AI6032DHS 0240 0811 BLCREGINA

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REPORT
ON THE
RATE SETTING AUDIT
BETHESDA LUTHERAN COMMUNITIES – REGINA
MISSION VIEJO, CALIFORNIA
PROVIDER NUMBER: LTC60787F
NPI NUMBER: 1417010604
FISCAL PERIOD ENDED
AUGUST 31, 2011

Audits Section - Fresno
Financial Audits Branch
Audits and Investigations
Department of Health Care Services

Section Chief: Michael Harrold
Audit Supervisor: Kathy Atkins
Auditor: Susan Calvino

State of California—Health and Human Services Agency

Department of Health Care Services
TOBY DOUGLAS
DIRECTOR

EDMUND G. BROWN JR.
GOVERNOR

January 29, 2013
Jack Tobias, CFO
Bethesda Lutheran Communities
600 Hoffmann Drive
Watertown, WI 53094
BETHESDA LUTHERAN HOMES – REGINA
NATIONAL PROVIDER IDENTIFIER (NPI) 1417010604
FISCAL PERIOD ENDED AUGUST 31, 2011
We have examined the facility's financial records/Medi-Cal Cost Report for the
above-referenced fiscal period. Our examination was made under the authority of
Section 14170 of the Welfare and Institutions Code and, accordingly, included such
tests of the accounting records and such other auditing procedures as we considered
necessary in the circumstances.
In our opinion, the data presented in the accompanying audit report schedules
represent a proper determination of the allowable costs, patient days, and use of share
of cost for the above fiscal period in accordance with Medi-Cal reimbursement
principles. The results of our examination are as follows:
COST AND COST PER DAY
Reported Cost/Cost Per Day
Net Audit Adjustment
Audited Cost/Cost Per Day

$
$

COST
446,055
(2,369)
443,686

COST PER DAY
$ 203.68
(1.08)
$ 202.60

This audit report includes the:
1.

Audit Report Schedules 1 and 2

2.

Audit Adjustments Schedule

Future Medi-Cal long-term care prospective rates may be affected by this examination.
The extent to which the rates change will be determined by the Department's Medi-Cal
Benefits, Waiver Analysis and Rates Division.

Financial Audits Branch/Audits Section—Fresno
1782 East Bullard Avenue, Suite 101, Fresno, CA 93710 - 5856
Telephone: (559) 446-2458 / Fax: (559) 446-2477
Internet Address: www.dhcs.ca.gov

Jack Tobias
Page 2

Notwithstanding this audit report, overpayments to the provider are subject to recovery
pursuant to Section 51458.1, Article 6 of Division 3, Title 22, California Code of
Regulations.
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)
Assistant Chief Counsel
Department of Health Care Services
Office of Legal Services
MS 0010
PO Box 997413
Sacramento, CA 95899

Courier (UPS, FedEx, etc.)
Assistant Chief Counsel
Department of Health Care Services
Office of Legal Services
MS 0010
1501 Capitol Avenue, Suite 71.5001
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.If
you have questions regarding this report, you may call the Audits Section—Fresno at
(559) 446-2458.
Original Signed By
Michael A. Harrold, Chief
Audits Section—Fresno
Financial Audits Branch
Certified

STATE OF CALIFORNIA

DDH/DDN SCHEDULE 1
SUMMARY OF AUDITED FACILITY CENSUS
AND AUDITED CLIENT COST PER DAY

Provider:
BETHESDA LUTHERAN COMMUNITIES - REGINA

Fiscal Period:
SEPTEMBER 1, 2010 THROUGH AUGUST 31, 2011

Provider NPI:
1417010604
AS
REPORTED

SUMMARY OF AUDITED FACILITY CENSUS
AND AUDITED CLIENT COST PER DAY

AS
AUDITED

1.

Medi-Cal Client Days (Adj )

0

2.

Medi-Cal Managed Care Days (Adj )

3.

Other Client Days (Adj )

4.

Total Client Days

5.

Total Client Care Expenses (From Sch. 2)

$

446,055 $

443,686

6.

AVERAGE CLIENT COST PER DAY (Line 4 / Line 3)

$

203.68 $

202.60

2,190

2,190
0

2,190

2,190

SHARE OF COST
1.

Share of Cost Audit Adjustment (Adj )

$

NA

$

0

0 $
0 $
0 $

0
0
0

OVERPAYMENTS
1.
2.
3.

Duplicate Payments (Adj )
Credit Balances (Adj )
Total Overpayments

$
$
$

STATE OF CALIFORNIA

DDH/DDN SCHEDULE 2
SUMMARY OF AUDITED FACILITY EXPENSES

Provider:
BETHESDA LUTHERAN COMMUNITIES - REGINA

Fiscal Period:
SEPTEMBER 1, 2010 THROUGH AUGUST 31, 2011

Provider NPI:
1417010604

Line
No.

DESCRIPTION

AS
REPORTED
Col. 1

ADJ
NO.

AUDIT
ADJUSTMENT
Col. 2

AS
AUDITED
Col. 3

EXPENSES: CLIENT SERVICES
Basic Facility Cost - Property Expenses
045
050
055
060
065
070

Depreciation and Amortization
Leases and Rentals
Real Property Taxes
Personal Property Taxes
Mortgage Interest
Property Insurance

$

13,603 $
0
78
0
0
2,496

$

13,603
0
78
0
0
2,496

075

TOTAL PROPERTY EXPENSES (Lines 045 through 070)

$

16,177 $

0 $

16,177

$

6,018 $
13,541
6,236
11,197
6,032

(688) $

(495)

5,330
13,541
6,173
11,197
5,537

Basic Facility Cost - General Home Expenses
080
085
090
095
100

Home Operations and Maintenance
Utilities
Client Transportation (excluding Adult Day Services)
Dietary
Personal Care and Laundry

2

105

TOTAL GENERAL HOME EXPENSES (Lines 080 through 100)

$

43,024 $

(1,246) $

41,778

110

TOTAL BASIC FACILITY COST (Lines 075 plus 105)

$

59,201 $

(1,246) $

57,955

3
4-5

(63)

EXPENSES: DIRECT CARE STAFF COSTS
115
120
125
130
135
140
145
150

QMRP Salaries
QMRP Fringe Benefits
Lead Salaries
Lead Fringe Benefits
Aides Salaries
Aides Fringe Benefits
Other Salaries
Other Fringe Benefits

$

27,448 $
10,976
19,403
7,759
143,630
57,434
13,456
5,381

$

27,448
10,976
19,403
7,759
143,630
57,434
13,456
5,381

155

TOTAL DIRECT CARE STAFF COSTS (Lines 115 through 150)

$

285,487 $

0 $

285,487
Page 1 of 2

STATE OF CALIFORNIA

DDH/DDN SCHEDULE 2
SUMMARY OF AUDITED FACILITY EXPENSES

Provider:
BETHESDA LUTHERAN COMMUNITIES - REGINA

Fiscal Period:
SEPTEMBER 1, 2010 THROUGH AUGUST 31, 2011

Provider NPI:
1417010604

Line
No.

DESCRIPTION

AS
REPORTED
Col. 1

ADJ
NO.

AUDIT
ADJUSTMENT
Col. 2

AS
AUDITED
Col. 3

EXPENSES: CONSULTANT COSTS
160
165
170
175
180
185
190
195
200
205
210
215

Dietician Consultant
Speech Pathology Consultant
Physical Therapy Consultant
Occupational Therapy Consultant
Pharmacist Consultant
Nurse Consultant
Psychologist Consultant
Physician Consultant
Recreational Consultant
Social Service Consultant
Other Consultant
TOTAL CONSULTANT COST (Lines 160 through 210)

1
6
7
8
1

$

9
10

$

1,038 $
575
700
765
530
0
193
0
580
0
0
4,381 $

90 $
(150)
(200)
(270)
(90)
(193)
(260)

(1,073) $

1,128
425
500
495
440
0
0
0
320
0
0
3,308

EXPENSES: ADMINISTRATIVE COSTS
220
225
226
230
235

Administrative Salaries **
Administrative Fringe Benefits
Quality Assurance Fees (excluding Adult Day Services)
Other General and Administrative***
Adult Day Services)

$

0 $
0
13,862

$

0
0
13,862

83,124
96,986 $

(50)
(50) $

83,074
96,936

$

446,055 $
(To Sch. 1)

(2,369) $

$

0 $
0

$

$

446,055 $

(2,369) $

(Excluding

11

TOTAL ADMINISTRATIVE COST (Lines 220 through 230)
TOTAL COSTS RELATED TO CLIENT CARE
(Lines 110, 155, 215 and 235)

$

443,686
(To Sch. 1)

NON-CLIENT CARE EXPENSES
240
241
245

Non-Program Services
Adult Day Services and Related Transportation
TOTAL FACILITY EXPENSES
(Lines 110, 155, 215, 235, 240 and 241)

0
0
443,686
Page 2 of 2

**
***

List only direct administrative salaries incurred at the facility level
List allocated administrative costs on Line 230

1

Adj.
No.

4.1
4.1

180
160

4
4

2
2

180
160

3
3

Pharmacist Consultant
Dietician Consultant
To reclassify dietician consultant expense for proper cost reporting.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300, 2302.4 and 2302.8

Explanation of Audit Adjustments
RECLASSIFICATION OF REPORTED COSTS
$530
1,038

As
Reported

SEPTEMBER 1, 2010 THROUGH AUGUST 31, 2011

Report References
Cost Report
Audit Report
DHS 3076
Page or
Exhibit
Line
Col.
Sch.
Line
Col

Provider NPI
1417010604

Fiscal Period

BETHESDA LUTHERAN COMMUNITIES - REGINA

($90)
90

Increase
(Decrease)

Page

$440
1,128

As
Adjusted

11

1

Adjustments

Department of Health Care Services

Provider Name

State of California

165

4

2

165

3

Personal Care and Laundry

Speech Pathology Consultant
To eliminate speech therapy expense due to lack of documentation.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300 and 2304
W&I Code 14124.2(b)

4.1

3

Client Transportation
To eliminate client transportation expense due to insufficient
documentation.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300 and 2304

Home Operations and Maintenance
To eliminate home operations and maintenance expense due to la
of documentation
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300 and 2304
W&I Code 14124.2(b)

6

100

3

3

To eliminate personal care and laundry expense due to insufficient
documentation.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300 and 2304

2

090

080

5

4

2

2

To eliminate items not included in the routine rate.
CCR, Title 22, 51510.2

100

4

4

4

Explanation of Audit Adjustments
ADJUSTMENTS TO REPORTED COSTS

4

090

4

3

080

4

2

Adj.
No.

$575

$6,032

$6,236

$6,018

As
Reported

SEPTEMBER 1, 2010 THROUGH AUGUST 31, 2011

Report References
Cost Report
Audit Report
DHS 3076
Page or
Exhibit
Line
Col.
Sch.
Line
Col

Provider NPI
1417010604

Fiscal Period

BETHESDA LUTHERAN COMMUNITIES - REGINA

($150)

(45)
($495)

($450)

($63)

($688)

Increase
(Decrease)

Page

$425

$5,537

$6,173

$5,330

As
Adjusted

11

2

Adjustments

Department of Health Care Services

Provider Name

State of California

4.1

4.1

4.1

4.1

4.1

7

8

9

10

11

Adj.
No.

230

200

190

175

170

4

4

4

4

4

2

2

2

2

2

230

200

190

175

170

3

3

3

3

3

Other General and Administrative
To eliminate nonallowable bank overdraft fees.
42 CFR 413.9(c)(3)
CMS Pub. 15-1, Sections 2102.3 and 2105.10

Recreational Consultant
To adjust recreational consultant expense to agree with the provider's
records.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300 and 2304

Psychologist Consultant
To reclassify consultant fees not included in the rate and billable
separately.
42 CFR 413.20 and 413.24 / CMS Pub. 15-1, Sections 2300 and 2304
CCR, Title 22, Section 51511(c)

Occupational Therapy Consultant
To eliminate occupational therapy expense due to lack of
documentation.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300 and 2304
W&I Code 14124.2(b)

Physical Therapy Consultant
To eliminate duplicate physical therapy expense.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300 and 2304

Explanation of Audit Adjustments
ADJUSTMENTS TO REPORTED COSTS

$83,124

$580

$193

$765

$700

As
Reported

SEPTEMBER 1, 2010 THROUGH AUGUST 31, 2011

Report References
Cost Report
Audit Report
DHS 3076
Page or
Exhibit
Line
Col.
Sch.
Line
Col

Provider NPI
1417010604

Fiscal Period

BETHESDA LUTHERAN COMMUNITIES - REGINA

($50)

($260)

($193)

($270)

($200)

Increase
(Decrease)

Page

$83,074

$320

$0

$495

$500

As
Adjusted

11

3

Adjustments

Department of Health Care Services

Provider Name

State of California



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