AI6032DHS 0240 0811 BLCREGINA

User Manual: AI6032DHS

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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 EDMUND G. BROWN JR.
DIRECTOR 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 COST COST PER DAY
Reported Cost/Cost Per Day $ 446,055 $ 203.68
Net Audit Adjustment (2,369) (1.08)
Audited Cost/Cost Per Day $ 443,686 $ 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) 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 71.5001
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.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: Fiscal Period:
BETHESDA LUTHERAN COMMUNITIES - REGINA SEPTEMBER 1, 2010 THROUGH AUGUST 31, 2011
Provider NPI:
1417010604
AS AS
SUMMARY OF AUDITED FACILITY CENSUS REPORTED AUDITED
AND AUDITED CLIENT COST PER DAY
1. Medi-Cal Client Days (Adj ) 0
2. Medi-Cal Managed Care Days (Adj ) 2,190 2,190
3. Other Client Days (Adj ) 0
4. Total Client Days 2,190 2,190
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
SHARE OF COST
1. Share of Cost Audit Adjustment (Adj ) $ NA $ 0
OVERPAYMENTS
1. Duplicate Payments (Adj ) $ 0 $ 0
2. Credit Balances (Adj ) $ 0 $ 0
3. Total Overpayments $ 0 $ 0
STATE OF CALIFORNIA DDH/DDN SCHEDULE 2
SUMMARY OF AUDITED FACILITY EXPENSES
Provider: Fiscal Period:
BETHESDA LUTHERAN COMMUNITIES - REGINA SEPTEMBER 1, 2010 THROUGH AUGUST 31, 2011
Provider NPI:
1417010604
Line
No.
DESCRIPTION ADJ
NO. Col. 1
AS
REPORTED
AUDIT
ADJUSTMENT
Col. 2
AS
Col. 3
AUDITED
EXPENSES: CLIENT SERVICES
Basic Facility Cost - Property Expenses
045 Depreciation and Amortization $ 13,603 $ $ 13,603
050 Leases and Rentals 0 0
055 Real Property Taxes 78 78
060 Personal Property Taxes 0 0
065 Mortgage Interest 0 0
070 Property Insurance 2,496 2,496
075 TOTAL PROPERTY EXPENSES (Lines 045 through 070) $ 16,177 $ 0 $ 16,177
Basic Facility Cost - General Home Expenses
080 Home Operations and Maintenance 2 $ 6,018 $ (688) $ 5,330
085 Utilities 13,541 13,541
090 Client Transportation (excluding Adult Day Services) 3 6,236 (63) 6,173
095 Dietary 11,197 11,197
100 Personal Care and Laundry 4-5 6,032 (495) 5,537
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
EXPENSES: DIRECT CARE STAFF COSTS
115 QMRP Salaries $ 27,448 $ $ 27,448
120 QMRP Fringe Benefits 10,976 10,976
125 Lead Salaries 19,403 19,403
130 Lead Fringe Benefits 7,759 7,759
135 Aides Salaries 143,630 143,630
140 Aides Fringe Benefits 57,434 57,434
145 Other Salaries 13,456 13,456
150 Other Fringe Benefits 5,381 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: Fiscal Period:
BETHESDA LUTHERAN COMMUNITIES - REGINA SEPTEMBER 1, 2010 THROUGH AUGUST 31, 2011
Provider NPI:
1417010604
Line
No.
DESCRIPTION ADJ
NO. Col. 1
REPORTED
AS AUDIT
Col. 2
ADJUSTMENT
AS
AUDITED
Col. 3
EXPENSES: CONSULTANT COSTS
160 Dietician Consultant 1 $ 1,038 $ 90 $ 1,128
165 Speech Pathology Consultant 6 575 (150) 425
170 Physical Therapy Consultant 7 700 (200) 500
175 Occupational Therapy Consultant 8 765 (270) 495
180 Pharmacist Consultant 1 530 (90) 440
185 Nurse Consultant 0 0
190 Psychologist Consultant 9 193 (193) 0
195 Physician Consultant 0 0
200 Recreational Consultant 10 580 (260) 320
205 Social Service Consultant 0 0
210 Other Consultant 0 0
215 TOTAL CONSULTANT COST (Lines 160 through 210) $ 4,381 $ (1,073) $ 3,308
EXPENSES: ADMINISTRATIVE COSTS
220 Administrative Salaries ** $ 0 $ $ 0
225 Administrative Fringe Benefits 0 0
226 Quality Assurance Fees (excluding Adult Day Services) 13,862 13,862
230
Other General and Administrative***
(Excluding
Adult Day Services)
11 83,124 (50) 83,074
235 TOTAL ADMINISTRATIVE COST (Lines 220 through 230) $ 96,986 $ (50) $ 96,936
TOTAL COSTS RELATED TO CLIENT CARE
(Lines 110, 155, 215 and 235) $ 446,055 $ (2,369) $ 443,686
NON-CLIENT CARE EXPENSES
(To Sch. 1) (To Sch. 1)
240 Non-Program Services $ 0 $ $ 0
241 Adult Day Services and Related Transportation 0 0
245 TOTAL FACILITY EXPENSES
(Lines 110, 155, 215, 235, 240 and 241) $ 446,055 $ (2,369) $ 443,686
Page 2 of 2
** List only direct administrative salaries incurred at the facility level
*** List allocated administrative costs on Line 230
State of California Department of Health Care Services
Provider Name
BETHESDA LUTHERAN COMMUNITIES - REGINA
Fiscal Period
SEPTEMBER 1, 2010 THROUGH AUGUST 31, 2011
Provider NPI
1417010604 11
Adjustments
Report References
Explanation of Audit Adjustments
As
Reported Increase
(Decrease) As
Adjusted
Adj.
No.
Cost Repor
t
A
udit Repor
t
DHS 3076
Page or
Exhibit Line Col. Sch. Line Col
RECLASSIFICATION OF REPORTED COSTS
1 4.1 180 4 2 180 3 Pharmacist Consultant $530 ($90) $440
4.1 160 4 2 160 3 Dietician Consultant 1,038 90 1,128
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
Page 1
State of California Department of Health Care Services
Provider Name
BETHESDA LUTHERAN COMMUNITIES - REGINA
Fiscal Period
SEPTEMBER 1, 2010 THROUGH AUGUST 31, 2011
Provider NPI
1417010604 11
Adjustments
Report References
Explanation of Audit Adjustments
As
Reported Increase
(Decrease) As
Adjusted
Adj.
No.
Cost Repor
t
A
udit Repor
t
DHS 3076
Page or
Exhibit Line Col. Sch. Line Col
ADJUSTMENTS TO REPORTED COSTS
2 4 080 4 2 080 3 Home Operations and Maintenance $6,018 ($688) $5,330
To eliminate home operations and maintenance expense due to la
of documentation
42 CFR 413.20 and 413.2
4
CMS Pub. 15-1, Sections 2300 and 2304
W&I Code 14124.2(b)
3 4 090 4 2 090 3 Client Transportation $6,236 ($63) $6,173
To eliminate client transportation expense due to insufficient
documentation.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300 and 2304
4 100 4 2 100 3 Personal Care and Laundry $6,032
4 To eliminate items not included in the routine rate. ($450)
CCR, Title 22, 51510.2
5 To eliminate personal care and laundry expense due to insufficient (45)
documentation. ($495) $5,537
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300 and 2304
6 4.1 165 4 2 165 3 Speech Pathology Consultant $575 ($150) $425
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)
Page 2
State of California Department of Health Care Services
Provider Name
BETHESDA LUTHERAN COMMUNITIES - REGINA
Fiscal Period
SEPTEMBER 1, 2010 THROUGH AUGUST 31, 2011
Provider NPI
1417010604 11
Adjustments
Report References
Explanation of Audit Adjustments
As
Reported Increase
(Decrease) As
Adjusted
Adj.
No.
Cost Repor
t
A
udit Repor
t
DHS 3076
Page or
Exhibit Line Col. Sch. Line Col
ADJUSTMENTS TO REPORTED COSTS
7 4.1 170 4 2 170 3 Physical Therapy Consultant $700 ($200) $500
To eliminate duplicate physical therapy expense.
42 CFR 413.20 and 413.24
CMS Pub. 15-1, Sections 2300 and 2304
8 4.1 175 4 2 175 3 Occupational Therapy Consultant $765 ($270) $495
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)
9 4.1 190 4 2 190 3 Psychologist Consultant $193 ($193) $0
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)
10 4.1 200 4 2 200 3 Recreational Consultant $580 ($260) $320
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
11 4.1 230 4 2 230 3 Other General and Administrative $83,124 ($50) $83,074
To eliminate nonallowable bank overdraft fees.
42 CFR 413.9(c)(3)
CMS Pub. 15-1, Sections 2102.3 and 2105.10
Page 3

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