devices Charged to Patients 558092 0 0 0 0 0 0 0 0 0 0 0 7300 Drugs Charged to Patients 972254 0 0 0 0 0 0 0 0 0 0 0 7400 Renal Dialysis 260774 126 100 0 0 0 0 0 0 0 0 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 4126916 138542 110443 0 0 0 0 0 0 0 0 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 5683 4530 0 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 137766 109825 0 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 512225 2202 1755 0 0 0 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 57057440 2744664 2187999 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 0 501 0 0 502 0 0 0 503 0 0 0 0 504 0 0 0 0 0 505 0 0 0 0 0 0 506 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 500 Administrative and General 0 154558 0 0 0 0 0 0 0 0 11228341 600 Maintenance and Repairs 0 0 0 0 0 0 0 0 0 0 723523 177266 700 Operation of Plant 0 22951 0 0 0 0 0 0 0 0 2609759 639403 800 Laundry and Linen Service 0 634 0 0 0 0 0 0 0 0 316257 77484 900 Housekeeping 0 17935 0 0 0 0 0 0 0 0 797216 195322
1000 Dietary 0 12138 0 0 0 0 0 0 0 0 969486 237529 1100 Cafeteria 0 3630 0 0 0 0 0 0 0 0 206442 50579 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 0 51300 0 0 0 0 0 0 0 0 1565046 383443 1400 Central Services and Supply 0 4664 0 0 0 0 0 0 0 0 534431 130938 1500 Pharmacy 0 40906 0 0 0 0 0 0 0 0 1218641 298573 1600 Medical Records amp Library 0 27157 0 0 0 0 0 0 0 0 1265227 309986 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 49131 0 0 0 0 0 0 0 0 1626506 398501 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 193276 47354 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 316959 0 0 0 0 0 0 0 0 10781100 2641419
3100 Intensive Care Unit 0 83801 0 0 0 0 0 0 0 0 2795223 684843 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
ANCILLARY COST CENTERS 5000 Operating Room 0 57734 0 0 0 0 0 0 0 0 1992908 488272 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 0 35520 0 0 0 0 0 0 0 0 1514602 371085 5401 Ultra Sound 0 16650 0 0 0 0 0 0 0 0 477530 116997 5600 Radioisotope 0 4554 0 0 0 0 0 0 0 0 246197 60319 5700 Computed Tomography (CT) Scan 0 17260 0 0 0 0 0 0 0 0 493961 121023 5800 Magnetic Resonance Imaging (MRI) 0 562 0 0 0 0 0 0 0 0 17470 4280 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 104001 0 0 0 0 0 0 0 0 3618110 886454 6001 GI Lab 0 10400 0 0 0 0 0 0 0 0 328829 80565 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3 1 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 33287 0 0 0 0 0 0 0 0 1200012 294009 6600 Physical Therapy 0 0 0 0 0 0 0 0 0 0 415944 101908 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 7758 0 0 0 0 0 0 0 0 279591 68501 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 2563528 628076 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 558092 136735 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 972254 238207 7400 Renal Dialysis 0 0 0 0 0 0 0 0 0 0 261000 63946 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 136296 0 0 0 0 0 0 0 0 4512197 1105509 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 0 0 10213 2502 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 0 0 247590 60661 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 755 0 0 0 0 0 0 0 0 516937 126652 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 1210541 0 0 0 0 0 0 0 0 57057440 11228341
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 122820 800 Laundry and Linen Service 11227 48661 900 Housekeeping 5069 21971 0
1000 Dietary 32389 140383 0 43356 1100 Cafeteria 9366 40597 0 12538 0 1200 Maintenance of Personnel 0 0 0 0 0 0 1300 Nursing Administration 6767 29330 0 9058 0 32774 0 1400 Central Services and Supply 48295 209325 0 64647 0 2815 0 0 1500 Pharmacy 9659 41865 0 12929 0 10368 0 0 0 1600 Medical Records amp Library 12746 55245 0 17062 0 13812 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 287355 1245493 194159 384654 1279497 101907 0 1122397 0 0 282741 0
3100 Intensive Care Unit 50407 218480 44463 67475 122109 22988 0 230707 0 0 57778 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
ANCILLARY COST CENTERS 5000 Operating Room 64371 279006 26097 86167 289 16495 0 179089 0 0 96649 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 39629 0 5400 Radiology-Diagnostic 38384 166369 32393 51381 0 12357 0 11607 0 0 72900 0 5401 Ultra Sound 1438 6232 0 1925 0 5123 0 0 0 0 34435 0 5600 Radioisotope 7677 33274 1304 10276 0 1680 0 10418 0 0 11704 0 5700 Computed Tomography (CT) Scan 3875 16795 0 5187 0 5733 0 0 0 0 115424 0 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 178 0 0 0 0 973 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 24956 108166 597 33406 0 35158 0 10684 0 0 141335 0 6001 GI Lab 5686 24647 1652 7612 0 3106 0 27809 0 0 30991 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3052 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 9310 40351 0 12462 0 10725 0 0 0 0 71751 0 6600 Physical Therapy 37710 163446 0 50478 0 0 0 0 0 0 8019 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 1137 4929 709 1522 0 2871 0 0 0 0 61930 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 990451 0 66024 0 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 34995 0 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 1592035 207938 0 7400 Renal Dialysis 49 211 0 65 0 0 0 0 0 0 7869 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 283 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 53672 232634 152254 71846 21247 41134 0 433708 0 0 327655 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA SCHEDULE 4B PROGRAM NONCONTRACT
COMPUTATION OF MEDI-CAL INPATIENT ROUTINE SERVICE COST
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period Ended DECEMBER 31 2011
Provider NPI 1962407460
SPECIAL CARE UNITS REPORTED AUDITED
1 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 2 Total Inpatient Days (Adj ) 3 Average Per Diem Cost 4 Medi-Cal Inpatient Days (Adj ) 5 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
00
00000
6 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26) 7 Total Inpatient Days (Adj ) 8 Average Per Diem Cost 9 Medi-Cal Inpatient Days (Adj ) 10 Cost Applicable to Medi-Cal
$ 00
$ 0000
$ 0
$
$
$
00
0000 0
11 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)12 Total Inpatient Days (Adj ) 13 Average Per Diem Cost14 Medi-Cal Inpatient Days (Adj ) 15 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
16 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)17 Total Inpatient Days (Adj ) 18 Average Per Diem Cost19 Medi-Cal Inpatient Days (Adj ) 20 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
21 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)22 Total Inpatient Days (Adj ) 23 Average Per Diem Cost24 Medi-Cal Inpatient Days (Adj ) 25 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
26 Total Inpatient Routine Cost (Sch 8 Line ___ Col 26)27 Total Inpatient Days (Adj ) 28 Average Per Diem Cost29 Medi-Cal Inpatient Days (Adj ) 30 Cost Applicable to Medi-Cal
$
$
$
00
0000 0
$
$
$
0 0
000 0 0
31 Medi-Cal Routine Cost (Sum of Lines 51015202530) $ 0 $ 0 (To Schedule 4)
STATE OF CALIFORNIA SCHEDULE 5 PROGRAM NONCONTRACT
SCHEDULE OF MEDI-CAL ANCILLARY COSTS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
TOTAL ANCILLARY
COST
TOTAL ANCILLARY CHARGES
(Adj )
RATIO COST TO CHARGES
CHARGES (From Schedule 6)
MEDI-CAL COST
MEDI-CAL
ANCILLARY COST CENTERS 5000 Operating Room $ 3554239 $ 14309479 0248384 $ 2584884 $ 642043 5100 Recovery Room 0 0 0000000 0 0 5300 Anesthesiology 39629 5867250 0006754 879414 5940 5400 Radiology-Diagnostic 2271078 10793343 0210415 794869 167252 5401 Ultra Sound 643680 5098375 0126252 295897 37358 5600 Radioisotope 382848 1732875 0220932 206257 45569 5700 Computed Tomography (CT) Scan 761998 17089310 0044589 1166436 52010 5800 Magnetic Resonance Imaging (MRI) 22902 144113 0158919 0 0 5900 Cardiac Catheterization 0 0 0000000 0 0 6000 Laboratory 4858864 20925490 0232198 2503211 581241 6001 GI Lab 510896 4588397 0111345 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0000000 0 0 6200 W hole Blood amp Packed Red Blood Cells 3056 451924 0006762 176584 1194 6300 Blood Storing Processing amp Trans 0 0 0000000 0 0 6400 Intravenous Therapy 0 0 0000000 0 0 6500 Respiratory Therapy 1638618 10623110 0154250 2225217 343240 6600 Physical Therapy 777505 1187297 0654853 154359 101082 6700 Occupational Therapy 0 0 0000000 0 0 6800 Speech Pathology 0 0 0000000 0 0 6900 Electrocardiology 421192 9169134 0045936 1956860 89890 7000 Electroencephalography 0 0 0000000 0 0 7100 Medical Supplies Charged to Patients 4248079 9775274 0434574 1732396 752854 7200 Implantable Devices Charged to Patients 729822 5181268 0140858 574210 80882 7300 Drugs Charged to Patients 3010434 30786573 0097784 4573271 447193 7400 Renal Dialysis 333141 1165060 0285943 284460 81339 7500 ASC (Non-Distinct Part) 0 0 0000000 0 0 7501 Other Ancillary (specify) 283 41845 0006754 0 0 7700 0 0 0000000 0 0 7800 0 0 0000000 0 0 7900 0 0 0000000 0 0 8000 0 0 0000000 0 0 8100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0 8700 0 0 0000000 0 0 8701 0 0 0000000 0 0 8800 Rural Health Clinic (RHC) 0 0 0000000 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0000000 0 0 9000 Clinic 0 0 0000000 0 0 9100 Emergency 7660663 48511384 0157915 2345733 370426 9200 Observation Beds 0 0 0000000 0 0 9300 Other Outpatient Services (Specify) 0 0 0000000 0 0 9301 0 0 0000000 0 0 9302 0 0 0000000 0 0 9303 0 0 0000000 0 0 9304 0 0 0000000 0 0 9305 0 0 0000000 0 0
TOTAL $ 31868926 $ 197441501 $ 22454058 $ 3799513 (To Schedule 3)
From Schedule 8 Column 26
STATE OF CALIFORNIA SCHEDULE 6 PROGRAM NONCONTRACT
ADJUSTMENTS TO MEDI-CAL CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
ANCILLARY CHARGES REPORTED ADJUSTMENTS
(Adj 32) AUDITED
5000 Operating Room $ 2372682 $ 212202 $ 2584884 5100 Recovery Room 0 5300 Anesthesiology 812663 66751 879414 5400 Radiology-Diagnostic 744425 50444 794869 5401 Ultra Sound 273774 22123 295897 5600 Radioisotope 201256 5001 206257 5700 Computed Tomography (CT) Scan 1104906 61530 1166436 5800 Magnetic Resonance Imaging (MRI) 0 0 5900 Cardiac Catheterization 0 0 6000 Laboratory 2539230 (36019) 2503211 6001 GI Lab 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 6200 W hole Blood amp Packed Red Blood Cells 168194 8390 176584 6300 Blood Storing Processing amp Trans 0 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1944943 280274 2225217 6600 Physical Therapy 140110 14249 154359 6700 Occupational Therapy 0 0 6800 Speech Pathology 0 0 6900 Electrocardiology 1664507 292353 1956860 7000 Electroencephalography 0 0 7100 Medical Supplies Charged to Patients 1472234 260162 1732396 7200 Implantable Devices Charged to Patients 496326 77884 574210 7300 Drugs Charged to Patients 4193928 379343 4573271 7400 Renal Dialysis 266026 18434 284460 7500 ASC (Non-Distinct Part) 0 0 7501 Other Ancillary (specify) 0 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 2228177 117556 2345733 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
TOTAL MEDI-CAL ANCILLARY CHARGES $ 20623381 $ 1830677 $ 22454058 (To Schedule 5)
STATE OF CALIFORNIA SCHEDULE 7 PROGRAM NONCONTRACT
COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED
PHYSICIANS REMUNERATION
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
PROFESSIONAL SERVICE
COST CENTERS REMUNERATION
HBP
(Adj )
TOTAL CHARGES TO ALL PATIENTS
(Adj )
RATIO OF REMUNERATION
TO CHARGES
MEDI-CAL
(Adj )
CHARGES COST MEDI-CAL
5300 Anesthesiology $ 0 $ 0 0000000 $ $ 0 5400 Radiology - Diagnostic 0 0 0000000 0 5500 Radioisotope 0 0 0000000 0 6000 Laboratory 0 0 0000000 0 6900 Electrocardiology 0 0 0000000 0 7000 Electroencephalography 0 0 0000000 0 9100 Emergency 0 0 0000000 0
0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0
TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 2744664 200 Capital Related Costs-Movable Equipment 2187999 0 300 Other Capital Related Costs 0 0 0 301 0 0 0 0 302 0 0 0 0 0 303 0 0 0 0 0 0 304 0 0 0 0 0 0 0 305 0 0 0 0 0 0 0 0 306 0 0 0 0 0 0 0 0 0 307 0 0 0 0 0 0 0 0 0 0 308 0 0 0 0 0 0 0 0 0 0 0 309 0 0 0 0 0 0 0 0 0 0 0 0 400 Employee Benefits 1058934 84358 67249 0 0 0 0 0 0 0 0 0 501 0 0 0 0 0 0 0 0 0 0 0 0 502 0 0 0 0 0 0 0 0 0 0 0 0 503 0 0 0 0 0 0 0 0 0 0 0 0 504 0 0 0 0 0 0 0 0 0 0 0 0 505 0 0 0 0 0 0 0 0 0 0 0 0 506 0 0 0 0 0 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 0 0 0 500 Administrative and General 10629665 247119 196999 0 0 0 0 0 0 0 0 0 600 Maintenance and Repairs 565321 88028 70174 0 0 0 0 0 0 0 0 0 700 Operation of Plant 2017048 317029 252730 0 0 0 0 0 0 0 0 0 800 Laundry and Linen Service 263543 28979 23102 0 0 0 0 0 0 0 0 0 900 Housekeeping 755766 13085 10431 0 0 0 0 0 0 0 0 0
1000 Dietary 807098 83603 66647 0 0 0 0 0 0 0 0 0 1100 Cafeteria 159362 24177 19274 0 0 0 0 0 0 0 0 0 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 1482354 17467 13924 0 0 0 0 0 0 0 0 0 1400 Central Services and Supply 305730 124660 99377 0 0 0 0 0 0 0 0 0 1500 Pharmacy 1132927 24932 19875 0 0 0 0 0 0 0 0 0 1600 Medical Records amp Library 1178942 32900 26228 0 0 0 0 0 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 193276 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9131110 741734 591297 0 0 0 0 0 0 0 0 0
3100 Intensive Care Unit 2477587 130112 103723 0 0 0 0 0 0 0 0 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
ANCILLARY COST CENTERS 5000 Operating Room 1636558 166158 132458 0 0 0 0 0 0 0 0 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 1301021 99078 78983 0 0 0 0 0 0 0 0 0 5401 Ultra Sound 454209 3711 2959 0 0 0 0 0 0 0 0 0 5600 Radioisotope 206030 19816 15797 0 0 0 0 0 0 0 0 0 5700 Computed Tomography (CT) Scan 458725 10002 7974 0 0 0 0 0 0 0 0 0 5800 Magnetic Resonance Imaging (MRI) 16908 0 0 0 0 0 0 0 0 0 0 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 3398341 64417 51352 0 0 0 0 0 0 0 0 0 6001 GI Lab 292049 14678 11701 0 0 0 0 0 0 0 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 3 0 0 0 0 0 0 0 0 0 0 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 1123538 24030 19157 0 0 0 0 0 0 0 0 0 6600 Physical Therapy 241010 97338 77596 0 0 0 0 0 0 0 0 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 266558 2936 2340 0 0 0 0 0 0 0 0 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 2563528 0 0 0 0 0 0 0 0 0 0 0 7200 Implantable Devices Charged to Patients 558092 0 0 0 0 0 0 0 0 0 0 0 7300 Drugs Charged to Patients 972254 0 0 0 0 0 0 0 0 0 0 0 7400 Renal Dialysis 260774 126 100 0 0 0 0 0 0 0 0 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 4126916 138542 110443 0 0 0 0 0 0 0 0 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 5683 4530 0 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 137766 109825 0 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 512225 2202 1755 0 0 0 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 57057440 2744664 2187999 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 0 501 0 0 502 0 0 0 503 0 0 0 0 504 0 0 0 0 0 505 0 0 0 0 0 0 506 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 500 Administrative and General 0 154558 0 0 0 0 0 0 0 0 11228341 600 Maintenance and Repairs 0 0 0 0 0 0 0 0 0 0 723523 177266 700 Operation of Plant 0 22951 0 0 0 0 0 0 0 0 2609759 639403 800 Laundry and Linen Service 0 634 0 0 0 0 0 0 0 0 316257 77484 900 Housekeeping 0 17935 0 0 0 0 0 0 0 0 797216 195322
1000 Dietary 0 12138 0 0 0 0 0 0 0 0 969486 237529 1100 Cafeteria 0 3630 0 0 0 0 0 0 0 0 206442 50579 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 0 51300 0 0 0 0 0 0 0 0 1565046 383443 1400 Central Services and Supply 0 4664 0 0 0 0 0 0 0 0 534431 130938 1500 Pharmacy 0 40906 0 0 0 0 0 0 0 0 1218641 298573 1600 Medical Records amp Library 0 27157 0 0 0 0 0 0 0 0 1265227 309986 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 49131 0 0 0 0 0 0 0 0 1626506 398501 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 193276 47354 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 316959 0 0 0 0 0 0 0 0 10781100 2641419
3100 Intensive Care Unit 0 83801 0 0 0 0 0 0 0 0 2795223 684843 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
ANCILLARY COST CENTERS 5000 Operating Room 0 57734 0 0 0 0 0 0 0 0 1992908 488272 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 0 35520 0 0 0 0 0 0 0 0 1514602 371085 5401 Ultra Sound 0 16650 0 0 0 0 0 0 0 0 477530 116997 5600 Radioisotope 0 4554 0 0 0 0 0 0 0 0 246197 60319 5700 Computed Tomography (CT) Scan 0 17260 0 0 0 0 0 0 0 0 493961 121023 5800 Magnetic Resonance Imaging (MRI) 0 562 0 0 0 0 0 0 0 0 17470 4280 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 104001 0 0 0 0 0 0 0 0 3618110 886454 6001 GI Lab 0 10400 0 0 0 0 0 0 0 0 328829 80565 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3 1 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 33287 0 0 0 0 0 0 0 0 1200012 294009 6600 Physical Therapy 0 0 0 0 0 0 0 0 0 0 415944 101908 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 7758 0 0 0 0 0 0 0 0 279591 68501 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 2563528 628076 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 558092 136735 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 972254 238207 7400 Renal Dialysis 0 0 0 0 0 0 0 0 0 0 261000 63946 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 136296 0 0 0 0 0 0 0 0 4512197 1105509 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 0 0 10213 2502 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 0 0 247590 60661 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 755 0 0 0 0 0 0 0 0 516937 126652 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 1210541 0 0 0 0 0 0 0 0 57057440 11228341
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 122820 800 Laundry and Linen Service 11227 48661 900 Housekeeping 5069 21971 0
1000 Dietary 32389 140383 0 43356 1100 Cafeteria 9366 40597 0 12538 0 1200 Maintenance of Personnel 0 0 0 0 0 0 1300 Nursing Administration 6767 29330 0 9058 0 32774 0 1400 Central Services and Supply 48295 209325 0 64647 0 2815 0 0 1500 Pharmacy 9659 41865 0 12929 0 10368 0 0 0 1600 Medical Records amp Library 12746 55245 0 17062 0 13812 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 287355 1245493 194159 384654 1279497 101907 0 1122397 0 0 282741 0
3100 Intensive Care Unit 50407 218480 44463 67475 122109 22988 0 230707 0 0 57778 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
ANCILLARY COST CENTERS 5000 Operating Room 64371 279006 26097 86167 289 16495 0 179089 0 0 96649 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 39629 0 5400 Radiology-Diagnostic 38384 166369 32393 51381 0 12357 0 11607 0 0 72900 0 5401 Ultra Sound 1438 6232 0 1925 0 5123 0 0 0 0 34435 0 5600 Radioisotope 7677 33274 1304 10276 0 1680 0 10418 0 0 11704 0 5700 Computed Tomography (CT) Scan 3875 16795 0 5187 0 5733 0 0 0 0 115424 0 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 178 0 0 0 0 973 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 24956 108166 597 33406 0 35158 0 10684 0 0 141335 0 6001 GI Lab 5686 24647 1652 7612 0 3106 0 27809 0 0 30991 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3052 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 9310 40351 0 12462 0 10725 0 0 0 0 71751 0 6600 Physical Therapy 37710 163446 0 50478 0 0 0 0 0 0 8019 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 1137 4929 709 1522 0 2871 0 0 0 0 61930 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 990451 0 66024 0 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 34995 0 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 1592035 207938 0 7400 Renal Dialysis 49 211 0 65 0 0 0 0 0 0 7869 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 283 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 53672 232634 152254 71846 21247 41134 0 433708 0 0 327655 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA SCHEDULE 5 PROGRAM NONCONTRACT
SCHEDULE OF MEDI-CAL ANCILLARY COSTS
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
TOTAL ANCILLARY
COST
TOTAL ANCILLARY CHARGES
(Adj )
RATIO COST TO CHARGES
CHARGES (From Schedule 6)
MEDI-CAL COST
MEDI-CAL
ANCILLARY COST CENTERS 5000 Operating Room $ 3554239 $ 14309479 0248384 $ 2584884 $ 642043 5100 Recovery Room 0 0 0000000 0 0 5300 Anesthesiology 39629 5867250 0006754 879414 5940 5400 Radiology-Diagnostic 2271078 10793343 0210415 794869 167252 5401 Ultra Sound 643680 5098375 0126252 295897 37358 5600 Radioisotope 382848 1732875 0220932 206257 45569 5700 Computed Tomography (CT) Scan 761998 17089310 0044589 1166436 52010 5800 Magnetic Resonance Imaging (MRI) 22902 144113 0158919 0 0 5900 Cardiac Catheterization 0 0 0000000 0 0 6000 Laboratory 4858864 20925490 0232198 2503211 581241 6001 GI Lab 510896 4588397 0111345 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0000000 0 0 6200 W hole Blood amp Packed Red Blood Cells 3056 451924 0006762 176584 1194 6300 Blood Storing Processing amp Trans 0 0 0000000 0 0 6400 Intravenous Therapy 0 0 0000000 0 0 6500 Respiratory Therapy 1638618 10623110 0154250 2225217 343240 6600 Physical Therapy 777505 1187297 0654853 154359 101082 6700 Occupational Therapy 0 0 0000000 0 0 6800 Speech Pathology 0 0 0000000 0 0 6900 Electrocardiology 421192 9169134 0045936 1956860 89890 7000 Electroencephalography 0 0 0000000 0 0 7100 Medical Supplies Charged to Patients 4248079 9775274 0434574 1732396 752854 7200 Implantable Devices Charged to Patients 729822 5181268 0140858 574210 80882 7300 Drugs Charged to Patients 3010434 30786573 0097784 4573271 447193 7400 Renal Dialysis 333141 1165060 0285943 284460 81339 7500 ASC (Non-Distinct Part) 0 0 0000000 0 0 7501 Other Ancillary (specify) 283 41845 0006754 0 0 7700 0 0 0000000 0 0 7800 0 0 0000000 0 0 7900 0 0 0000000 0 0 8000 0 0 0000000 0 0 8100 0 0 0000000 0 0 8200 0 0 0000000 0 0 8300 0 0 0000000 0 0 8400 0 0 0000000 0 0 8500 0 0 0000000 0 0 8600 0 0 0000000 0 0 8700 0 0 0000000 0 0 8701 0 0 0000000 0 0 8800 Rural Health Clinic (RHC) 0 0 0000000 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0000000 0 0 9000 Clinic 0 0 0000000 0 0 9100 Emergency 7660663 48511384 0157915 2345733 370426 9200 Observation Beds 0 0 0000000 0 0 9300 Other Outpatient Services (Specify) 0 0 0000000 0 0 9301 0 0 0000000 0 0 9302 0 0 0000000 0 0 9303 0 0 0000000 0 0 9304 0 0 0000000 0 0 9305 0 0 0000000 0 0
TOTAL $ 31868926 $ 197441501 $ 22454058 $ 3799513 (To Schedule 3)
From Schedule 8 Column 26
STATE OF CALIFORNIA SCHEDULE 6 PROGRAM NONCONTRACT
ADJUSTMENTS TO MEDI-CAL CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
ANCILLARY CHARGES REPORTED ADJUSTMENTS
(Adj 32) AUDITED
5000 Operating Room $ 2372682 $ 212202 $ 2584884 5100 Recovery Room 0 5300 Anesthesiology 812663 66751 879414 5400 Radiology-Diagnostic 744425 50444 794869 5401 Ultra Sound 273774 22123 295897 5600 Radioisotope 201256 5001 206257 5700 Computed Tomography (CT) Scan 1104906 61530 1166436 5800 Magnetic Resonance Imaging (MRI) 0 0 5900 Cardiac Catheterization 0 0 6000 Laboratory 2539230 (36019) 2503211 6001 GI Lab 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 6200 W hole Blood amp Packed Red Blood Cells 168194 8390 176584 6300 Blood Storing Processing amp Trans 0 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1944943 280274 2225217 6600 Physical Therapy 140110 14249 154359 6700 Occupational Therapy 0 0 6800 Speech Pathology 0 0 6900 Electrocardiology 1664507 292353 1956860 7000 Electroencephalography 0 0 7100 Medical Supplies Charged to Patients 1472234 260162 1732396 7200 Implantable Devices Charged to Patients 496326 77884 574210 7300 Drugs Charged to Patients 4193928 379343 4573271 7400 Renal Dialysis 266026 18434 284460 7500 ASC (Non-Distinct Part) 0 0 7501 Other Ancillary (specify) 0 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 2228177 117556 2345733 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
TOTAL MEDI-CAL ANCILLARY CHARGES $ 20623381 $ 1830677 $ 22454058 (To Schedule 5)
STATE OF CALIFORNIA SCHEDULE 7 PROGRAM NONCONTRACT
COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED
PHYSICIANS REMUNERATION
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
PROFESSIONAL SERVICE
COST CENTERS REMUNERATION
HBP
(Adj )
TOTAL CHARGES TO ALL PATIENTS
(Adj )
RATIO OF REMUNERATION
TO CHARGES
MEDI-CAL
(Adj )
CHARGES COST MEDI-CAL
5300 Anesthesiology $ 0 $ 0 0000000 $ $ 0 5400 Radiology - Diagnostic 0 0 0000000 0 5500 Radioisotope 0 0 0000000 0 6000 Laboratory 0 0 0000000 0 6900 Electrocardiology 0 0 0000000 0 7000 Electroencephalography 0 0 0000000 0 9100 Emergency 0 0 0000000 0
0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0
TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 2744664 200 Capital Related Costs-Movable Equipment 2187999 0 300 Other Capital Related Costs 0 0 0 301 0 0 0 0 302 0 0 0 0 0 303 0 0 0 0 0 0 304 0 0 0 0 0 0 0 305 0 0 0 0 0 0 0 0 306 0 0 0 0 0 0 0 0 0 307 0 0 0 0 0 0 0 0 0 0 308 0 0 0 0 0 0 0 0 0 0 0 309 0 0 0 0 0 0 0 0 0 0 0 0 400 Employee Benefits 1058934 84358 67249 0 0 0 0 0 0 0 0 0 501 0 0 0 0 0 0 0 0 0 0 0 0 502 0 0 0 0 0 0 0 0 0 0 0 0 503 0 0 0 0 0 0 0 0 0 0 0 0 504 0 0 0 0 0 0 0 0 0 0 0 0 505 0 0 0 0 0 0 0 0 0 0 0 0 506 0 0 0 0 0 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 0 0 0 500 Administrative and General 10629665 247119 196999 0 0 0 0 0 0 0 0 0 600 Maintenance and Repairs 565321 88028 70174 0 0 0 0 0 0 0 0 0 700 Operation of Plant 2017048 317029 252730 0 0 0 0 0 0 0 0 0 800 Laundry and Linen Service 263543 28979 23102 0 0 0 0 0 0 0 0 0 900 Housekeeping 755766 13085 10431 0 0 0 0 0 0 0 0 0
1000 Dietary 807098 83603 66647 0 0 0 0 0 0 0 0 0 1100 Cafeteria 159362 24177 19274 0 0 0 0 0 0 0 0 0 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 1482354 17467 13924 0 0 0 0 0 0 0 0 0 1400 Central Services and Supply 305730 124660 99377 0 0 0 0 0 0 0 0 0 1500 Pharmacy 1132927 24932 19875 0 0 0 0 0 0 0 0 0 1600 Medical Records amp Library 1178942 32900 26228 0 0 0 0 0 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 193276 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9131110 741734 591297 0 0 0 0 0 0 0 0 0
3100 Intensive Care Unit 2477587 130112 103723 0 0 0 0 0 0 0 0 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
ANCILLARY COST CENTERS 5000 Operating Room 1636558 166158 132458 0 0 0 0 0 0 0 0 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 1301021 99078 78983 0 0 0 0 0 0 0 0 0 5401 Ultra Sound 454209 3711 2959 0 0 0 0 0 0 0 0 0 5600 Radioisotope 206030 19816 15797 0 0 0 0 0 0 0 0 0 5700 Computed Tomography (CT) Scan 458725 10002 7974 0 0 0 0 0 0 0 0 0 5800 Magnetic Resonance Imaging (MRI) 16908 0 0 0 0 0 0 0 0 0 0 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 3398341 64417 51352 0 0 0 0 0 0 0 0 0 6001 GI Lab 292049 14678 11701 0 0 0 0 0 0 0 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 3 0 0 0 0 0 0 0 0 0 0 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 1123538 24030 19157 0 0 0 0 0 0 0 0 0 6600 Physical Therapy 241010 97338 77596 0 0 0 0 0 0 0 0 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 266558 2936 2340 0 0 0 0 0 0 0 0 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 2563528 0 0 0 0 0 0 0 0 0 0 0 7200 Implantable Devices Charged to Patients 558092 0 0 0 0 0 0 0 0 0 0 0 7300 Drugs Charged to Patients 972254 0 0 0 0 0 0 0 0 0 0 0 7400 Renal Dialysis 260774 126 100 0 0 0 0 0 0 0 0 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 4126916 138542 110443 0 0 0 0 0 0 0 0 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 5683 4530 0 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 137766 109825 0 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 512225 2202 1755 0 0 0 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 57057440 2744664 2187999 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 0 501 0 0 502 0 0 0 503 0 0 0 0 504 0 0 0 0 0 505 0 0 0 0 0 0 506 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 500 Administrative and General 0 154558 0 0 0 0 0 0 0 0 11228341 600 Maintenance and Repairs 0 0 0 0 0 0 0 0 0 0 723523 177266 700 Operation of Plant 0 22951 0 0 0 0 0 0 0 0 2609759 639403 800 Laundry and Linen Service 0 634 0 0 0 0 0 0 0 0 316257 77484 900 Housekeeping 0 17935 0 0 0 0 0 0 0 0 797216 195322
1000 Dietary 0 12138 0 0 0 0 0 0 0 0 969486 237529 1100 Cafeteria 0 3630 0 0 0 0 0 0 0 0 206442 50579 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 0 51300 0 0 0 0 0 0 0 0 1565046 383443 1400 Central Services and Supply 0 4664 0 0 0 0 0 0 0 0 534431 130938 1500 Pharmacy 0 40906 0 0 0 0 0 0 0 0 1218641 298573 1600 Medical Records amp Library 0 27157 0 0 0 0 0 0 0 0 1265227 309986 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 49131 0 0 0 0 0 0 0 0 1626506 398501 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 193276 47354 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 316959 0 0 0 0 0 0 0 0 10781100 2641419
3100 Intensive Care Unit 0 83801 0 0 0 0 0 0 0 0 2795223 684843 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
ANCILLARY COST CENTERS 5000 Operating Room 0 57734 0 0 0 0 0 0 0 0 1992908 488272 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 0 35520 0 0 0 0 0 0 0 0 1514602 371085 5401 Ultra Sound 0 16650 0 0 0 0 0 0 0 0 477530 116997 5600 Radioisotope 0 4554 0 0 0 0 0 0 0 0 246197 60319 5700 Computed Tomography (CT) Scan 0 17260 0 0 0 0 0 0 0 0 493961 121023 5800 Magnetic Resonance Imaging (MRI) 0 562 0 0 0 0 0 0 0 0 17470 4280 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 104001 0 0 0 0 0 0 0 0 3618110 886454 6001 GI Lab 0 10400 0 0 0 0 0 0 0 0 328829 80565 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3 1 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 33287 0 0 0 0 0 0 0 0 1200012 294009 6600 Physical Therapy 0 0 0 0 0 0 0 0 0 0 415944 101908 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 7758 0 0 0 0 0 0 0 0 279591 68501 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 2563528 628076 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 558092 136735 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 972254 238207 7400 Renal Dialysis 0 0 0 0 0 0 0 0 0 0 261000 63946 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 136296 0 0 0 0 0 0 0 0 4512197 1105509 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 0 0 10213 2502 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 0 0 247590 60661 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 755 0 0 0 0 0 0 0 0 516937 126652 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 1210541 0 0 0 0 0 0 0 0 57057440 11228341
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 122820 800 Laundry and Linen Service 11227 48661 900 Housekeeping 5069 21971 0
1000 Dietary 32389 140383 0 43356 1100 Cafeteria 9366 40597 0 12538 0 1200 Maintenance of Personnel 0 0 0 0 0 0 1300 Nursing Administration 6767 29330 0 9058 0 32774 0 1400 Central Services and Supply 48295 209325 0 64647 0 2815 0 0 1500 Pharmacy 9659 41865 0 12929 0 10368 0 0 0 1600 Medical Records amp Library 12746 55245 0 17062 0 13812 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 287355 1245493 194159 384654 1279497 101907 0 1122397 0 0 282741 0
3100 Intensive Care Unit 50407 218480 44463 67475 122109 22988 0 230707 0 0 57778 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
ANCILLARY COST CENTERS 5000 Operating Room 64371 279006 26097 86167 289 16495 0 179089 0 0 96649 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 39629 0 5400 Radiology-Diagnostic 38384 166369 32393 51381 0 12357 0 11607 0 0 72900 0 5401 Ultra Sound 1438 6232 0 1925 0 5123 0 0 0 0 34435 0 5600 Radioisotope 7677 33274 1304 10276 0 1680 0 10418 0 0 11704 0 5700 Computed Tomography (CT) Scan 3875 16795 0 5187 0 5733 0 0 0 0 115424 0 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 178 0 0 0 0 973 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 24956 108166 597 33406 0 35158 0 10684 0 0 141335 0 6001 GI Lab 5686 24647 1652 7612 0 3106 0 27809 0 0 30991 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3052 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 9310 40351 0 12462 0 10725 0 0 0 0 71751 0 6600 Physical Therapy 37710 163446 0 50478 0 0 0 0 0 0 8019 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 1137 4929 709 1522 0 2871 0 0 0 0 61930 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 990451 0 66024 0 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 34995 0 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 1592035 207938 0 7400 Renal Dialysis 49 211 0 65 0 0 0 0 0 0 7869 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 283 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 53672 232634 152254 71846 21247 41134 0 433708 0 0 327655 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA SCHEDULE 6 PROGRAM NONCONTRACT
ADJUSTMENTS TO MEDI-CAL CHARGES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
ANCILLARY CHARGES REPORTED ADJUSTMENTS
(Adj 32) AUDITED
5000 Operating Room $ 2372682 $ 212202 $ 2584884 5100 Recovery Room 0 5300 Anesthesiology 812663 66751 879414 5400 Radiology-Diagnostic 744425 50444 794869 5401 Ultra Sound 273774 22123 295897 5600 Radioisotope 201256 5001 206257 5700 Computed Tomography (CT) Scan 1104906 61530 1166436 5800 Magnetic Resonance Imaging (MRI) 0 0 5900 Cardiac Catheterization 0 0 6000 Laboratory 2539230 (36019) 2503211 6001 GI Lab 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 6200 W hole Blood amp Packed Red Blood Cells 168194 8390 176584 6300 Blood Storing Processing amp Trans 0 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1944943 280274 2225217 6600 Physical Therapy 140110 14249 154359 6700 Occupational Therapy 0 0 6800 Speech Pathology 0 0 6900 Electrocardiology 1664507 292353 1956860 7000 Electroencephalography 0 0 7100 Medical Supplies Charged to Patients 1472234 260162 1732396 7200 Implantable Devices Charged to Patients 496326 77884 574210 7300 Drugs Charged to Patients 4193928 379343 4573271 7400 Renal Dialysis 266026 18434 284460 7500 ASC (Non-Distinct Part) 0 0 7501 Other Ancillary (specify) 0 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 2228177 117556 2345733 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
TOTAL MEDI-CAL ANCILLARY CHARGES $ 20623381 $ 1830677 $ 22454058 (To Schedule 5)
STATE OF CALIFORNIA SCHEDULE 7 PROGRAM NONCONTRACT
COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED
PHYSICIANS REMUNERATION
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
PROFESSIONAL SERVICE
COST CENTERS REMUNERATION
HBP
(Adj )
TOTAL CHARGES TO ALL PATIENTS
(Adj )
RATIO OF REMUNERATION
TO CHARGES
MEDI-CAL
(Adj )
CHARGES COST MEDI-CAL
5300 Anesthesiology $ 0 $ 0 0000000 $ $ 0 5400 Radiology - Diagnostic 0 0 0000000 0 5500 Radioisotope 0 0 0000000 0 6000 Laboratory 0 0 0000000 0 6900 Electrocardiology 0 0 0000000 0 7000 Electroencephalography 0 0 0000000 0 9100 Emergency 0 0 0000000 0
0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0
TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 2744664 200 Capital Related Costs-Movable Equipment 2187999 0 300 Other Capital Related Costs 0 0 0 301 0 0 0 0 302 0 0 0 0 0 303 0 0 0 0 0 0 304 0 0 0 0 0 0 0 305 0 0 0 0 0 0 0 0 306 0 0 0 0 0 0 0 0 0 307 0 0 0 0 0 0 0 0 0 0 308 0 0 0 0 0 0 0 0 0 0 0 309 0 0 0 0 0 0 0 0 0 0 0 0 400 Employee Benefits 1058934 84358 67249 0 0 0 0 0 0 0 0 0 501 0 0 0 0 0 0 0 0 0 0 0 0 502 0 0 0 0 0 0 0 0 0 0 0 0 503 0 0 0 0 0 0 0 0 0 0 0 0 504 0 0 0 0 0 0 0 0 0 0 0 0 505 0 0 0 0 0 0 0 0 0 0 0 0 506 0 0 0 0 0 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 0 0 0 500 Administrative and General 10629665 247119 196999 0 0 0 0 0 0 0 0 0 600 Maintenance and Repairs 565321 88028 70174 0 0 0 0 0 0 0 0 0 700 Operation of Plant 2017048 317029 252730 0 0 0 0 0 0 0 0 0 800 Laundry and Linen Service 263543 28979 23102 0 0 0 0 0 0 0 0 0 900 Housekeeping 755766 13085 10431 0 0 0 0 0 0 0 0 0
1000 Dietary 807098 83603 66647 0 0 0 0 0 0 0 0 0 1100 Cafeteria 159362 24177 19274 0 0 0 0 0 0 0 0 0 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 1482354 17467 13924 0 0 0 0 0 0 0 0 0 1400 Central Services and Supply 305730 124660 99377 0 0 0 0 0 0 0 0 0 1500 Pharmacy 1132927 24932 19875 0 0 0 0 0 0 0 0 0 1600 Medical Records amp Library 1178942 32900 26228 0 0 0 0 0 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 193276 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9131110 741734 591297 0 0 0 0 0 0 0 0 0
3100 Intensive Care Unit 2477587 130112 103723 0 0 0 0 0 0 0 0 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
ANCILLARY COST CENTERS 5000 Operating Room 1636558 166158 132458 0 0 0 0 0 0 0 0 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 1301021 99078 78983 0 0 0 0 0 0 0 0 0 5401 Ultra Sound 454209 3711 2959 0 0 0 0 0 0 0 0 0 5600 Radioisotope 206030 19816 15797 0 0 0 0 0 0 0 0 0 5700 Computed Tomography (CT) Scan 458725 10002 7974 0 0 0 0 0 0 0 0 0 5800 Magnetic Resonance Imaging (MRI) 16908 0 0 0 0 0 0 0 0 0 0 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 3398341 64417 51352 0 0 0 0 0 0 0 0 0 6001 GI Lab 292049 14678 11701 0 0 0 0 0 0 0 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 3 0 0 0 0 0 0 0 0 0 0 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 1123538 24030 19157 0 0 0 0 0 0 0 0 0 6600 Physical Therapy 241010 97338 77596 0 0 0 0 0 0 0 0 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 266558 2936 2340 0 0 0 0 0 0 0 0 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 2563528 0 0 0 0 0 0 0 0 0 0 0 7200 Implantable Devices Charged to Patients 558092 0 0 0 0 0 0 0 0 0 0 0 7300 Drugs Charged to Patients 972254 0 0 0 0 0 0 0 0 0 0 0 7400 Renal Dialysis 260774 126 100 0 0 0 0 0 0 0 0 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 4126916 138542 110443 0 0 0 0 0 0 0 0 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 5683 4530 0 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 137766 109825 0 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 512225 2202 1755 0 0 0 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 57057440 2744664 2187999 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 0 501 0 0 502 0 0 0 503 0 0 0 0 504 0 0 0 0 0 505 0 0 0 0 0 0 506 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 500 Administrative and General 0 154558 0 0 0 0 0 0 0 0 11228341 600 Maintenance and Repairs 0 0 0 0 0 0 0 0 0 0 723523 177266 700 Operation of Plant 0 22951 0 0 0 0 0 0 0 0 2609759 639403 800 Laundry and Linen Service 0 634 0 0 0 0 0 0 0 0 316257 77484 900 Housekeeping 0 17935 0 0 0 0 0 0 0 0 797216 195322
1000 Dietary 0 12138 0 0 0 0 0 0 0 0 969486 237529 1100 Cafeteria 0 3630 0 0 0 0 0 0 0 0 206442 50579 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 0 51300 0 0 0 0 0 0 0 0 1565046 383443 1400 Central Services and Supply 0 4664 0 0 0 0 0 0 0 0 534431 130938 1500 Pharmacy 0 40906 0 0 0 0 0 0 0 0 1218641 298573 1600 Medical Records amp Library 0 27157 0 0 0 0 0 0 0 0 1265227 309986 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 49131 0 0 0 0 0 0 0 0 1626506 398501 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 193276 47354 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 316959 0 0 0 0 0 0 0 0 10781100 2641419
3100 Intensive Care Unit 0 83801 0 0 0 0 0 0 0 0 2795223 684843 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
ANCILLARY COST CENTERS 5000 Operating Room 0 57734 0 0 0 0 0 0 0 0 1992908 488272 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 0 35520 0 0 0 0 0 0 0 0 1514602 371085 5401 Ultra Sound 0 16650 0 0 0 0 0 0 0 0 477530 116997 5600 Radioisotope 0 4554 0 0 0 0 0 0 0 0 246197 60319 5700 Computed Tomography (CT) Scan 0 17260 0 0 0 0 0 0 0 0 493961 121023 5800 Magnetic Resonance Imaging (MRI) 0 562 0 0 0 0 0 0 0 0 17470 4280 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 104001 0 0 0 0 0 0 0 0 3618110 886454 6001 GI Lab 0 10400 0 0 0 0 0 0 0 0 328829 80565 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3 1 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 33287 0 0 0 0 0 0 0 0 1200012 294009 6600 Physical Therapy 0 0 0 0 0 0 0 0 0 0 415944 101908 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 7758 0 0 0 0 0 0 0 0 279591 68501 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 2563528 628076 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 558092 136735 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 972254 238207 7400 Renal Dialysis 0 0 0 0 0 0 0 0 0 0 261000 63946 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 136296 0 0 0 0 0 0 0 0 4512197 1105509 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 0 0 10213 2502 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 0 0 247590 60661 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 755 0 0 0 0 0 0 0 0 516937 126652 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 1210541 0 0 0 0 0 0 0 0 57057440 11228341
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 122820 800 Laundry and Linen Service 11227 48661 900 Housekeeping 5069 21971 0
1000 Dietary 32389 140383 0 43356 1100 Cafeteria 9366 40597 0 12538 0 1200 Maintenance of Personnel 0 0 0 0 0 0 1300 Nursing Administration 6767 29330 0 9058 0 32774 0 1400 Central Services and Supply 48295 209325 0 64647 0 2815 0 0 1500 Pharmacy 9659 41865 0 12929 0 10368 0 0 0 1600 Medical Records amp Library 12746 55245 0 17062 0 13812 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 287355 1245493 194159 384654 1279497 101907 0 1122397 0 0 282741 0
3100 Intensive Care Unit 50407 218480 44463 67475 122109 22988 0 230707 0 0 57778 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
ANCILLARY COST CENTERS 5000 Operating Room 64371 279006 26097 86167 289 16495 0 179089 0 0 96649 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 39629 0 5400 Radiology-Diagnostic 38384 166369 32393 51381 0 12357 0 11607 0 0 72900 0 5401 Ultra Sound 1438 6232 0 1925 0 5123 0 0 0 0 34435 0 5600 Radioisotope 7677 33274 1304 10276 0 1680 0 10418 0 0 11704 0 5700 Computed Tomography (CT) Scan 3875 16795 0 5187 0 5733 0 0 0 0 115424 0 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 178 0 0 0 0 973 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 24956 108166 597 33406 0 35158 0 10684 0 0 141335 0 6001 GI Lab 5686 24647 1652 7612 0 3106 0 27809 0 0 30991 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3052 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 9310 40351 0 12462 0 10725 0 0 0 0 71751 0 6600 Physical Therapy 37710 163446 0 50478 0 0 0 0 0 0 8019 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 1137 4929 709 1522 0 2871 0 0 0 0 61930 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 990451 0 66024 0 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 34995 0 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 1592035 207938 0 7400 Renal Dialysis 49 211 0 65 0 0 0 0 0 0 7869 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 283 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 53672 232634 152254 71846 21247 41134 0 433708 0 0 327655 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA SCHEDULE 7 PROGRAM NONCONTRACT
COMPUTATION OF PROFESSIONAL COMPONENT OF HOSPITAL BASED
PHYSICIANS REMUNERATION
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
Provider NPI 1962407460
PROFESSIONAL SERVICE
COST CENTERS REMUNERATION
HBP
(Adj )
TOTAL CHARGES TO ALL PATIENTS
(Adj )
RATIO OF REMUNERATION
TO CHARGES
MEDI-CAL
(Adj )
CHARGES COST MEDI-CAL
5300 Anesthesiology $ 0 $ 0 0000000 $ $ 0 5400 Radiology - Diagnostic 0 0 0000000 0 5500 Radioisotope 0 0 0000000 0 6000 Laboratory 0 0 0000000 0 6900 Electrocardiology 0 0 0000000 0 7000 Electroencephalography 0 0 0000000 0 9100 Emergency 0 0 0000000 0
0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0 0 0 0000000 0
TOTAL $ 0 $ 0 $ 0 $ 0 (To Schedule 3)
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 2744664 200 Capital Related Costs-Movable Equipment 2187999 0 300 Other Capital Related Costs 0 0 0 301 0 0 0 0 302 0 0 0 0 0 303 0 0 0 0 0 0 304 0 0 0 0 0 0 0 305 0 0 0 0 0 0 0 0 306 0 0 0 0 0 0 0 0 0 307 0 0 0 0 0 0 0 0 0 0 308 0 0 0 0 0 0 0 0 0 0 0 309 0 0 0 0 0 0 0 0 0 0 0 0 400 Employee Benefits 1058934 84358 67249 0 0 0 0 0 0 0 0 0 501 0 0 0 0 0 0 0 0 0 0 0 0 502 0 0 0 0 0 0 0 0 0 0 0 0 503 0 0 0 0 0 0 0 0 0 0 0 0 504 0 0 0 0 0 0 0 0 0 0 0 0 505 0 0 0 0 0 0 0 0 0 0 0 0 506 0 0 0 0 0 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 0 0 0 500 Administrative and General 10629665 247119 196999 0 0 0 0 0 0 0 0 0 600 Maintenance and Repairs 565321 88028 70174 0 0 0 0 0 0 0 0 0 700 Operation of Plant 2017048 317029 252730 0 0 0 0 0 0 0 0 0 800 Laundry and Linen Service 263543 28979 23102 0 0 0 0 0 0 0 0 0 900 Housekeeping 755766 13085 10431 0 0 0 0 0 0 0 0 0
1000 Dietary 807098 83603 66647 0 0 0 0 0 0 0 0 0 1100 Cafeteria 159362 24177 19274 0 0 0 0 0 0 0 0 0 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 1482354 17467 13924 0 0 0 0 0 0 0 0 0 1400 Central Services and Supply 305730 124660 99377 0 0 0 0 0 0 0 0 0 1500 Pharmacy 1132927 24932 19875 0 0 0 0 0 0 0 0 0 1600 Medical Records amp Library 1178942 32900 26228 0 0 0 0 0 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 193276 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9131110 741734 591297 0 0 0 0 0 0 0 0 0
3100 Intensive Care Unit 2477587 130112 103723 0 0 0 0 0 0 0 0 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
ANCILLARY COST CENTERS 5000 Operating Room 1636558 166158 132458 0 0 0 0 0 0 0 0 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 1301021 99078 78983 0 0 0 0 0 0 0 0 0 5401 Ultra Sound 454209 3711 2959 0 0 0 0 0 0 0 0 0 5600 Radioisotope 206030 19816 15797 0 0 0 0 0 0 0 0 0 5700 Computed Tomography (CT) Scan 458725 10002 7974 0 0 0 0 0 0 0 0 0 5800 Magnetic Resonance Imaging (MRI) 16908 0 0 0 0 0 0 0 0 0 0 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 3398341 64417 51352 0 0 0 0 0 0 0 0 0 6001 GI Lab 292049 14678 11701 0 0 0 0 0 0 0 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 3 0 0 0 0 0 0 0 0 0 0 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 1123538 24030 19157 0 0 0 0 0 0 0 0 0 6600 Physical Therapy 241010 97338 77596 0 0 0 0 0 0 0 0 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 266558 2936 2340 0 0 0 0 0 0 0 0 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 2563528 0 0 0 0 0 0 0 0 0 0 0 7200 Implantable Devices Charged to Patients 558092 0 0 0 0 0 0 0 0 0 0 0 7300 Drugs Charged to Patients 972254 0 0 0 0 0 0 0 0 0 0 0 7400 Renal Dialysis 260774 126 100 0 0 0 0 0 0 0 0 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 4126916 138542 110443 0 0 0 0 0 0 0 0 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 5683 4530 0 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 137766 109825 0 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 512225 2202 1755 0 0 0 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 57057440 2744664 2187999 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 0 501 0 0 502 0 0 0 503 0 0 0 0 504 0 0 0 0 0 505 0 0 0 0 0 0 506 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 500 Administrative and General 0 154558 0 0 0 0 0 0 0 0 11228341 600 Maintenance and Repairs 0 0 0 0 0 0 0 0 0 0 723523 177266 700 Operation of Plant 0 22951 0 0 0 0 0 0 0 0 2609759 639403 800 Laundry and Linen Service 0 634 0 0 0 0 0 0 0 0 316257 77484 900 Housekeeping 0 17935 0 0 0 0 0 0 0 0 797216 195322
1000 Dietary 0 12138 0 0 0 0 0 0 0 0 969486 237529 1100 Cafeteria 0 3630 0 0 0 0 0 0 0 0 206442 50579 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 0 51300 0 0 0 0 0 0 0 0 1565046 383443 1400 Central Services and Supply 0 4664 0 0 0 0 0 0 0 0 534431 130938 1500 Pharmacy 0 40906 0 0 0 0 0 0 0 0 1218641 298573 1600 Medical Records amp Library 0 27157 0 0 0 0 0 0 0 0 1265227 309986 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 49131 0 0 0 0 0 0 0 0 1626506 398501 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 193276 47354 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 316959 0 0 0 0 0 0 0 0 10781100 2641419
3100 Intensive Care Unit 0 83801 0 0 0 0 0 0 0 0 2795223 684843 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
ANCILLARY COST CENTERS 5000 Operating Room 0 57734 0 0 0 0 0 0 0 0 1992908 488272 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 0 35520 0 0 0 0 0 0 0 0 1514602 371085 5401 Ultra Sound 0 16650 0 0 0 0 0 0 0 0 477530 116997 5600 Radioisotope 0 4554 0 0 0 0 0 0 0 0 246197 60319 5700 Computed Tomography (CT) Scan 0 17260 0 0 0 0 0 0 0 0 493961 121023 5800 Magnetic Resonance Imaging (MRI) 0 562 0 0 0 0 0 0 0 0 17470 4280 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 104001 0 0 0 0 0 0 0 0 3618110 886454 6001 GI Lab 0 10400 0 0 0 0 0 0 0 0 328829 80565 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3 1 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 33287 0 0 0 0 0 0 0 0 1200012 294009 6600 Physical Therapy 0 0 0 0 0 0 0 0 0 0 415944 101908 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 7758 0 0 0 0 0 0 0 0 279591 68501 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 2563528 628076 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 558092 136735 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 972254 238207 7400 Renal Dialysis 0 0 0 0 0 0 0 0 0 0 261000 63946 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 136296 0 0 0 0 0 0 0 0 4512197 1105509 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 0 0 10213 2502 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 0 0 247590 60661 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 755 0 0 0 0 0 0 0 0 516937 126652 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 1210541 0 0 0 0 0 0 0 0 57057440 11228341
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 122820 800 Laundry and Linen Service 11227 48661 900 Housekeeping 5069 21971 0
1000 Dietary 32389 140383 0 43356 1100 Cafeteria 9366 40597 0 12538 0 1200 Maintenance of Personnel 0 0 0 0 0 0 1300 Nursing Administration 6767 29330 0 9058 0 32774 0 1400 Central Services and Supply 48295 209325 0 64647 0 2815 0 0 1500 Pharmacy 9659 41865 0 12929 0 10368 0 0 0 1600 Medical Records amp Library 12746 55245 0 17062 0 13812 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 287355 1245493 194159 384654 1279497 101907 0 1122397 0 0 282741 0
3100 Intensive Care Unit 50407 218480 44463 67475 122109 22988 0 230707 0 0 57778 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
ANCILLARY COST CENTERS 5000 Operating Room 64371 279006 26097 86167 289 16495 0 179089 0 0 96649 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 39629 0 5400 Radiology-Diagnostic 38384 166369 32393 51381 0 12357 0 11607 0 0 72900 0 5401 Ultra Sound 1438 6232 0 1925 0 5123 0 0 0 0 34435 0 5600 Radioisotope 7677 33274 1304 10276 0 1680 0 10418 0 0 11704 0 5700 Computed Tomography (CT) Scan 3875 16795 0 5187 0 5733 0 0 0 0 115424 0 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 178 0 0 0 0 973 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 24956 108166 597 33406 0 35158 0 10684 0 0 141335 0 6001 GI Lab 5686 24647 1652 7612 0 3106 0 27809 0 0 30991 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3052 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 9310 40351 0 12462 0 10725 0 0 0 0 71751 0 6600 Physical Therapy 37710 163446 0 50478 0 0 0 0 0 0 8019 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 1137 4929 709 1522 0 2871 0 0 0 0 61930 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 990451 0 66024 0 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 34995 0 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 1592035 207938 0 7400 Renal Dialysis 49 211 0 65 0 0 0 0 0 0 7869 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 283 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 53672 232634 152254 71846 21247 41134 0 433708 0 0 327655 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 2744664 200 Capital Related Costs-Movable Equipment 2187999 0 300 Other Capital Related Costs 0 0 0 301 0 0 0 0 302 0 0 0 0 0 303 0 0 0 0 0 0 304 0 0 0 0 0 0 0 305 0 0 0 0 0 0 0 0 306 0 0 0 0 0 0 0 0 0 307 0 0 0 0 0 0 0 0 0 0 308 0 0 0 0 0 0 0 0 0 0 0 309 0 0 0 0 0 0 0 0 0 0 0 0 400 Employee Benefits 1058934 84358 67249 0 0 0 0 0 0 0 0 0 501 0 0 0 0 0 0 0 0 0 0 0 0 502 0 0 0 0 0 0 0 0 0 0 0 0 503 0 0 0 0 0 0 0 0 0 0 0 0 504 0 0 0 0 0 0 0 0 0 0 0 0 505 0 0 0 0 0 0 0 0 0 0 0 0 506 0 0 0 0 0 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 0 0 0 500 Administrative and General 10629665 247119 196999 0 0 0 0 0 0 0 0 0 600 Maintenance and Repairs 565321 88028 70174 0 0 0 0 0 0 0 0 0 700 Operation of Plant 2017048 317029 252730 0 0 0 0 0 0 0 0 0 800 Laundry and Linen Service 263543 28979 23102 0 0 0 0 0 0 0 0 0 900 Housekeeping 755766 13085 10431 0 0 0 0 0 0 0 0 0
1000 Dietary 807098 83603 66647 0 0 0 0 0 0 0 0 0 1100 Cafeteria 159362 24177 19274 0 0 0 0 0 0 0 0 0 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 1482354 17467 13924 0 0 0 0 0 0 0 0 0 1400 Central Services and Supply 305730 124660 99377 0 0 0 0 0 0 0 0 0 1500 Pharmacy 1132927 24932 19875 0 0 0 0 0 0 0 0 0 1600 Medical Records amp Library 1178942 32900 26228 0 0 0 0 0 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 193276 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9131110 741734 591297 0 0 0 0 0 0 0 0 0
3100 Intensive Care Unit 2477587 130112 103723 0 0 0 0 0 0 0 0 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
ANCILLARY COST CENTERS 5000 Operating Room 1636558 166158 132458 0 0 0 0 0 0 0 0 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 1301021 99078 78983 0 0 0 0 0 0 0 0 0 5401 Ultra Sound 454209 3711 2959 0 0 0 0 0 0 0 0 0 5600 Radioisotope 206030 19816 15797 0 0 0 0 0 0 0 0 0 5700 Computed Tomography (CT) Scan 458725 10002 7974 0 0 0 0 0 0 0 0 0 5800 Magnetic Resonance Imaging (MRI) 16908 0 0 0 0 0 0 0 0 0 0 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 3398341 64417 51352 0 0 0 0 0 0 0 0 0 6001 GI Lab 292049 14678 11701 0 0 0 0 0 0 0 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 3 0 0 0 0 0 0 0 0 0 0 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 1123538 24030 19157 0 0 0 0 0 0 0 0 0 6600 Physical Therapy 241010 97338 77596 0 0 0 0 0 0 0 0 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 266558 2936 2340 0 0 0 0 0 0 0 0 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 2563528 0 0 0 0 0 0 0 0 0 0 0 7200 Implantable Devices Charged to Patients 558092 0 0 0 0 0 0 0 0 0 0 0 7300 Drugs Charged to Patients 972254 0 0 0 0 0 0 0 0 0 0 0 7400 Renal Dialysis 260774 126 100 0 0 0 0 0 0 0 0 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 4126916 138542 110443 0 0 0 0 0 0 0 0 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 5683 4530 0 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 137766 109825 0 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 512225 2202 1755 0 0 0 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 57057440 2744664 2187999 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 0 501 0 0 502 0 0 0 503 0 0 0 0 504 0 0 0 0 0 505 0 0 0 0 0 0 506 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 500 Administrative and General 0 154558 0 0 0 0 0 0 0 0 11228341 600 Maintenance and Repairs 0 0 0 0 0 0 0 0 0 0 723523 177266 700 Operation of Plant 0 22951 0 0 0 0 0 0 0 0 2609759 639403 800 Laundry and Linen Service 0 634 0 0 0 0 0 0 0 0 316257 77484 900 Housekeeping 0 17935 0 0 0 0 0 0 0 0 797216 195322
1000 Dietary 0 12138 0 0 0 0 0 0 0 0 969486 237529 1100 Cafeteria 0 3630 0 0 0 0 0 0 0 0 206442 50579 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 0 51300 0 0 0 0 0 0 0 0 1565046 383443 1400 Central Services and Supply 0 4664 0 0 0 0 0 0 0 0 534431 130938 1500 Pharmacy 0 40906 0 0 0 0 0 0 0 0 1218641 298573 1600 Medical Records amp Library 0 27157 0 0 0 0 0 0 0 0 1265227 309986 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 49131 0 0 0 0 0 0 0 0 1626506 398501 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 193276 47354 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 316959 0 0 0 0 0 0 0 0 10781100 2641419
3100 Intensive Care Unit 0 83801 0 0 0 0 0 0 0 0 2795223 684843 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
ANCILLARY COST CENTERS 5000 Operating Room 0 57734 0 0 0 0 0 0 0 0 1992908 488272 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 0 35520 0 0 0 0 0 0 0 0 1514602 371085 5401 Ultra Sound 0 16650 0 0 0 0 0 0 0 0 477530 116997 5600 Radioisotope 0 4554 0 0 0 0 0 0 0 0 246197 60319 5700 Computed Tomography (CT) Scan 0 17260 0 0 0 0 0 0 0 0 493961 121023 5800 Magnetic Resonance Imaging (MRI) 0 562 0 0 0 0 0 0 0 0 17470 4280 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 104001 0 0 0 0 0 0 0 0 3618110 886454 6001 GI Lab 0 10400 0 0 0 0 0 0 0 0 328829 80565 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3 1 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 33287 0 0 0 0 0 0 0 0 1200012 294009 6600 Physical Therapy 0 0 0 0 0 0 0 0 0 0 415944 101908 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 7758 0 0 0 0 0 0 0 0 279591 68501 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 2563528 628076 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 558092 136735 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 972254 238207 7400 Renal Dialysis 0 0 0 0 0 0 0 0 0 0 261000 63946 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 136296 0 0 0 0 0 0 0 0 4512197 1105509 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 0 0 10213 2502 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 0 0 247590 60661 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 755 0 0 0 0 0 0 0 0 516937 126652 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 1210541 0 0 0 0 0 0 0 0 57057440 11228341
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 122820 800 Laundry and Linen Service 11227 48661 900 Housekeeping 5069 21971 0
1000 Dietary 32389 140383 0 43356 1100 Cafeteria 9366 40597 0 12538 0 1200 Maintenance of Personnel 0 0 0 0 0 0 1300 Nursing Administration 6767 29330 0 9058 0 32774 0 1400 Central Services and Supply 48295 209325 0 64647 0 2815 0 0 1500 Pharmacy 9659 41865 0 12929 0 10368 0 0 0 1600 Medical Records amp Library 12746 55245 0 17062 0 13812 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 287355 1245493 194159 384654 1279497 101907 0 1122397 0 0 282741 0
3100 Intensive Care Unit 50407 218480 44463 67475 122109 22988 0 230707 0 0 57778 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
ANCILLARY COST CENTERS 5000 Operating Room 64371 279006 26097 86167 289 16495 0 179089 0 0 96649 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 39629 0 5400 Radiology-Diagnostic 38384 166369 32393 51381 0 12357 0 11607 0 0 72900 0 5401 Ultra Sound 1438 6232 0 1925 0 5123 0 0 0 0 34435 0 5600 Radioisotope 7677 33274 1304 10276 0 1680 0 10418 0 0 11704 0 5700 Computed Tomography (CT) Scan 3875 16795 0 5187 0 5733 0 0 0 0 115424 0 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 178 0 0 0 0 973 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 24956 108166 597 33406 0 35158 0 10684 0 0 141335 0 6001 GI Lab 5686 24647 1652 7612 0 3106 0 27809 0 0 30991 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3052 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 9310 40351 0 12462 0 10725 0 0 0 0 71751 0 6600 Physical Therapy 37710 163446 0 50478 0 0 0 0 0 0 8019 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 1137 4929 709 1522 0 2871 0 0 0 0 61930 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 990451 0 66024 0 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 34995 0 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 1592035 207938 0 7400 Renal Dialysis 49 211 0 65 0 0 0 0 0 0 7869 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 283 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 53672 232634 152254 71846 21247 41134 0 433708 0 0 327655 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
ANCILLARY COST CENTERS 5000 Operating Room 1636558 166158 132458 0 0 0 0 0 0 0 0 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 1301021 99078 78983 0 0 0 0 0 0 0 0 0 5401 Ultra Sound 454209 3711 2959 0 0 0 0 0 0 0 0 0 5600 Radioisotope 206030 19816 15797 0 0 0 0 0 0 0 0 0 5700 Computed Tomography (CT) Scan 458725 10002 7974 0 0 0 0 0 0 0 0 0 5800 Magnetic Resonance Imaging (MRI) 16908 0 0 0 0 0 0 0 0 0 0 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 3398341 64417 51352 0 0 0 0 0 0 0 0 0 6001 GI Lab 292049 14678 11701 0 0 0 0 0 0 0 0 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 3 0 0 0 0 0 0 0 0 0 0 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 1123538 24030 19157 0 0 0 0 0 0 0 0 0 6600 Physical Therapy 241010 97338 77596 0 0 0 0 0 0 0 0 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 266558 2936 2340 0 0 0 0 0 0 0 0 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 2563528 0 0 0 0 0 0 0 0 0 0 0 7200 Implantable Devices Charged to Patients 558092 0 0 0 0 0 0 0 0 0 0 0 7300 Drugs Charged to Patients 972254 0 0 0 0 0 0 0 0 0 0 0 7400 Renal Dialysis 260774 126 100 0 0 0 0 0 0 0 0 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 4126916 138542 110443 0 0 0 0 0 0 0 0 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 5683 4530 0 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 137766 109825 0 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 512225 2202 1755 0 0 0 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 57057440 2744664 2187999 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 0 501 0 0 502 0 0 0 503 0 0 0 0 504 0 0 0 0 0 505 0 0 0 0 0 0 506 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 500 Administrative and General 0 154558 0 0 0 0 0 0 0 0 11228341 600 Maintenance and Repairs 0 0 0 0 0 0 0 0 0 0 723523 177266 700 Operation of Plant 0 22951 0 0 0 0 0 0 0 0 2609759 639403 800 Laundry and Linen Service 0 634 0 0 0 0 0 0 0 0 316257 77484 900 Housekeeping 0 17935 0 0 0 0 0 0 0 0 797216 195322
1000 Dietary 0 12138 0 0 0 0 0 0 0 0 969486 237529 1100 Cafeteria 0 3630 0 0 0 0 0 0 0 0 206442 50579 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 0 51300 0 0 0 0 0 0 0 0 1565046 383443 1400 Central Services and Supply 0 4664 0 0 0 0 0 0 0 0 534431 130938 1500 Pharmacy 0 40906 0 0 0 0 0 0 0 0 1218641 298573 1600 Medical Records amp Library 0 27157 0 0 0 0 0 0 0 0 1265227 309986 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 49131 0 0 0 0 0 0 0 0 1626506 398501 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 193276 47354 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 316959 0 0 0 0 0 0 0 0 10781100 2641419
3100 Intensive Care Unit 0 83801 0 0 0 0 0 0 0 0 2795223 684843 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
ANCILLARY COST CENTERS 5000 Operating Room 0 57734 0 0 0 0 0 0 0 0 1992908 488272 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 0 35520 0 0 0 0 0 0 0 0 1514602 371085 5401 Ultra Sound 0 16650 0 0 0 0 0 0 0 0 477530 116997 5600 Radioisotope 0 4554 0 0 0 0 0 0 0 0 246197 60319 5700 Computed Tomography (CT) Scan 0 17260 0 0 0 0 0 0 0 0 493961 121023 5800 Magnetic Resonance Imaging (MRI) 0 562 0 0 0 0 0 0 0 0 17470 4280 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 104001 0 0 0 0 0 0 0 0 3618110 886454 6001 GI Lab 0 10400 0 0 0 0 0 0 0 0 328829 80565 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3 1 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 33287 0 0 0 0 0 0 0 0 1200012 294009 6600 Physical Therapy 0 0 0 0 0 0 0 0 0 0 415944 101908 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 7758 0 0 0 0 0 0 0 0 279591 68501 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 2563528 628076 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 558092 136735 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 972254 238207 7400 Renal Dialysis 0 0 0 0 0 0 0 0 0 0 261000 63946 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 136296 0 0 0 0 0 0 0 0 4512197 1105509 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 0 0 10213 2502 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 0 0 247590 60661 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 755 0 0 0 0 0 0 0 0 516937 126652 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 1210541 0 0 0 0 0 0 0 0 57057440 11228341
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 122820 800 Laundry and Linen Service 11227 48661 900 Housekeeping 5069 21971 0
1000 Dietary 32389 140383 0 43356 1100 Cafeteria 9366 40597 0 12538 0 1200 Maintenance of Personnel 0 0 0 0 0 0 1300 Nursing Administration 6767 29330 0 9058 0 32774 0 1400 Central Services and Supply 48295 209325 0 64647 0 2815 0 0 1500 Pharmacy 9659 41865 0 12929 0 10368 0 0 0 1600 Medical Records amp Library 12746 55245 0 17062 0 13812 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 287355 1245493 194159 384654 1279497 101907 0 1122397 0 0 282741 0
3100 Intensive Care Unit 50407 218480 44463 67475 122109 22988 0 230707 0 0 57778 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
ANCILLARY COST CENTERS 5000 Operating Room 64371 279006 26097 86167 289 16495 0 179089 0 0 96649 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 39629 0 5400 Radiology-Diagnostic 38384 166369 32393 51381 0 12357 0 11607 0 0 72900 0 5401 Ultra Sound 1438 6232 0 1925 0 5123 0 0 0 0 34435 0 5600 Radioisotope 7677 33274 1304 10276 0 1680 0 10418 0 0 11704 0 5700 Computed Tomography (CT) Scan 3875 16795 0 5187 0 5733 0 0 0 0 115424 0 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 178 0 0 0 0 973 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 24956 108166 597 33406 0 35158 0 10684 0 0 141335 0 6001 GI Lab 5686 24647 1652 7612 0 3106 0 27809 0 0 30991 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3052 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 9310 40351 0 12462 0 10725 0 0 0 0 71751 0 6600 Physical Therapy 37710 163446 0 50478 0 0 0 0 0 0 8019 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 1137 4929 709 1522 0 2871 0 0 0 0 61930 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 990451 0 66024 0 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 34995 0 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 1592035 207938 0 7400 Renal Dialysis 49 211 0 65 0 0 0 0 0 0 7869 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 283 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 53672 232634 152254 71846 21247 41134 0 433708 0 0 327655 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 8
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NET EXP FOR CAPITAL CAPITAL OTHER CAP TRIAL BALANCE COST ALLOC BLDG amp MOVABLE RELATED ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC
EXPENSES (From Sch 10) FIXTURES EQUIP COSTS COST COST COST COST COST COST COST COST 000 100 200 300 301 302 303 304 305 306 307 308
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 5683 4530 0 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 137766 109825 0 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 512225 2202 1755 0 0 0 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 57057440 2744664 2187999 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 0 501 0 0 502 0 0 0 503 0 0 0 0 504 0 0 0 0 0 505 0 0 0 0 0 0 506 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 500 Administrative and General 0 154558 0 0 0 0 0 0 0 0 11228341 600 Maintenance and Repairs 0 0 0 0 0 0 0 0 0 0 723523 177266 700 Operation of Plant 0 22951 0 0 0 0 0 0 0 0 2609759 639403 800 Laundry and Linen Service 0 634 0 0 0 0 0 0 0 0 316257 77484 900 Housekeeping 0 17935 0 0 0 0 0 0 0 0 797216 195322
1000 Dietary 0 12138 0 0 0 0 0 0 0 0 969486 237529 1100 Cafeteria 0 3630 0 0 0 0 0 0 0 0 206442 50579 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 0 51300 0 0 0 0 0 0 0 0 1565046 383443 1400 Central Services and Supply 0 4664 0 0 0 0 0 0 0 0 534431 130938 1500 Pharmacy 0 40906 0 0 0 0 0 0 0 0 1218641 298573 1600 Medical Records amp Library 0 27157 0 0 0 0 0 0 0 0 1265227 309986 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 49131 0 0 0 0 0 0 0 0 1626506 398501 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 193276 47354 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 316959 0 0 0 0 0 0 0 0 10781100 2641419
3100 Intensive Care Unit 0 83801 0 0 0 0 0 0 0 0 2795223 684843 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
ANCILLARY COST CENTERS 5000 Operating Room 0 57734 0 0 0 0 0 0 0 0 1992908 488272 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 0 35520 0 0 0 0 0 0 0 0 1514602 371085 5401 Ultra Sound 0 16650 0 0 0 0 0 0 0 0 477530 116997 5600 Radioisotope 0 4554 0 0 0 0 0 0 0 0 246197 60319 5700 Computed Tomography (CT) Scan 0 17260 0 0 0 0 0 0 0 0 493961 121023 5800 Magnetic Resonance Imaging (MRI) 0 562 0 0 0 0 0 0 0 0 17470 4280 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 104001 0 0 0 0 0 0 0 0 3618110 886454 6001 GI Lab 0 10400 0 0 0 0 0 0 0 0 328829 80565 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3 1 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 33287 0 0 0 0 0 0 0 0 1200012 294009 6600 Physical Therapy 0 0 0 0 0 0 0 0 0 0 415944 101908 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 7758 0 0 0 0 0 0 0 0 279591 68501 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 2563528 628076 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 558092 136735 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 972254 238207 7400 Renal Dialysis 0 0 0 0 0 0 0 0 0 0 261000 63946 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 136296 0 0 0 0 0 0 0 0 4512197 1105509 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 0 0 10213 2502 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 0 0 247590 60661 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 755 0 0 0 0 0 0 0 0 516937 126652 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 1210541 0 0 0 0 0 0 0 0 57057440 11228341
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 122820 800 Laundry and Linen Service 11227 48661 900 Housekeeping 5069 21971 0
1000 Dietary 32389 140383 0 43356 1100 Cafeteria 9366 40597 0 12538 0 1200 Maintenance of Personnel 0 0 0 0 0 0 1300 Nursing Administration 6767 29330 0 9058 0 32774 0 1400 Central Services and Supply 48295 209325 0 64647 0 2815 0 0 1500 Pharmacy 9659 41865 0 12929 0 10368 0 0 0 1600 Medical Records amp Library 12746 55245 0 17062 0 13812 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 287355 1245493 194159 384654 1279497 101907 0 1122397 0 0 282741 0
3100 Intensive Care Unit 50407 218480 44463 67475 122109 22988 0 230707 0 0 57778 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
ANCILLARY COST CENTERS 5000 Operating Room 64371 279006 26097 86167 289 16495 0 179089 0 0 96649 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 39629 0 5400 Radiology-Diagnostic 38384 166369 32393 51381 0 12357 0 11607 0 0 72900 0 5401 Ultra Sound 1438 6232 0 1925 0 5123 0 0 0 0 34435 0 5600 Radioisotope 7677 33274 1304 10276 0 1680 0 10418 0 0 11704 0 5700 Computed Tomography (CT) Scan 3875 16795 0 5187 0 5733 0 0 0 0 115424 0 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 178 0 0 0 0 973 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 24956 108166 597 33406 0 35158 0 10684 0 0 141335 0 6001 GI Lab 5686 24647 1652 7612 0 3106 0 27809 0 0 30991 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3052 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 9310 40351 0 12462 0 10725 0 0 0 0 71751 0 6600 Physical Therapy 37710 163446 0 50478 0 0 0 0 0 0 8019 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 1137 4929 709 1522 0 2871 0 0 0 0 61930 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 990451 0 66024 0 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 34995 0 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 1592035 207938 0 7400 Renal Dialysis 49 211 0 65 0 0 0 0 0 0 7869 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 283 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 53672 232634 152254 71846 21247 41134 0 433708 0 0 327655 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 0 501 0 0 502 0 0 0 503 0 0 0 0 504 0 0 0 0 0 505 0 0 0 0 0 0 506 0 0 0 0 0 0 0 507 0 0 0 0 0 0 0 0 508 0 0 0 0 0 0 0 0 0 500 Administrative and General 0 154558 0 0 0 0 0 0 0 0 11228341 600 Maintenance and Repairs 0 0 0 0 0 0 0 0 0 0 723523 177266 700 Operation of Plant 0 22951 0 0 0 0 0 0 0 0 2609759 639403 800 Laundry and Linen Service 0 634 0 0 0 0 0 0 0 0 316257 77484 900 Housekeeping 0 17935 0 0 0 0 0 0 0 0 797216 195322
1000 Dietary 0 12138 0 0 0 0 0 0 0 0 969486 237529 1100 Cafeteria 0 3630 0 0 0 0 0 0 0 0 206442 50579 1200 Maintenance of Personnel 0 0 0 0 0 0 0 0 0 0 0 0 1300 Nursing Administration 0 51300 0 0 0 0 0 0 0 0 1565046 383443 1400 Central Services and Supply 0 4664 0 0 0 0 0 0 0 0 534431 130938 1500 Pharmacy 0 40906 0 0 0 0 0 0 0 0 1218641 298573 1600 Medical Records amp Library 0 27157 0 0 0 0 0 0 0 0 1265227 309986 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 49131 0 0 0 0 0 0 0 0 1626506 398501 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 193276 47354 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 316959 0 0 0 0 0 0 0 0 10781100 2641419
3100 Intensive Care Unit 0 83801 0 0 0 0 0 0 0 0 2795223 684843 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0 0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
ANCILLARY COST CENTERS 5000 Operating Room 0 57734 0 0 0 0 0 0 0 0 1992908 488272 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 0 35520 0 0 0 0 0 0 0 0 1514602 371085 5401 Ultra Sound 0 16650 0 0 0 0 0 0 0 0 477530 116997 5600 Radioisotope 0 4554 0 0 0 0 0 0 0 0 246197 60319 5700 Computed Tomography (CT) Scan 0 17260 0 0 0 0 0 0 0 0 493961 121023 5800 Magnetic Resonance Imaging (MRI) 0 562 0 0 0 0 0 0 0 0 17470 4280 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 104001 0 0 0 0 0 0 0 0 3618110 886454 6001 GI Lab 0 10400 0 0 0 0 0 0 0 0 328829 80565 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3 1 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 33287 0 0 0 0 0 0 0 0 1200012 294009 6600 Physical Therapy 0 0 0 0 0 0 0 0 0 0 415944 101908 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 7758 0 0 0 0 0 0 0 0 279591 68501 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 2563528 628076 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 558092 136735 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 972254 238207 7400 Renal Dialysis 0 0 0 0 0 0 0 0 0 0 261000 63946 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 136296 0 0 0 0 0 0 0 0 4512197 1105509 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 0 0 10213 2502 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 0 0 247590 60661 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 755 0 0 0 0 0 0 0 0 516937 126652 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 1210541 0 0 0 0 0 0 0 0 57057440 11228341
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 122820 800 Laundry and Linen Service 11227 48661 900 Housekeeping 5069 21971 0
1000 Dietary 32389 140383 0 43356 1100 Cafeteria 9366 40597 0 12538 0 1200 Maintenance of Personnel 0 0 0 0 0 0 1300 Nursing Administration 6767 29330 0 9058 0 32774 0 1400 Central Services and Supply 48295 209325 0 64647 0 2815 0 0 1500 Pharmacy 9659 41865 0 12929 0 10368 0 0 0 1600 Medical Records amp Library 12746 55245 0 17062 0 13812 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 287355 1245493 194159 384654 1279497 101907 0 1122397 0 0 282741 0
3100 Intensive Care Unit 50407 218480 44463 67475 122109 22988 0 230707 0 0 57778 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
ANCILLARY COST CENTERS 5000 Operating Room 64371 279006 26097 86167 289 16495 0 179089 0 0 96649 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 39629 0 5400 Radiology-Diagnostic 38384 166369 32393 51381 0 12357 0 11607 0 0 72900 0 5401 Ultra Sound 1438 6232 0 1925 0 5123 0 0 0 0 34435 0 5600 Radioisotope 7677 33274 1304 10276 0 1680 0 10418 0 0 11704 0 5700 Computed Tomography (CT) Scan 3875 16795 0 5187 0 5733 0 0 0 0 115424 0 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 178 0 0 0 0 973 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 24956 108166 597 33406 0 35158 0 10684 0 0 141335 0 6001 GI Lab 5686 24647 1652 7612 0 3106 0 27809 0 0 30991 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3052 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 9310 40351 0 12462 0 10725 0 0 0 0 71751 0 6600 Physical Therapy 37710 163446 0 50478 0 0 0 0 0 0 8019 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 1137 4929 709 1522 0 2871 0 0 0 0 61930 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 990451 0 66024 0 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 34995 0 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 1592035 207938 0 7400 Renal Dialysis 49 211 0 65 0 0 0 0 0 0 7869 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 283 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 53672 232634 152254 71846 21247 41134 0 433708 0 0 327655 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
ANCILLARY COST CENTERS 5000 Operating Room 0 57734 0 0 0 0 0 0 0 0 1992908 488272 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 0 0 5400 Radiology-Diagnostic 0 35520 0 0 0 0 0 0 0 0 1514602 371085 5401 Ultra Sound 0 16650 0 0 0 0 0 0 0 0 477530 116997 5600 Radioisotope 0 4554 0 0 0 0 0 0 0 0 246197 60319 5700 Computed Tomography (CT) Scan 0 17260 0 0 0 0 0 0 0 0 493961 121023 5800 Magnetic Resonance Imaging (MRI) 0 562 0 0 0 0 0 0 0 0 17470 4280 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 104001 0 0 0 0 0 0 0 0 3618110 886454 6001 GI Lab 0 10400 0 0 0 0 0 0 0 0 328829 80565 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3 1 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 33287 0 0 0 0 0 0 0 0 1200012 294009 6600 Physical Therapy 0 0 0 0 0 0 0 0 0 0 415944 101908 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 7758 0 0 0 0 0 0 0 0 279591 68501 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 0 0 2563528 628076 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 558092 136735 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 0 972254 238207 7400 Renal Dialysis 0 0 0 0 0 0 0 0 0 0 261000 63946 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 0 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 136296 0 0 0 0 0 0 0 0 4512197 1105509 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 0 0 10213 2502 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 0 0 247590 60661 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 755 0 0 0 0 0 0 0 0 516937 126652 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 1210541 0 0 0 0 0 0 0 0 57057440 11228341
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 122820 800 Laundry and Linen Service 11227 48661 900 Housekeeping 5069 21971 0
1000 Dietary 32389 140383 0 43356 1100 Cafeteria 9366 40597 0 12538 0 1200 Maintenance of Personnel 0 0 0 0 0 0 1300 Nursing Administration 6767 29330 0 9058 0 32774 0 1400 Central Services and Supply 48295 209325 0 64647 0 2815 0 0 1500 Pharmacy 9659 41865 0 12929 0 10368 0 0 0 1600 Medical Records amp Library 12746 55245 0 17062 0 13812 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 287355 1245493 194159 384654 1279497 101907 0 1122397 0 0 282741 0
3100 Intensive Care Unit 50407 218480 44463 67475 122109 22988 0 230707 0 0 57778 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
ANCILLARY COST CENTERS 5000 Operating Room 64371 279006 26097 86167 289 16495 0 179089 0 0 96649 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 39629 0 5400 Radiology-Diagnostic 38384 166369 32393 51381 0 12357 0 11607 0 0 72900 0 5401 Ultra Sound 1438 6232 0 1925 0 5123 0 0 0 0 34435 0 5600 Radioisotope 7677 33274 1304 10276 0 1680 0 10418 0 0 11704 0 5700 Computed Tomography (CT) Scan 3875 16795 0 5187 0 5733 0 0 0 0 115424 0 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 178 0 0 0 0 973 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 24956 108166 597 33406 0 35158 0 10684 0 0 141335 0 6001 GI Lab 5686 24647 1652 7612 0 3106 0 27809 0 0 30991 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3052 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 9310 40351 0 12462 0 10725 0 0 0 0 71751 0 6600 Physical Therapy 37710 163446 0 50478 0 0 0 0 0 0 8019 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 1137 4929 709 1522 0 2871 0 0 0 0 61930 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 990451 0 66024 0 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 34995 0 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 1592035 207938 0 7400 Renal Dialysis 49 211 0 65 0 0 0 0 0 0 7869 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 283 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 53672 232634 152254 71846 21247 41134 0 433708 0 0 327655 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 81
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
ADMINIS-TRIAL BALANCE ALLOC EMPLOYEE ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ALLOC ACCUMULATE TRATIVE amp
EXPENSES COST BENEFITS COST COST COST COST COST COST COST COST COST GENERAL 309 400 501 502 503 504 505 506 507 508 500
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 0 0 10213 2502 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 0 0 247590 60661 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 755 0 0 0 0 0 0 0 0 516937 126652 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
TOTAL 0 1210541 0 0 0 0 0 0 0 0 57057440 11228341
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 122820 800 Laundry and Linen Service 11227 48661 900 Housekeeping 5069 21971 0
1000 Dietary 32389 140383 0 43356 1100 Cafeteria 9366 40597 0 12538 0 1200 Maintenance of Personnel 0 0 0 0 0 0 1300 Nursing Administration 6767 29330 0 9058 0 32774 0 1400 Central Services and Supply 48295 209325 0 64647 0 2815 0 0 1500 Pharmacy 9659 41865 0 12929 0 10368 0 0 0 1600 Medical Records amp Library 12746 55245 0 17062 0 13812 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 287355 1245493 194159 384654 1279497 101907 0 1122397 0 0 282741 0
3100 Intensive Care Unit 50407 218480 44463 67475 122109 22988 0 230707 0 0 57778 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
ANCILLARY COST CENTERS 5000 Operating Room 64371 279006 26097 86167 289 16495 0 179089 0 0 96649 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 39629 0 5400 Radiology-Diagnostic 38384 166369 32393 51381 0 12357 0 11607 0 0 72900 0 5401 Ultra Sound 1438 6232 0 1925 0 5123 0 0 0 0 34435 0 5600 Radioisotope 7677 33274 1304 10276 0 1680 0 10418 0 0 11704 0 5700 Computed Tomography (CT) Scan 3875 16795 0 5187 0 5733 0 0 0 0 115424 0 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 178 0 0 0 0 973 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 24956 108166 597 33406 0 35158 0 10684 0 0 141335 0 6001 GI Lab 5686 24647 1652 7612 0 3106 0 27809 0 0 30991 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3052 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 9310 40351 0 12462 0 10725 0 0 0 0 71751 0 6600 Physical Therapy 37710 163446 0 50478 0 0 0 0 0 0 8019 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 1137 4929 709 1522 0 2871 0 0 0 0 61930 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 990451 0 66024 0 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 34995 0 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 1592035 207938 0 7400 Renal Dialysis 49 211 0 65 0 0 0 0 0 0 7869 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 283 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 53672 232634 152254 71846 21247 41134 0 433708 0 0 327655 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 122820 800 Laundry and Linen Service 11227 48661 900 Housekeeping 5069 21971 0
1000 Dietary 32389 140383 0 43356 1100 Cafeteria 9366 40597 0 12538 0 1200 Maintenance of Personnel 0 0 0 0 0 0 1300 Nursing Administration 6767 29330 0 9058 0 32774 0 1400 Central Services and Supply 48295 209325 0 64647 0 2815 0 0 1500 Pharmacy 9659 41865 0 12929 0 10368 0 0 0 1600 Medical Records amp Library 12746 55245 0 17062 0 13812 0 0 0 0 1700 Social Service 0 0 0 0 0 0 0 0 0 0 0 1800 Other General Service (specify) 0 0 0 0 0 0 0 0 0 0 0 0 1900 Nonphysician Anesthetists 0 0 0 0 0 0 0 0 0 0 0 0 2000 Nursing School 0 0 0 0 0 0 0 0 0 0 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 0 0 0 0 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 0 0 0 0 0 0 0 2301 0 0 0 0 0 0 0 0 0 0 0 0 2302 0 0 0 0 0 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 287355 1245493 194159 384654 1279497 101907 0 1122397 0 0 282741 0
3100 Intensive Care Unit 50407 218480 44463 67475 122109 22988 0 230707 0 0 57778 0 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
ANCILLARY COST CENTERS 5000 Operating Room 64371 279006 26097 86167 289 16495 0 179089 0 0 96649 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 39629 0 5400 Radiology-Diagnostic 38384 166369 32393 51381 0 12357 0 11607 0 0 72900 0 5401 Ultra Sound 1438 6232 0 1925 0 5123 0 0 0 0 34435 0 5600 Radioisotope 7677 33274 1304 10276 0 1680 0 10418 0 0 11704 0 5700 Computed Tomography (CT) Scan 3875 16795 0 5187 0 5733 0 0 0 0 115424 0 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 178 0 0 0 0 973 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 24956 108166 597 33406 0 35158 0 10684 0 0 141335 0 6001 GI Lab 5686 24647 1652 7612 0 3106 0 27809 0 0 30991 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3052 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 9310 40351 0 12462 0 10725 0 0 0 0 71751 0 6600 Physical Therapy 37710 163446 0 50478 0 0 0 0 0 0 8019 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 1137 4929 709 1522 0 2871 0 0 0 0 61930 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 990451 0 66024 0 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 34995 0 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 1592035 207938 0 7400 Renal Dialysis 49 211 0 65 0 0 0 0 0 0 7869 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 283 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 53672 232634 152254 71846 21247 41134 0 433708 0 0 327655 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
ANCILLARY COST CENTERS 5000 Operating Room 64371 279006 26097 86167 289 16495 0 179089 0 0 96649 0 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 0 0 39629 0 5400 Radiology-Diagnostic 38384 166369 32393 51381 0 12357 0 11607 0 0 72900 0 5401 Ultra Sound 1438 6232 0 1925 0 5123 0 0 0 0 34435 0 5600 Radioisotope 7677 33274 1304 10276 0 1680 0 10418 0 0 11704 0 5700 Computed Tomography (CT) Scan 3875 16795 0 5187 0 5733 0 0 0 0 115424 0 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 178 0 0 0 0 973 0 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 24956 108166 597 33406 0 35158 0 10684 0 0 141335 0 6001 GI Lab 5686 24647 1652 7612 0 3106 0 27809 0 0 30991 0 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 0 0 3052 0 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 9310 40351 0 12462 0 10725 0 0 0 0 71751 0 6600 Physical Therapy 37710 163446 0 50478 0 0 0 0 0 0 8019 0 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 1137 4929 709 1522 0 2871 0 0 0 0 61930 0 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 990451 0 66024 0 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 0 0 34995 0 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 0 1592035 207938 0 7400 Renal Dialysis 49 211 0 65 0 0 0 0 0 0 7869 0 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 0 0 283 0 7700 0 0 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 0 0 9100 Emergency 53672 232634 152254 71846 21247 41134 0 433708 0 0 327655 0 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 82
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CENTRAL MEDICAL TRIAL BALANCE MAINT amp OPERATION LAUNDRY amp MAINT OF NURSING SERVICE RECORDS SOCIAL
EXPENSES REPAIR OF PLANT LINEN HOUSEKEEP DIETARY CAFETERIA PERSONNEL ADMIN amp SUPPLY PHARMACY amp LIBRARY SERVICE 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 2201 9542 0 2947 0 0 0 0 0 0 0 0 19100 Research 0 0 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 53372 231331 0 71444 0 0 0 0 0 0 0 0 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 853 3697 0 1142 0 300 0 0 0 0 0 0 19302 0 0 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0 0 0
0 TOTAL 900789 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
GENERAL SERVICE COST CENTER (Adj 21) 100 Capital Related Costs-Buildings and Fixture 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 0 0 2200 Intern amp Res Other Program Costs (Approved) 0 0 0 0 2300 Paramedical Ed Program (specify) 0 0 0 0 0 2301 0 0 0 0 0 0 2302 0 0 0 0 0 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 0 0 0 1084961 128925 0 0 0 19534607 0 19534607
3100 Intensive Care Unit 0 0 0 16133 1917 0 0 0 4312523 0 4312523 3200 Coronary Care Unit 0 0 0 0 0 0 0 0 0 0 3300 Burn Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3400 Surgical Intensive Care Unit 0 0 0 0 0 0 0 0 0 0 3500 Other Special Care (specify) 0 0 0 0 0 0 0 0 0 0 4000 Subprovider - IPF 0 0 0 0 0 0 0 0 0 0 4100 Subprovider - IRF 0 0 0 0 0 0 0 0 0 0 4200 Subprovider (specify) 4300 Nursery
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
4400 Skilled Nursing Facility 0 0 0 0 0 0 0 0 0 0 4500 Nursing Facility 0 0 0 0 0 0 0 0 0 0 4600 Other Long Term Care 0 0 0 0 0 0 0 0 0 0 4700 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
ANCILLARY COST CENTERS 5000 Operating Room 0 0 0 290389 34507 0 0 0 3554239 0 3554239 5100 Recovery Room 0 0 0 0 0 0 0 0 0 0 5300 Anesthesiology 0 0 0 0 0 0 0 0 39629 39629 5400 Radiology-Diagnostic 0 0 0 0 0 0 0 0 2271078 2271078 5401 Ultra Sound 0 0 0 0 0 0 0 0 643680 643680 5600 Radioisotope 0 0 0 0 0 0 0 0 382848 382848 5700 Computed Tomography (CT) Scan 0 0 0 0 0 0 0 0 761998 761998 5800 Magnetic Resonance Imaging (MRI) 0 0 0 0 0 0 0 0 22902 22902 5900 Cardiac Catheterization 0 0 0 0 0 0 0 0 0 0 6000 Laboratory 0 0 0 0 0 0 0 0 4858864 4858864 6001 GI Lab 0 0 0 0 0 0 0 0 510896 510896 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 0 0 0 0 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 0 0 0 0 0 0 0 0 3056 3056 6300 Blood Storing Processing amp Trans 0 0 0 0 0 0 0 0 0 0 6400 Intravenous Therapy 0 0 0 0 0 0 0 0 0 0 6500 Respiratory Therapy 0 0 0 0 0 0 0 0 1638618 1638618 6600 Physical Therapy 0 0 0 0 0 0 0 0 777505 777505 6700 Occupational Therapy 0 0 0 0 0 0 0 0 0 0 6800 Speech Pathology 0 0 0 0 0 0 0 0 0 0 6900 Electrocardiology 0 0 0 0 0 0 0 0 421192 421192 7000 Electroencephalography 0 0 0 0 0 0 0 0 0 0 7100 Medical Supplies Charged to Patients 0 0 0 0 0 0 0 0 4248079 4248079 7200 Implantable Devices Charged to Patients 0 0 0 0 0 0 0 0 729822 729822 7300 Drugs Charged to Patients 0 0 0 0 0 0 0 0 3010434 3010434 7400 Renal Dialysis 0 0 0 0 0 0 0 0 333141 333141 7500 ASC (Non-Distinct Part) 0 0 0 0 0 0 0 0 0 0 7501 Other Ancillary (specify) 0 0 0 0 0 0 0 0 283 283 7700 0 0 0 0 0 0 0 0 0 0 7800 0 0 0 0 0 0 0 0 0 0 7900 0 0 0 0 0 0 0 0 0 0 8000 0 0 0 0 0 0 0 0 0 0 8100 0 0 0 0 0 0 0 0 0 0 8200 0 0 0 0 0 0 0 0 0 0 8300 0 0 0 0 0 0 0 0 0 0 8400 0 0 0 0 0 0 0 0 0 0 8500 0 0 0 0 0 0 0 0 0 0 8600 0 0 0 0 0 0 0 0 0 0 8700 0 0 0 0 0 0 0 0 0 0 8701 0 0 0 0 0 0 0 0 0 0 8800 Rural Health Clinic (RHC) 0 0 0 0 0 0 0 0 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 0 0 0 0 0 0 0 0 9000 Clinic 0 0 0 0 0 0 0 0 0 0 9100 Emergency 0 0 0 633525 75281 0 0 0 7660663 0 7660663 9200 Observation Beds 0 0 0 0 0 0 0 0 0 0 9300 Other Outpatient Services (Specify) 0 0 0 0 0 0 0 0 0 0 9301 0 0 0 0 0 0 0 0 0 0 9302 0 0 0 0 0 0 0 0 0 0 9303 0 0 0 0 0 0 0 0 0 0 9304 0 0 0 0 0 0 0 0 0 0 9305 0 0 0 0 0 0 0 0 0 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 0 0 0 0 0 0 0 0 0 9500 Ambulance Services 0 0 0 0 0 0 0 0 0 0 9600 Durable Medical Equipment-Rented 0 0 0 0 0 0 0 0 0 0 9700 Durable Medical Equipment-Sold 0 0 0 0 0 0 0 0 0 0 9800 Other Reimbursable (specify) 0 0 0 0 0 0 0 0 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0 0 0 0 0 0 0 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 0 0 0 0 0 0 0 0
10100 Home Health Agency 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA COMPUTATION OF COST ALLOCATION (WS B) SCHEDULE 83
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
POST OTHER GEN IampR OTHER PARAMEDICAL STEP-DOWN TOTAL
TRIAL BALANCE SVC NONPHYSICIAN NURSING I amp R SVC PROGRAM EDUCATION ALLOC ALLOC SUBTOTAL ADJUSTMENT COST EXPENSES (SPECIFIC) ANESTHETIST SCHOOL SAL amp BENEFITS COSTS PROGRAM COST COST
1800 1900 2000 2100 2200 2300 2301 2302 2400 2500 2600
10500 Kidney Acquisition 0 0 0 0 0 0 0 0 0 0 10600 Heart Acquisition 0 0 0 0 0 0 0 0 0 0 10700 Liver Acquisition 0 0 0 0 0 0 0 0 0 0 10800 Lung Acquisition 0 0 0 0 0 0 0 0 0 0 10900 Pancreas Acquisition 0 0 0 0 0 0 0 0 0 0 11000 Intestinal Acquisition 0 0 0 0 0 0 0 0 0 0 11100 Islet Acquisition 0 0 0 0 0 0 0 0 0 0 11200 Other Organ Acquisition (specify) 0 0 0 0 0 0 0 0 0 0 11300 Interest Expense 0 0 0 0 0 0 0 0 0 0 11400 Utilization Review-SNF 0 0 0 0 0 0 0 0 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 0 0 0 0 0 0 0 0 11600 Hospice 0 0 0 0 0 0 0 0 0 0 11700 Other Special Purpose (specify) 0 0 0 0 0 0 0 0 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 0 0 0 0 0 0 27405 27405 19100 Research 0 0 0 0 0 0 0 0 0 0 19200 Physicians Private Offices 0 0 0 0 0 0 0 0 664398 664398 19300 Nonpaid W orkers 0 0 0 0 0 0 0 0 0 0 19301 Public Relations 0 0 0 0 0 0 0 0 649581 649581 19302 0 0 0 0 0 0 0 0 0 0 19303 0 0 0 0 0 0 0 0 0 0 19304 0 0 0 0 0 0 0 0 0 0
TOTAL 0 0 0 2025007 240630 0 0 0 57057440 0 57057440
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 4023 4023 501 502 503 504 505 506 507 508 500 Administrative and General 11785 11785 600 Maintenance and Repairs 4198 4198 700 Operation of Plant 15119 15119 800 Laundry and Linen Service 1382 1382 900 Housekeeping 624 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 1400 Central Services and Supply 5945 5945 1500 Pharmacy 1189 1189 1600 Medical Records amp Library 1569 1569 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 35373
3100 Intensive Care Unit 6205 6205 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
ANCILLARY COST CENTERS 5000 Operating Room 7924 7924 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 4725 4725 5401 Ultra Sound 177 177 5600 Radioisotope 945 945 5700 Computed Tomography (CT) Scan 477 477 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 3072 3072 6001 GI Lab 700 700 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 1146 1146 6600 Physical Therapy 4642 4642 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 140 140 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 6 6 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 6607 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 9
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
CAP REL CAP REL OTHER STAT STAT STAT STAT STAT STAT STAT STAT STAT BLDG amp FIX MOV EQUIP CAP REL
(SQ FT) (SQ FT) (SQ FT) 100 200 300 301 302 303 304 305 306 307 308 309
(Adj 22) (Adj 22) (Adj 25) (Adj 25)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 19302 19303 19304
TOTAL 130892 130892 0 0 0 0 0 0 0 0 0 0 COST TO BE ALLOCATED 2744664 2187999 0 0 0 0 0 0 0 0 0 0 UNIT COST MULTIPLIER - SCH 8 20968921 16716064 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping 1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine)
3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Fiscal Period Ended DECEM BER 31 2011
EMP BENE (GROSS
SALARIES) 400
STAT
501
STAT
502
STAT
503
STAT
504
STAT
505
STAT
506
STAT
507
STAT
508
RECON-CILIATION
ADM amp GEN (ACCUM COST) 500
MANT amp REPAIRS (SQ FT)
600 (Adjs 23-24)
(Adj 26)
3496750 0 723523
519255 2609759 15119 14333 316257 1382
405764 797216 624 274612 969486 3987 82119 206442 1153
0 1160621 1565046 833
105512 534431 5945 925466 1218641 1189 614403 1265227 1569
0 0 0 0
1111539 1626506 193276
0 0 0 0
7170912 10781100 35373
1895923 2795223 6205 0 0 0 0 0 0 0 0 0 0 0 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
ANCILLARY COST CENTERS 0 5000 Operating Room 1306188 1992908 7924 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 803602 1514602 4725 5401 Ultra Sound 376699 477530 177 5600 Radioisotope 103037 246197 945 5700 Computed Tomography (CT) Scan 390489 493961 477 5800 Magnetic Resonance Imaging (MRI) 12723 17470 5900 Cardiac Catheterization 0 6000 Laboratory 2352934 3618110 3072 6001 GI Lab 235296 328829 700 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 3 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 753091 1200012 1146 6600 Physical Therapy 415944 4642 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 175507 279591 140 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2563528 7200 Implantable Devices Charged to Patients 558092 7300 Drugs Charged to Patients 972254 7400 Renal Dialysis 261000 6 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 3083574 4512197 6607 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 0 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0 10000 Intern-Resident Service (not appvd tchng prgm) 0
10100 Home Health Agency 0
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 91
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
EMP BENE STAT STAT STAT STAT STAT STAT STAT STAT RECON- ADM amp GEN MANT amp (GROSS CILIATION (ACCUM REPAIRS
SALARIES) COST) (SQ FT) 400 501 502 503 504 505 506 507 508 500 600
(Adjs 23-24) (Adj 26)
10500 Kidney Acquisition 0 10600 Heart Acquisition 0 10700 Liver Acquisition 0 10800 Lung Acquisition 0 10900 Pancreas Acquisition 0 11000 Intestinal Acquisition 0 11100 Islet Acquisition 0 11200 Other Organ Acquisition (specify) 0 11300 Interest Expense 0 11400 Utilization Review-SNF 0 11500 Ambulatory Surgical Center (Distinct Part) 0 11600 Hospice 0 11700 Other Special Purpose (specify) 0 19000 Gift Flower Coffee Shop amp Canteen 10213 271 19100 Research 0 19200 Physicians Private Offices 247590 6570 19300 Nonpaid W orkers 0 19301 Public Relations 17078 516937 105 19302 0 19303 0 19304 0
TOTAL 27387427 0 0 0 0 0 0 0 0 45829099 110886 COST TO BE ALLOCATED 1210541 0 0 0 0 0 0 0 0 11228341 900789 UNIT COST MULTIPLIER - SCH 8 0044201 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0000000 0245005 8123559
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 1382 900 Housekeeping 624
1000 Dietary 3987 3987 1100 Cafeteria 1153 1153 1200 Maintenance of Personnel 1300 Nursing Administration 833 833 3493 1400 Central Services and Supply 5945 0 5945 300 1500 Pharmacy 1189 1189 1105 1600 Medical Records amp Library 1569 1569 1472 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved) 0 2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 35373 140225 35373 35469 10861 198133 41861576
3100 Intensive Care Unit 6205 32112 6205 3385 2450 40726 8554460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) (CSTD REQUIS) REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
ANCILLARY COST CENTERS 5000 Operating Room 7924 18848 7924 8 1758 31614 14309479 5100 Recovery Room 5300 Anesthesiology 5867250 5400 Radiology-Diagnostic 4725 23395 4725 1317 2049 10793343 5401 Ultra Sound 177 177 546 5098375 5600 Radioisotope 945 942 945 179 1839 1732875 5700 Computed Tomography (CT) Scan 477 477 611 17089310 5800 Magnetic Resonance Imaging (MRI) 19 144113 5900 Cardiac Catheterization 0 6000 Laboratory 3072 431 3072 3747 1886 20925490 6001 GI Lab 700 1193 700 331 4909 4588397 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells 451924 6300 Blood Storing Processing amp Trans 0 6400 Intravenous Therapy 0 6500 Respiratory Therapy 1146 1146 1143 10623110 6600 Physical Therapy 4642 4642 0 1187297 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 140 512 140 306 9169134 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 2489391 9775274 7200 Implantable Devices Charged to Patients 5181268 7300 Drugs Charged to Patients 972254 30786573 7400 Renal Dialysis 6 6 1165060 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 41845 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 6607 109960 6607 589 4384 76561 48511384 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 92
Provider Nam e Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
OPER LAUNDRY HOUSE- DIETARY CAFETERIA MANT OF NURSING CENT SERV PHARMACY MED REC SOC SERV OTHER SVC PLANT amp LINEN KEEPING (MEALS (PAID PERSONNEL ADMIN amp SUPPLY (COST (GROSS (TIME (TIME (SQ FT) (LB LNDRY) (SQ FT) SERVED) FTES) (NURSE HR) CSTD REQUIS REQUIS) CHARGES) SPENT) SPENT)
700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 (Adj 24) (Adj 27) (Adj 24) (Adj 28) (Adj 29) (Adj 30) (Adj 26) (Adj 26)
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 271 271 19100 Research 19200 Physicians Private Offices 6570 6570 19300 Nonpaid W orkers 19301 Public Relations 105 105 32 19302 19303 19304
TOTAL 95767 327618 93761 39451 34054 0 357717 2489391 972254 247857537 0 0 COST TO BE ALLOCATED 3371982 453629 1019578 1423142 319524 0 2026419 990451 1592035 1674077 0 0 UNIT COST MULTIPLIER - SCH 8 35210267 1384628 10874228 36073664 9382855 0000000 5664866 0397869 1637468 0006754 0000000 0000000
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Approved)
2200 Intern amp Res Other Program Costs (Approved) 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 30936 30936
3100 Intensive Care Unit 460 460 3200 Coronary Care Unit 3300 Burn Intensive Care Unit 3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 4300
Subprovider (specify) Nursery
4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
ANCILLARY COST CENTERS 5000 Operating Room 8280 8280 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 18064 18064 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify) 10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA STATISTICS FOR COST ALLOCATION (WS B-1) SCHEDULE 93
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
NONPHY- NURSING IampR IampR PARAMEDICAL STAT STAT SICIAN ANE SCHOOL SVCampSAL OTHER PROG ED PROG
(ASG TIME) (ASG TIME) (ASG TIME) 1900 2000 2100 2200 2300 2301 2302
10500 Kidney Acquisition 10600 Heart Acquisition 10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
TOTAL 0 0 57740 57740 0 0 0 COST TO BE ALLOCATED 0 0 2025007 240630 0 0 0 UNIT COST MULTIPLIER - SCH 8 0000000 0000000 35071131 4167466 0000000 0000000 0000000
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
GENERAL SERVICE COST CENTERS 100 Capital Related Costs-Buildings and Fixtures $ 9739993 $ (6995329) $ 2744664 200 Capital Related Costs-Movable Equipment 2577485 (389486) 2187999 300 Other Capital Related Costs 0 0 0 301 0 0 302 0 0 303 0 0 304 0 0 305 0 0 306 0 0 307 0 0 308 0 0 309 0 0 400 Employee Benefits 409863 649071 1058934 501 0 0 502 0 0 503 0 0 504 0 0 505 0 0 506 0 0 507 0 0 508 0 0 500 Administrative and General 12477689 (1848024) 10629665 600 Maintenance and Repairs 560114 5207 565321 700 Operation of Plant 2014739 2309 2017048 800 Laundry and Linen Service 263543 0 263543 900 Housekeeping 755766 0 755766
1000 Dietary 714892 92206 807098 1100 Cafeteria 248666 (89304) 159362 1200 Maintenance of Personnel 0 0 1300 Nursing Administration 1477711 4643 1482354 1400 Central Services and Supply 456208 (150478) 305730 1500 Pharmacy 1126021 6906 1132927 1600 Medical Records amp Library 1163547 15395 1178942 1700 Social Service 0 0 1800 Other General Service (specify) 0 0 1900 Nonphysician Anesthetists 0 0 2000 Nursing School 0 0 2100 Intern amp Res Service-Salary amp Fringes (Approved) 1577375 0 1577375 2200 Intern amp Res Other Program Costs (Approved) 192612 664 193276 2300 Paramedical Ed Program (specify) 0 0 2301 0 0 2302 0 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 9107033 24077 9131110 3100 Intensive Care Unit 2452364 25223 2477587 3200 Coronary Care Unit 0 0 3300 Burn Intensive Care Unit 0 0 3400 Surgical Intensive Care Unit 0 0 3500 Other Special Care (specify) 0 0 4000 Subprovider - IPF 0 0 4100 Subprovider - IRF 0 0 4200 Subprovider (specify) 0 0 4300 Nursery 0 0 4400 Skilled Nursing Facility 0 0 4500 Nursing Facility 0 0 4600 Other Long Term Care 0 0 4700 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
ANCILLARY COST CENTERS 5000 Operating Room $ 1659142 $ (22584) $ 1636558 5100 Recovery Room 0 0 5300 Anesthesiology 0 0 5400 Radiology-Diagnostic 1300400 621 1301021 5401 Ultra Sound 454209 0 454209 5600 Radioisotope 206030 0 206030 5700 Computed Tomography (CT) Scan 458725 0 458725 5800 Magnetic Resonance Imaging (MRI) 16908 0 16908 5900 Cardiac Catheterization 0 0 0 6000 Laboratory 3307280 91061 3398341 6001 GI Lab 295165 (3116) 292049 6100 PBP Clinical Laboratory Services-Program Only 0 0 0 6200 W hole Blood amp Packed Red Blood Cells 292724 (292721) 3 6300 Blood Storing Processing amp Trans (292721) 292721 0 6400 Intravenous Therapy 0 0 6500 Respiratory Therapy 1111797 11741 1123538 6600 Physical Therapy 239587 1423 241010 6700 Occupational Therapy 0 0 0 6800 Speech Pathology 0 0 0 6900 Electrocardiology 265465 1093 266558 7000 Electroencephalography 0 0 0 7100 Medical Supplies Charged to Patients 2347539 215989 2563528 7200 Implantable Devices Charged to Patients 558092 0 558092 7300 Drugs Charged to Patients 972254 0 972254 7400 Renal Dialysis 260774 0 260774 7500 ASC (Non-Distinct Part) 0 0 0 7501 Other Ancillary (specify) 0 0 0 7700 0 0 7800 0 0 7900 0 0 8000 0 0 8100 0 0 8200 0 0 8300 0 0 8400 0 0 8500 0 0 8600 0 0 8700 0 0 8701 0 0 8800 Rural Health Clinic (RHC) 0 0 8900 Federally Qualified Health Center (FQHC) 0 0 9000 Clinic 0 0 9100 Emergency 4119875 7041 4126916 9200 Observation Beds 0 0 9300 Other Outpatient Services (Specify) 0 0 9301 0 0 9302 0 0 9303 0 0 9304 0 0 9305 0 0
SUBTOTAL $ 64888866 $ (8343651) $ 56545215 NONREIMBURSABLE COST CENTERS
9400 Home Program Dialysis 0 0 9500 Ambulance Services 0 0 9600 Durable Medical Equipment-Rented 0 0 9700 Durable Medical Equipment-Sold 0 0
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA SCHEDULE 10
TRIAL BALANCE OF EXPENSES
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
REPORTED (From Sch 10A) ADJUSTMENTS AUDITED
9800 Other Reimbursable (specify) 0 0 9900 Outpatient Rehabilitation Provider (specify) 0 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 0 10100 Home Health Agency 0 0 10500 Kidney Acquisition 0 0 10600 Heart Acquisition 0 0 10700 Liver Acquisition 0 0 10800 Lung Acquisition 0 0 10900 Pancreas Acquisition 0 0 11000 Intestinal Acquisition 0 0 11100 Islet Acquisition 0 0 11200 Other Organ Acquisition (specify) 0 0 11300 Interest Expense 0 0 11400 Utilization Review-SNF 0 0 11500 Ambulatory Surgical Center (Distinct Part) 0 0 11600 Hospice 0 0 11700 Other Special Purpose (specify) 0 0 19000 Gift Flower Coffee Shop amp Canteen 0 0 19100 Research 0 0 19200 Physicians Private Offices 0 0 19300 Nonpaid W orkers 0 0 19301 Public Relations 512225 0 512225 19302 0 0 19303 0 0 19304 0 0
SUBTOTAL $ 512225 $ 0 $ 512225 200 TOTAL $ 65401091 $ (8343651) $ 57057440
(To Schedule 8)
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures ($6995329) (7230419) (105867) 340957 200 Capital Related Costs-Movable Equipment (389486) (271572) (117914) 300 Other Capital Related Costs 0 301 0 302 0 303 0 304 0 305 0 306 0 307 0 308 0 309 0 400 Employee Benefits 649071 649071 501 0 502 0 503 0 504 0 505 0 506 0 507 0 508 0 500 Administrative and General (1848024) 36662 (649071) (763089) (472526) 600 Maintenance and Repairs 5207 12451 (7244) 700 Operation of Plant 2309 2309 800 Laundry and Linen Service 0 900 Housekeeping 0
1000 Dietary 92206 2902 89304 1100 Cafeteria (89304) (89304) 1200 Maintenance of Personnel 0 1300 Nursing Administration 4643 4643 1400 Central Services and Supply (150478) 5546 (156024) 1500 Pharmacy 6906 6906 1600 Medical Records amp Library 15395 15395 1700 Social Service 0 1800 Other General Service (specify) 0 1900 Nonphysician Anesthetists 0 2000 Nursing School 0 2100 Intern amp Res Service-Salary amp Fringes (Appr 0 2200 Intern amp Res Other Program Costs (Approve 664 664 2300 Paramedical Ed Program (specify) 0 2301 0 2302 0
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 24077 27830 (3753) 3100 Intensive Care Unit 25223 25223 3200 Coronary Care Unit 0 3300 Burn Intensive Care Unit 0
3400 Surgical Intensive Care Unit 0 3500 Other Special Care (specify) 0 4000 Subprovider - IPF 0 4100 Subprovider - IRF 0 4200 Subprovider (specify) 0 4300 Nursery 0 4400 Skilled Nursing Facility 0 4500 Nursing Facility 0 4600 Other Long Term Care 0 4700 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEMBER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
ANCILLARY COST CENTERS 5000 Operating Room (22584) 9788 (32372) 5100 Recovery Room 0 5300 Anesthesiology 0 5400 Radiology-Diagnostic 621 813 (192) 5401 Ultra Sound 0 5600 Radioisotope 0 5700 Computed Tomography (CT) Scan 0 5800 Magnetic Resonance Imaging (MRI) 0 5900 Cardiac Catheterization 0 6000 Laboratory 91061 99454 (8393) 6001 GI Lab (3116) (3116) 6100 PBP Clinical Laboratory Services-Program Only 0 6200 W hole Blood amp Packed Red Blood Cells (292721) (292721) 6300 Blood Storing Processing amp Trans 292721 292721 6400 Intravenous Therapy 0 6500 Respiratory Therapy 11741 11741 6600 Physical Therapy 1423 1423 6700 Occupational Therapy 0 6800 Speech Pathology 0 6900 Electrocardiology 1093 1093 7000 Electroencephalography 0 7100 Medical Supplies Charged to Patients 215989 215989 7200 Implantable Devices Charged to Patients 0 7300 Drugs Charged to Patients 0 7400 Renal Dialysis 0 7500 ASC (Non-Distinct Part) 0 7501 Other Ancillary (specify) 0 7700 0 7800 0 7900 0 8000 0 8100 0 8200 0 8300 0 8400 0 8500 0 8600 0 8700 0 8701 0 8800 Rural Health Clinic (RHC) 0 8900 Federally Qualified Health Center (FQHC) 0 9000 Clinic 0 9100 Emergency 7041 19180 (12139) 9200 Observation Beds 0 9300 Other Outpatient Services (Specify) 0 9301 0 9302 0 9303 0 9304 0 9305 0
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 0 9500 Ambulance Services 0 9600 Durable Medical Equipment-Rented 0 9700 Durable Medical Equipment-Sold 0 9800 Other Reimbursable (specify) 0 9900 Outpatient Rehabilitation Provider (specify) 0
10000 Intern-Resident Service (not appvd tchng prgm) 0 10100 Home Health Agency 0
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA
Provider Name CHINO VALLEY MEDICAL CENTER
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 1
Fiscal Period Ended DECEM BER 31 2011
TOTAL ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ (Page 1 amp 2) 3 4 5 6 7 8-13 14 15 16-19 20
0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
($8343651) 0 (To Sch 10)
0 0 0 0 (7230419) (986870) 353408 (472526) (7244) 0 0
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
GENERAL SERVICE COST CENTER 100 Capital Related Costs-Buildings and Fixtures 200 Capital Related Costs-Movable Equipment 300 Other Capital Related Costs 301 302 303 304 305 306 307 308 309 400 Employee Benefits 501 502 503 504 505 506 507 508 500 Administrative and General 600 Maintenance and Repairs 700 Operation of Plant 800 Laundry and Linen Service 900 Housekeeping
1000 Dietary 1100 Cafeteria 1200 Maintenance of Personnel 1300 Nursing Administration 1400 Central Services and Supply 1500 Pharmacy 1600 Medical Records amp Library 1700 Social Service 1800 Other General Service (specify) 1900 Nonphysician Anesthetists 2000 Nursing School 2100 Intern amp Res Service-Salary amp Fringes (Appro 2200 Intern amp Res Other Program Costs (Approved 2300 Paramedical Ed Program (specify) 2301 2302
INPATIENT ROUTINE COST CENTERS 3000 Adults amp Pediatrics (Gen Routine) 3100 Intensive Care Unit 3200 Coronary Care Unit 3300 Burn Intensive Care Unit
3400 Surgical Intensive Care Unit 3500 Other Special Care (specify) 4000 Subprovider - IPF 4100 Subprovider - IRF 4200 Subprovider (specify) 4300 Nursery 4400 Skilled Nursing Facility 4500 Nursing Facility 4600 Other Long Term Care 4700
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
ANCILLARY COST CENTERS 5000 Operating Room 5100 Recovery Room 5300 Anesthesiology 5400 Radiology-Diagnostic 5401 Ultra Sound 5600 Radioisotope 5700 Computed Tomography (CT) Scan 5800 Magnetic Resonance Imaging (MRI) 5900 Cardiac Catheterization 6000 Laboratory 6001 GI Lab 6100 PBP Clinical Laboratory Services-Program Only
6200 W hole Blood amp Packed Red Blood Cells 6300 Blood Storing Processing amp Trans 6400 Intravenous Therapy 6500 Respiratory Therapy 6600 Physical Therapy 6700 Occupational Therapy 6800 Speech Pathology 6900 Electrocardiology 7000 Electroencephalography 7100 Medical Supplies Charged to Patients 7200 Implantable Devices Charged to Patients 7300 Drugs Charged to Patients 7400 Renal Dialysis 7500 ASC (Non-Distinct Part) 7501 Other Ancillary (specify) 7700 7800 7900 8000 8100 8200 8300 8400 8500 8600 8700 8701 8800 Rural Health Clinic (RHC) 8900 Federally Qualified Health Center (FQHC) 9000 Clinic 9100 Emergency 9200 Observation Beds 9300 Other Outpatient Services (Specify) 9301 9302 9303 9304 9305
NONREIMBURSABLE COST CENTERS 9400 Home Program Dialysis 9500 Ambulance Services 9600 Durable Medical Equipment-Rented 9700 Durable Medical Equipment-Sold 9800 Other Reimbursable (specify) 9900 Outpatient Rehabilitation Provider (specify)
10000 Intern-Resident Service (not appvd tchng prgm)
10100 Home Health Agency
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
STATE OF CALIFORNIA ADJUSTMENTS TO REPORTED COSTS SCHEDULE 10A Page 2
Provider Name Fiscal Period Ended CHINO VALLEY MEDICAL CENTER DECEM BER 31 2011
10500 Kidney Acquisition 10600 Heart Acquisition
10700 Liver Acquisition 10800 Lung Acquisition 10900 Pancreas Acquisition 11000 Intestinal Acquisition 11100 Islet Acquisition 11200 Other Organ Acquisition (specify) 11300 Interest Expense 11400 Utilization Review-SNF 11500 Ambulatory Surgical Center (Distinct Part) 11600 Hospice 11700 Other Special Purpose (specify) 19000 Gift Flower Coffee Shop amp Canteen 19100 Research 19200 Physicians Private Offices 19300 Nonpaid W orkers 19301 Public Relations 19302 19303 19304
20000 TOTAL
AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ AUDIT ADJ
0 0 0 0 0 0 0 0 0 0 0 0 0
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
MEMORANDUM ADJUSTMENTS
1 The services provided to Medi-Cal inpatients in Noncontract acute hospitals are subject to various reimbursement limitations identified in AB 5 These limitations are addressed on Noncontract Schedule A and are incorporated on Noncontract Schedule 1 Line 9 W ampI Code 1401519 and 14166245
2 1 E-3 VII XIX 4300 100 Protested Amounts To eliminate protested amounts 42 CFR 41320 41324 and 4135 CMS Pub 15-1 Sections 2300 and 2304 CMS Pub 15-2 Section 1152
$228878 ($228878) $0
Page 1
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
3 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
4 10A A 10A A
200 500 700
1000 1300 1400 1500 1600 2200 3000 3100 5000 5400 6000 6500 6600 6900 9100
1000 1100
7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Capital Related Costs-Movable Equipment Administrative and General Operation of Plant Dietary Nursing Administration Central Services and Supply Pharmacy Medical Records and Library Intern and Residents Other Program Costs (Approved) Adults and Pediatrics (General Routine Care) Intensive Care Unit Operating Room Radiology-Diagnostic Laboratory Respiratory Therapy Physical Therapy Electrocardiology Emergency
To reverse the providers reclassification of departmental equipment rental expense in order to directly assign the costs 42 CFR 41324 CMS Pub 15-1 Sections 23024A 2304 and 2307A
Dietary Cafeteria
To reverse the providers abatement of cafeteria revenue against Dietary cost center and to abate the revenue against the related cost 42 CFR 4139 CMS Pub 15-1 Section 2328D CMS Pub 15-2 Section 3613
Balance carried forward from priorto subsequent adjustments
$2577485 12477689 2014739
714892 1477711
456208 1126021 1163547
192612 9107033 2452364 1659142 1300400 3307280 1111797
239587 265465
4119875
$717794 248666
($271572) 36662 2309 2902 4643 5546 6906
15395 664
27830 25223 9788
813 99454 11741 1423 1093
19180
$89304 (89304)
$2305913 12514351 2017048
717794 1482354
461754 1132927 1178942
193276 9134863 2477587 1668930 1301213 3406734 1123538
241010 266558
4139055
$807098 159362
Page 2
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
5 10A A 10A A
6 10A A 10A A 10A A 10A A 10A A 10A A 10A A 10A A
7 10A A 10A A
400 500
1400 3000 5000 5400 6000 6001 9100 7100
6200 6300
7 7
7 7 7 7 7 7 7 7
7 7
RECLASSIFICATIONS OF REPORTED COSTS
Employee Benefits Administrative and General
To reclassify FICA and Health Plan costs to agree with the providers general ledger 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304
Central Services and Supply Adults and Pediatrics Operating Room Radiology-Diagnostic Laboratory G I Laboratory Emergency Medical Supplies Charged to Patients
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
W hole Blood and Packed Red Blood Cells Blood Storing Processing and Trans
To adjust the providers reclassification of Central Services and Supplies to Medical Supplies Charged to Patients to agree with the providers general ledger 42 CFR 41320 41324 and 41350 CMS Pub 15-1 Sections 2300 2304 and 2306
Balance carried forward from priorto subsequent adjustments
$409863 12514351
$461754 9134863 1668930 1301213 3406734
295165 4139055 2347539
$292724 (292721)
$649071 (649071)
($156024) (3753)
(32372) (192)
(8393) (3116)
(12139) 215989
($292721) 292721
$1058934 11865280
$305730 9131110 1636558 1301021 3398341
292049 4126916 2563528
$3 0
Page 3
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
8
9
10
11
12
13
100 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures
To eliminate parking lot rent expenses due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate hospital lease expenses paid to MPT 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate apartment rent expenses paid to a related party 42 CFR 4139(c)(3) CMS Pub 15-1 Section 21023
To eliminate auto expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To include cost of ownership in lieu of MPT lease expenses 42 CFR 41317 41320 and 41324 CMS Pub 15-1 Sections 10115 2300 and 2304
To eliminate the rent paid for employee for the convenience of the provider 42 CFR 4139(c)(3) CMS Pub 15-1 Sections 21023 and 21443
Balance carried forward from priorto subsequent adjustments
$9739993
($3600000)
(5797796)
(60000)
(46241)
2284406
(10788) ($7230419) $2509574
Page 4
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
14 10A A 10A A 10A A
15 10A A 10A A
100 200 500
100 600
7 7 7
7 7
ADJUSTMENTS TO REPORTED COSTS
Capital Related Costs-Buildings and Fixtures Capital Related Costs-Movable Equipment Administrative and General
To adjust reported home office costs to agree with the Prime Healthcare Services Inc Home Office Audit Report for fiscal period ended December 31 2011 42 CFR 41317 and 41324 CMS Pub 15-1 Sections 21502 and 2304
Capital Related Costs-Buildings and Fixtures Maintenance and Repairs
To include the property taxes and repair expenses to agree with the providers property tax bills and repair invoices 42 CFR 41320 and 41324 W ampI Code 141242(b)
Balance carried forward from priorto subsequent adjustments
$2509574 2305913 11865280
$2403707 560114
($105867) (117914) (763089)
$340957 12451
$2403707 2187999
11102191
$2744664 572565
Page 5
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
10A A
16
17
18
19
20 10A A
500
600
7
7
ADJUSTMENTS TO REPORTED COSTS
Administrative and General
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To eliminate interest expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
To abate interest income against interest expense 42 CFR 413153(b)(2)(iii) CMS Pub 15-1 Section 2022 CMS Pub 15-2 Section 3613
To eliminate other direct expense due to lack of documentation 42 CFR 41320 41324 and 431107 CMS Pub 15-1 Sections 2300 and 2304 W ampI Code 141242(b)
Maintenance and Repairs To eliminate the profit factor for the maintenance and repairs expenses from Bio Med Services Inc a related party 42 CFR 41312 CMS Pub 15-1 Section 1005
Balance carried forward from priorto subsequent adjustments
$11102191
$572565
($10779)
(359220)
(30832)
(71695) ($472526)
($7244)
$10629665
$565321
Page 6
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
21 8 B I 8 B I 8 B I 8 B I
3000 3100 5000 9100
25 25 25 25
ADJUSTMENTS TO REPORTED COSTS
Adults and Pediatrics Intensive Care Unit Operating Room Emergency
To reverse the providers post step-down adjustment relating to Interns and Residents teaching costs 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2120 2300 and 2304
($1240290) (18443)
(331962) (724224)
$1240290 18443
331962 724224
$0 0 0 0
Page 7
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
22 9 B-1 9 B-1 9 B-1 9 B-1
23 9 B-1 9 B-1
24 9 B-1 9 B-1 9 B-1 9 B-1
25 9 B-1 9 B-1
26 9 B-1 9 B-1 9 B-1 9 B-1
ADJUSTMENTS TO REPORTED STATISTICS
600 12 Maintenance and Repairs (Square Feet) 700 12 Operation of Plant
7400 12 Renal Dialysis 12 12 Total - Square Feet
700 6 Operation of Plant (Square Feet) 600 6 Total - Square Feet
7400 6 7 9 Renal Dialysis (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To adjust square footage statistics to agree with the providers documentation 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
19200 12 Physicians Private Offices (Square Feet) 12 12 Total - Square Feet
19200 679 Physicians Private Offices (Square Feet) 600 6 Total - Square Feet 700 7 Total - Square Feet 900 9 Total - Square Feet
To establish square footage statistics for a nonreimbursable cost center 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2306 and 2328
Balance carried forward from priorto subsequent adjustments
19317 0 0
124316
0 89191
0 104310
89191 87185
0 124322
0 104316 89197 87191
(15119) 15119
6 6
15119 15119
6 6 6 6
6570 6570
6570 6570 6570 6570
4198 15119
6 124322
15119 104310
6 104316 89197 87191
6570 130892
6570 110886 95767 93761
Page 8
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
27 9 B-1 9 B-1
28 9 B-1 9 B-1 9 B-1 9 B-1 9 B-1
29 9 B-1 9 B-1 9 B-1 9 B-1
30 9 B-1 9 B-1
1400 5000
3000 3100 5000 9100 1000
1300 2100 6600 1100
5600 1300
8 8
10 10 10 10 10
11 11 11 11
13 13
ADJUSTMENTS TO REPORTED STATISTICS
Central Services and Supply (Pounds of Laundry) Operating Room
To adjust pounds of laundry statistics to agree with the providers laundry usage report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Adults and Pediatrics (Meals Served) Intensive Care Unit Operating Room Emergency Total - Meals Served
To adjust meal served statistics to agree with the providers patient meals report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Nursing Administration (FTEs) Intern and Res Service-Salary and Fringes (Approved) Physical Therapy Total - FTEs
To adjust FTEs statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
Radioisotope (Direct Nursing Hours) Total - Direct Nursing Hours
To adjust direct nursing hours statistics to agree with the providers Dollars and Hours report 42 CFR 41324 and 41350 CMS Pub 15-1 Sections 2304 and 2306
3805 15043
46776 5353
0 0
52129
1310 2184
306 34361
1027 356905
(3805) 3805
(11307) (1968)
8 589
(12678)
2183 (2184)
(306) (307)
812 812
0 18848
35469 3385
8 589
39451
3493 0 0
34054
1839 357717
Page 9
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
31 4 D-1 I XIX 4A D-1 II XIX
32 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX 6 D-3 XIX
33 2 E-3 VII XIX 2 E-3 VII XIX
34 3 E-3 VII XIX 3 E-3 VII XIX
35 1 E-3 VII XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
900 1 Medi-Cal Days - Adults and Pediatrics 229500 4300 4 Medi-Cal Days - Intensive Care Unit 33200
5000 2 Medi-Cal Ancillary Charges - Operating Room $2372682 5300 2 Medi-Cal Ancillary Charges - Anesthesiology 812663 5400 2 Medi-Cal Ancillary Charges - Radiology-Diagnostic 744425 5401 2 Medi-Cal Ancillary Charges - Ultra Sound 273774 5600 2 Medi-Cal Ancillary Charges - Radioisotope 201256 5700 2 Medi-Cal Ancillary Charges - Computed Tomography (CT) Scan 1104906 6000 2 Medi-Cal Ancillary Charges - Laboratory 2539230 6200 2 Medi-Cal Ancillary Charges - W hole Blood and Packed Red Blood Cells 168194 6500 2 Medi-Cal Ancillary Charges - Respiratory Therapy 1944943 6600 2 Medi-Cal Ancillary Charges - Physical Therapy 140110 6900 2 Medi-Cal Ancillary Charges - Electrocardiology 1664507 7100 2 Medi-Cal Ancillary Charges - Medical Supplies Charged to Patients 1472234 7200 2 Medi-Cal Ancillary Charges - Implantable Devices Charged to Patients 496326 7300 2 Medi-Cal Ancillary Charges - Drugs Charged to Patients 4193928 7400 2 Medi-Cal Ancillary Charges - Renal Dialysis 266026 9100 2 Medi-Cal Ancillary Charges - Emergency 2228177
20000 2 Medi-Cal Ancillary Charges - Total 20623381
800 1 Medi-Cal Routine Service Charges $6182850 900 1 Medi-Cal Ancillary Service Charges 20623381
3200 1 Medi-Cal Deductible $19255 3300 1 Medi-Cal Coinsurance 161322
4100 1 Medi-Cal Interim Payments $6628834
-Continued on next pageshy
Balance carried forward from priorto subsequent adjustments
42200 5400
$212202 66751 50444 22123 5001
61530 (36019)
8390 280274 14249
292353 260162 77884
379343 18434
117556 1830677
$2308250 1830677
($368) 18454
$628047
271700 38600
$2584884 879414 794869 295897 206257
1166436 2503211
176584 2225217
154359 1956860 1732396
574210 4573271
284460 2345733
22454058
$8491100 22454058
$18887 179776
$7256881
Page 10
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
State of California Department of Health Care Services
Provider Name CHINO VALLEY MEDICAL CENTER
Fiscal Period JANUARY 1 2011 THROUGH DECEMBER 31 2011
Provider NPI 1962407460 38
Adjustments
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
-Continued from previous pageshy
36 4 D-1 I XIX 4A D-1 II XIX
ADJUSTMENTS TO REPORTED MEDI-CAL SETTLEMENT DATA - NONCONTRACT
To adjust Medi-Cal Settlement Data to agree with the following Fiscal Intermediary Payment Data Service Period January 1 2011 through December 31 2011 Payment Period January 1 2011 through July 15 2013 Report Date July 25 2013 42 CFR 41320 41324 41350 41353 41360 41364 and 433139 CMS Pub 15-1 Sections 2300 2304 2404 and 2408 CCR Title 22 Sections 51173 51511 51541 and 51542
900 1 Medi-Cal Days - Adults and Pediatrics 271700 4300 4 Medi-Cal Days - Intensive Care Units 38600
To eliminate Medi-Cal days for billed Medi-Cal days by 25 and 50 for claims submitted during the 7th through the 9th month (RAD Code 475) and 10th through the 12th month (RAD 476) after the month of services respectively 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Section 514581 W ampI Code 14115
Balance carried forward from priorto subsequent adjustments
(850) (025)
270850 38575
Page 11
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12
State of California Department of Health Care Services
Provider Name Fiscal Period Provider NPI Adjustments CHINO VALLEY MEDICAL CENTER JANUARY 1 2011 THROUGH DECEMBER 31 2011 1962407460 38
Report References
Explanation of Audit Adjustments As
Reported Increase
(Decrease) As
Adjusted Adj No
Audit Report
Cost Report W ork Sheet Part Title Line Col
ADJUSTMENTS TO OTHER MATTERS
1 Not Reported
37
38
Medi-Cal Overpayments
To recover outstanding Medi-Cal credit balances 42 CFR 41320 and 41324 CMS Pub 15-1 Sections 2300 and 2304 CCR Title 22 Sections 50761 and 514581
To recover Medi-Cal overpayments because the Share of Cost was not properly deducted from the amount billed 42 CFR 4135 and 41320 CMS Pub 15-1 Sections 2300 and 2409 CCR Title 22 Sections 50786 and 514581
$0
$19340
4004 $23344 $23344
Page 12