Florida Agency For Health Care Administration 000169300 -2016… › ... › ICF_Not_Public_July_2016.pdf · 2016-07-07 · Florida Agency For Health Care Administration Office of

Florida Agency For Health Care Administration Office of Medicaid Cost Reimbursement Planning and Finance

000169300 - 2016/07

Rl:264.64 / NM:0.00

St. Augustine Center for Living

5155 U.S. 1 South

St. Augustine, FL 32086

Provider Type: ICF/IID

Level of Care

#7 Institutional

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Current Rate

250.83 #8 Non-Ambulatory & #9 Medical 0.00

Rate Type:

Provider Number: 000169300

Date: 6/23/2016

FYE: 11/30/2015

Audit Status: Unaudited

New Rate

Effective Date

264.64 7/1/2016

0.00 7/1/2016

Interim X Prospective

Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component

Settlement Based on Costs

Budget

Unaudited Costs

Field Audited Costs

Field Audit - Interim Portion

Comments:

Printed on: 6/23/2016 3:28 PM.Batch ID: Y7R2F. User ID: FDHC\pridgeoc

X Total Prospective

Prospective Adjusted for New Cost

Desk Audited Costs

Desk Audit - Interim Portion

Desk Audit - Prospective Portion

W.Rydell Samuel

Medicaid Cost Reimbursement Analysis

For Information only - No Change in rate

Provider Name:

Provider Number:

Audit Status:

Date:


ICF/IID Profile Sheet

Rate Period(s) 07/2016 to 7/2016

St. Augustine Center for Living Cost Report Entered By :

00169300 Rate Semester :

Unaudited Cost Report :

6/23/2016 Days In Reporting Period:

Number of Beds:

Column A Column B

000169300

Pridgeon, Chantelle

July, 2016

12/1/2014 - 11/30/2015

365

60

Column C Total Residential Non-Ambulatory Medical Institutional

A. Allocation of Exgenses (excluding B & C)

1 . Resident Days 21,577 0 21,577

2. Operating Expenses component

A. Administration 687,779

B. Plant Operation 275,104

C. Laundry 26,968

D. Housekeeping 55,766

E. Operating Expense Component & Per Diem 48.4598 1,045,617

3. Resident Care

A. Dietary 401,600

B. Other 0

C. Nursing 402,249

D. Resident Care & Per Diem 37.2549 803,849

4. Prop Exp & Per Diem 24.9602 538,567

5. ROE/Use Per Diem 0.5814 12,544

B. Direct Care Exgense

1. Staffing 0.50 1.00

2.Total Staffing Required 10,788.50 0.00 10,788.50

3. Staffing Percent 1.00 0.00 1.00

4. Allocation of Direct Care 2,184,457.00 0.00 2,184,457.00

5. Direct Care Expense Per Diem 101.2401 0.0000

C. Additional Services Exgense

1. Medicaid Inpatient Days 21,577 0 21,577

2. Additional Services 358,065 0 358,065

3. Additional Services Exp & Per Diem 16.5948 0.0000

D. Medicaid Per Diem Cost

1.0perating Component 48.4598 0.0000 1,045,617

2. Resident Care Component 155.0898 0.0000 3,346,371

3. Property Cost Component 24.9602 0.0000 538,567

4. ROE/Use Allow Component 0.5814 0.0000 12,544

5. Total Cost Per Diem 229.0912 0.0000 4,943,099 Printed on: 6/23/2016 8:41 AM, Batch ID: Y7R2F

Resident Care Component Per-Diem Calculation

Facility Name: St. Augustine Center for Living

A3D Allowable Resident Care Exp

B5 Allocation of D/C Expenses

C3 Additional Services per Diem

Total Resident Care Component

Printed on: 6/23/2016 8:41 AM

No N/M Days

R/1 N/M

37.2549 0.0000

101.2401 0.0000

16.5948 0.0000

155.0898 0.0000


FYE: 11/30/2015





TOTALS

803,849

2,184,457

358,065

3,346,371

Florida Agency for Health Care Administration

Office of Medicaid Cost Reimbursement Planning and Finance

ICF/110 Calculation Sheet

Rates Effective 07/01/2016 through 06/30/2017

St. Augustine Center for Living

Ownership:Private

Incentive Rating: Ineligible from 04/28/2016 - 04/30/2016 Days Eligible: 363 of 366

Eligibility Factor : 99.18%

Fiscal Year Begin Fiscal Year End Audit Status

I Current Cost Report 12/1/2014 11/30/2015 Unaudited

Prior Cost Report 12/1/2012 11/30/2013 Unaudited

Residential / Institutional

000169300 · 2016/07

RI: 264.64

NM: 0.00

Base Semester

201507

Non-Ambulatory/ Medical

Operating Resident Care Total Operating Resident Care Total

1.Prior Period Base: 47.926 153.873 201.800 0.000 0.000 0.000

2.lnflate Line 1 by Inflation Factor 1.04531341 50.0981 160.846 210.944 0.0001 0.0001 0.000

3.Line 1 X 1.4000 X Inflation Factor 1.06343877 50.967 163.635 214.602 0.0001 o.oooj 0.000

4.Current Period Cost 48.460 155.090 203.550 0.0001 00001 0.000

5.lncentive Basis (line 3 - line 4) 2.507 8.545 0 0001 0.0001

6.Allowed Current Period Costs (Min of line 3 or 4) 48.460 155.090 203.550 o.oooj 0.0001 0.000

?.Incentive Line 5 x Oper 50% Res 50% 1.253 4273 5.526 0.0001 0 0001 0 000

8.lncentive - Line 4 x Oper 10% Res 3% 48461 4.653 9.499 0 0001 0 0001 0.000

9.lncentive - Min of Line 7,8 x Eligibility factor 99.18% 1.2431 4 238 5.481 0.0001 00001 0.000

1 O.Final Incentive 1.2431 4.238 5.481 0.0001 0.0001 0.000

11.Current Period Base: (line 6 + line 10) I 49.7031 159.327 209.030 0.0001 0.0001 0.000

12.Plus: Property Rate Component 24.960

1

0.000

13.Plus: ROE/Use Rate 0.581 0.000

14.Total Current Period Base 234.572 I 0.000

15.Prospective Rate: Line 11 x Inflation 1.04097721 51.740 165.856 217.596 0.0001 0 0001 0 000

16.lnterim Rate Component: 0.000 0.000 0.000 0.0001 0 0001 0.000

17.NA 0.000 0.000 0.000 0.0001 0 0001 0.000

18.Total Operating & Residential Care Rate 51.740 I 165.856 217.596 0.0001 00001 0.000

19.Property Rate Component 24.960 I 0.000

20.ROE Component+ ROE Interim Component 0.581 I 0.000

21.Plus: Property Interim Rate Component 0.000 I 0.000

22.Final Per Diem 243.14 0.00 -------- . .. ···----------- -- ·--·······-··------- ..

23.Medicaid Days 21,577 0

24.Resident Days I 21,577 0

25.Medicaid Utilization I 100.00% 0.00%

26.Quality Assessment ($21.06) 21.06 0.00

27.Less or Plus: Buy Back - OAF (.001684964) 0.45 0.00

28.Less Rate Cut (0%) Based on Days 0.00 0.00

29. 0.00 0.00

30.Final Per Diem After Adjustments 264.64 0.00

Printed on 6/23/2016 8:43 AM Batch ID: Y7R2F


001069500 - 2016/07

Rl:385.94 / NM:461.57

Minor North

85609 Miner Road

Yulee, FL 32097


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 5/31/2015


New Rate

Effective Date

385.94 7/1/2016

461.57 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs


Care Centers of Nassau, LLC

95146 Hendricks Road

Fernandina Beach, FL 32034

Comments:

Printed on: 6/23/2016 3:28 PM.Batch ID: Y7R2F, User ID: FDHC\pridgeoc

X Total Prospective


Desk Audited Costs



W.Rydell Samuel





001069500


Provider Name: Minor North



Date: 6/23/2016

A. Allocation of ExQenses (excluding B & C)

1. Resident Days


A. Administration

B. Plant Operation

C. Laundry

D. Housekeeping

E. Operating Expense Component & Per Diem

3. Resident Care

A. Dietary

B. Other

C. Nursing

D. Resident Care & Per Diem

4. Prop Exp & Per Diem

5. ROE/Use Per Diem

B. Direct Care ExQense

1. Staffing

2.Total Staffing Required

3. Staffing Percent

4. Allocation of Direct Care

5. Direct Care Expense Per Diem

C. Additional Services ExQense

1. Medicaid Inpatient Days

2. Additional Services

3. Additional Services Exp & Per Diem


1. Operating Component

2. Resident Care Component

3. Property Cost Component

4. ROE/Use Allow Component

5. Total Cost Per Diem Printed on: 6/23/2016 8:41 AM, Batch ID: Y7R2F

Cost Report Entered By :

Rate Semester :

Cost Report :

Days In Reporting Period:

Number of Beds:

Pridgeon, Chantelle

July, 2016

6/1/2014 - 5/31/2015

365

24

Column A Column B Column C Total Residential Non-Ambulatory Medical Institutional

860 7,836 8,696

679,362

393,349

54,772

67,148

137.3771 137.3771 1,194,631

262,996

0

418,546

78.3742 78.3742 681,542

53.4646 53.4646 464,928

3.7762 3.7762 32,838

0.50 1.00

430.00 7,836.00 8,266.00

0.05 0.95 1.00

57,319.99 1,044,557.01 1,101,877.00

66.6512 133.3023

860 7,836 8,696

22,113 201,489 223,602

25.7128 25.7132

137.3771 137.3771 1,194,631

170.7382 237.3897 2,007,021

53.4646 53.4646 464,928

3.7762 3.7762 32,838

365.3561 432.0076 3,699,418


Facility Name: Minor North





Printed on: 6/23/2016 8:41 AM

R/1 & N/M Days

R/1 N/M

78.3742 78.3742

66.6512 133.3023

25.7128 25.7132

170.7382 237.3897


FYE: 05/31/2015





TOTALS

681,542

1,101,877

223,602

2,007,021





Minor North

Ownership:Private

Incentive Rating: Eligible from 05/01/2015 - 04/30/2016 Days Eligible: 366 of 366

Eligibility Factor: 100.00%




Residential/ Institutional

001069500 • 2016/07

RI: 385.94

NM: 461.57

Base Semester

201507

Non-Ambulatory / Medical



2.lnflate Line 1 by Inflation Factor 1.02343244 119.8511 168.7691 288.6201 119.8511 244 2781 364.130

3.Line 1 X 1.4000 X Inflation Factor 1.03280542 120.9491 170.3141 291 2631 120.9491 246.5151 367.464

4.Current Period Cost 137.3771 170.7381 308.1151 137 3771 237.3901 374.767

5.lncentive Basis (line 3 - line 4) 0.0001 00001 I 0.0001 9.1261

6.Allowed Current Period Costs (Min of line 3 or 4) 120.9491 170.3141 291.2631 120.9491 237.390 I 358.339

?.Incentive Line 5 x Oper 50% Res 50% 0 0001 0.0001 0.0001 0 0001 4.5631 4.563

8.lncentive - Line 4 x Oper 10% Res 3% 0.0001 0.0001 0.0001 00001 7 1221 7.122

9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% 0.0001 0.0001 0 0001 0.0001 45631 4.563

1 a.Final Incentive 0.0001 0.0001 0.0001 0.0001 45631 4.563

11.Current Period Base: (line 6 + line 10) 120.9491 170.3141 291.2631 120.9491 241.9531 362.902

12.Plus: Property Rate Component I 53.4651 I 53.465

13.Plus: ROE/Use Rate I 3.7761 I 3.776

14.Total Current Period Base I 348.5041 I 420.142

15.Prospective Rate: Line 11 x Inflation 1.05398512 127.4781 179.5091 306.9871 127.4781 255.0141 382.493

16.lnterim Rate Component: 0.0001 0 0001 0.0001 0.0001 0 0001 0.000

17.NA 0.0001 0.0001 0.0001 0.0001 0.0001 0.000

18.Total Operating & Residential Care Rate 127.4781 179.5091 306.9871 127.4781 255.0141 382.493

19.Property Rate Component I 53.4651 I 53.465

20.ROE Component+ ROE Interim Component I 3 7761 I 3.776

21.Plus: Property Interim Rate Component I 0.0001 I 0.000

22.Final Per Diem I 364.231 439.73 23.Medicaid Days

I 860

I 7,836

24.Resident Days 860 7,836

25.Medicaid Utilization I 100.00% I 100.00%

26.Quality Assessment ($21.06) I 21.061 21.06

27.Less or Plus: Buy Back - QAF (.001684964) I 0.651 0.78

28.Less Rate Cut (0%) Based on Days I 0.001 0.00

29.

I 0.001 0.00


Printed on: 6/23/2016 8:43 AM Batch ID: Y7R2F


001071000 - 2016/07

Rl:354.32 / NM:427.64

Minor South

854 7 4 Miner Road

Yulee, FL 32097


Level of Care

#7 Institutional



Current Rate

336.25

#8 Non-Ambulatory & #9 Medical 416.86

Rate Type:


Date: 6/23/2016

FYE: 5/31/2015


New Rate

Effective Date

354.32 7/1/2016

427.64 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs





Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel





001071000


Provider Name: Minor South



Date: 6/23/2016


1. Resident Days


A. Administration

B. Plant Operation

C. Laundry

D. Housekeeping


3. Resident Care

A. Dietary

B. Other

C. Nursing



5. ROE/Use Per Diem


1. Staffing


3. Staffing Percent








1.0perating Component






Rate Semester :

Cost Report :


Number of Beds:

Pridgeon, Chantelle

July, 2016

6/1/2014 - 5/31/2015

365

24


1,095 7,637 8,732

650,061

368,897

51,804

43,433

127.5991 127.5991 1,114,195

273,737

0

255,220

60.5768 60.5768 528,957

52.5514 52.5514 458,879

3.7503 3.7503 32,748

0.50 1.00

547.50 7,637.00 8,184.50

0.07 0.93 1.00

70,574.22 984,429.78 1,055,004.00

64.4513 128.9027

1,095 7,637 8,732

25,925 180,810 206,735

23.6758 23.6755

127.5991 127.5991 1,114,195

148.7039 213.1550 1,790,696

52.5514 52.5514 458,879

3.7503 3.7503 32,748

332.6047 397.0558 3,396,518


Facility Name: Minor South





Printed on: 6/23/2016 8:41 AM

R/1 & N/M Days

R/1 N/M

60.5768 60.5768

64.4513 128.9027

23.6758 23.6755

148.7039 213.1550


FYE: 05/31/2015





TOTALS

528,957

1,055,004

206,735

1,790,696



ICF/IID Calculation Sheet


Minor South

Ownership:Private







001071000 - 2016/07

RI: 354.32

NM: 427.64

Base Semester

201507




2.lnflate Line 1 by Inflation Factor 1.02343244 111.0851 150.1321 2612171 111.0851 230.6631 341.748

3.Line 1 X 1.4000 X Inflation Factor 1.03280542 112.1021 1515071 263.6091 112.1021 232.7761 344.878

4.Current Period Cost 127.5991 148.7041 276.3031 127.5991 213.1551 340.754


6.Allowed Current Period Costs (Min of line 3 or 4) 1121021 148 7041 260.8061 112.1021 213.1551 325.257

?.Incentive Line 5 x Oper 50% Res 50% 0.0001 1.4011 1.4011 0.0001 9.8101 9.810

8.lncentive - Line 4 x Oper 10% Res 3% 00001 4.4611 4.4611 0 0001 6.3951 6.395

9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% 0.0001 1.4011 1.4011 0.0001 6.3951 6.395

10.Final Incentive 0.0001 1.4011 1.4011 0.0001 6.3951 6.395






16.lnterim Rate Component: 0 0001 0 0001 0.0001 0.0001 0.0001 0.000

17.NA 0.0001 0.0001 0.0001 0.0001 0.0001 0.000

18.Total Operating & Residential Care Rate 118.1541 158 2091 276.3631 118.1541 231.4021 349.556


20.ROE Component+ ROE Interim Component I 3 7501 I 3.750


22.Final Per Diem I 332.66i 405.86 23. Medicaid Days I 1,095 I 7,637

24.Resident Days I 1,095 I 7,637


26.0uality Assessment ($21.06) I 21.061 21.06

27.Less or Plus: Buy Back - OAF (.001684964) I 0.601 0.72

28.Less Rate Cut (0%) Based on Days I 0001 0.00

29.

I 0.001 0.00




012037000 - 2016/07

Rl:326.43 / NM:366.66

Bayview (Mentor)

2133 E 12th Street

Lynn Haven, FL 32444-3109


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 7/31/2015


New Rate

Effective Date

326.43 7/1/2016

366.66 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs


National Mentor Healthcare, LLC

3258 Parkside Center Circle

Tampa, FL 33619

Comments:

Printed on: 6/23/2016 3:28 PM,Batch ID Y7R2F, User ID: FDHC\pridgeoc

X Total Prospective


Desk Audited Costs



W.Rydell Samuel






Provider Name: Bayview (Mentor) Cost Report Entered By :

Provider Number: 12037000 Rate Semester :

Audit Status: Unaudited Cost Report :

Date: 6/23/2016 Days In Reporting Period:

Number of Beds:

012037000

Pridgeon, Chantelle

July, 2016

8/1/2014 - 7/31/2015

365

6



1. Resident Days 1,457 672 2,129




C. Laundry 0


E. Operating Expense Component & Per Diem 63.1691 63.1691 134,487

3. Resident Care

A. Dietary 18,360

B. Other 0

C. Nursing 79,289

D. Resident Care & Per Diem 45.8661 45.8661 97,649

4. Prop Exp & Per Diem 21.0117 21.0117 44,734

5. ROE/Use Per Diem 0.0000 0.0000 0


1. Staffing 0.75 1.00



4. Allocation of Direct Care 175,549.61 107,956.39 283,506.00




2. Additional Services 79,092 36,478 115,570



1.0perating Component 63.1691 63.1691 134,487

2. Resident Care Component 220.6372 260.7982 496,725


4. ROE/Use Allow Component 0.0000 0.0000 0

5. Total Cost Per Diem 304.8180 344.9790 675,946 Printed on: 6/23/2016 8:41 AM, Batch ID: Y7R2F


Facility Name: Bayview (Mentor)





Printed on: 6/23/2016 8:41 AM

R/1 & N/M Days

R/1 N/M

45.8661 45.8661

120.4870 160.6494

54.2841 54.2827

220.6372 260.7982


FYE: 07/31/2015





TOTALS

97,649

283,506

115,570

496,725





Bayview (Mentor)

Ownership:Private





Prior Cost Report


012037000 - 2016/07

RI: 326.43

NM: 366.66

Base Semester

201404




2.lnflate Line 1 by Inflation Factor 0.00000000 00001 0.0001 0 0001 0.0001 0.0001 0.000



5.lncentive Basis (line 3 - line 4) 0.0001 0.0001 I 00001 0.0001

6.Allowed Current Period Costs (Min of line 3 or 4) 63.1691 220 6371 283.8061 63.1691 260.7981 323.967

?.Incentive Line 5 x Oper 50% Res 50% 0.0001 0 0001 0.0001 0.0001 0.0001 0.000

8.lncentive - Line 4 x Oper 10% Res 3% 0 0001 0.0001 0 0001 0 0001 0.0001 0.000

9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% 0 0001 0.0001 0.0001 0.0001 0.0001 0 000

1 O.Final Incentive 0 0001 0.0001 0.0001 0.0001 0.0001 0.000



13.Plus: ROE/Use Rate I 00001 I 0.000



16.lnterim Rate Component: 0.0001 0 0001 0.0001 0.0001 0.0001 0.000

17.NA 0.0001 0.0001 0.0001 0.0001 0.0001 0.000

18.Total Operating & Residential Care Rate 63.1691 220.6371 283.8061 63 1691 260.7981 323.967


20.ROE Component+ ROE Interim Component I 00001 I 0.000



I 1,457

I 672

24.Resident Days 1,457 672


26.Quality Assessment ($21.06) I 21 061 21 06



29.

I 0.001 0.00




012038000 - 2016/07

Rl:384.92 / NM:425.21

Seaview (Mentor)

1204 West 13th Street

Panama City, FL 32401-2015


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 7/31/2015


New Rate

Effective Date

384.92 7/1/2016

425.21 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs


Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






Provider Name: Seaview (Mentor) Cost Report Entered By :




Number of Beds:

012038000

Pridgeon, Chantelle

July, 2016

8/1/2014 - 7/31/2015

365

6


A. Allocation of Expenses (excluding B & C)

1. Resident Days 884 728 1,612




C. Laundry 0



3. Resident Care

A. Dietary 18,360

B. Other 0

C. Nursing 79,289


4. Prop Exp & Per Diem 25.5949 25.5949 41,259

5. ROE/Use Per Diem 0.0000 0.0000 0

B. Direct Care Expense

1. Staffing 0.75 1.00

2.Total Staffing Required 663.00 728.00 1,391.00




C. Additional Services Expense

1. Medicaid Inpatient Days 884 728 1,612










Facility Name: Seaview (Mentor)





Printed on: 6/23/2016 8:41 AM

R/1 & N/M Days

R/1 N/M

60.5763 60.5763

152.8609 203.8145

71.6946 71.6923

285.1318 336.0831


FYE: 07/31/2015





TOTALS

97,649

283,506

115,570

496,725





Seaview (Mentor)

Ownership:Private





Prior Cost Report


012038000 - 2016/07

RI: 384.92

NM: 425.21

Base Semester

201404




2.lnflate Line 1 by Inflation Factor 0.00000000 0 0001 0.0001 0 0001 00001 0.0001 0.000

3.Line 1 X 1.4000 X Inflation Factor 0.00000000 00001 0.0001 0.0001 0.0001 0.0001 0.000


5.lncentive Basis (line 3 - line 4) 00001 0.0001 I 0.0001 0.0001

6.Allowed Current Period Costs (Min of line 3 or 4) 76.2481 263.5701 339.8181 76.2481 303.7901 380.038

?.Incentive Line 5 x Oper 50% Res 50% 0 0001 00001 0.0001 0.0001 0.0001 0.000

8.lncentive - Line 4 x Oper 10% Res 3% 0.0001 0 0001 0.0001 0.0001 0.0001 0.000


10.Final Incentive 0.0001 0.0001 0.0001 00001 0.0001 0.000

11.Current Period Base: (line 6 + line 10) 76.2481 263.5701 339.8181 76.2481 303.790 I 380.038


13 Plus: ROE/Use Rate I 0.0001 I 0.000

14.Total Current Period Base I 363 2101 I 403.430


16.lnterim Rate Component: 0.0001 0.0001 0 0001 00001 0.0001 0.000

17.NA 0 0001 0.0001 0.0001 0.0001 0.0001 0000



20.ROE Component+ ROE Interim Component I 0.0001 I 0.000


22.Final Per Diem I 363.21 I 403.43 23.Medicaid Days

I 884 I 728

24.Resident Days 884 I 728



27.Less or Plus: Buy Back - OAF (.001684964) I 0 651 0.72


29.

I 0.001 0.00




012040300 - 2016/07

Rl:384.92 / NM:425.21

Gulfview (Mentor)

2603 N State Ave E 12th ST

Panama City, FL 32405-4359


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 7/31/2015


New Rate

Effective Date

384.92 7/1/2016

425.21 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Tampa, FL 33619

Comments:

Printed on: 6/23/2016 3 28 PM,Batch ID: Y7R2F, User ID: FDHC\pridgeoc

X Total Prospective


Desk Audited Costs



W.Rydell Samuel





012040300


Provider Name: Gulfview (Mentor)



Date: 6/23/2016


1. Resident Days


A. Administration

B. Plant Operation

C. Laundry

D. Housekeeping


3. Resident Care

A. Dietary

B. Other

C. Nursing



5. ROE/Use Per Diem


1. Staffing


3. Staffing Percent














Rate Semester :

Cost Report :


Number of Beds:

Pridgeon, Chantelle

July, 2016

8/1/2014 - 7/31/2015

365

6


575 1,098 1,673

67,057

60,830

0

6,600

80.3867 80.3867 134,487

18,360

0

79,289

58.3676 58.3676 97,649

26.0825 26.0825 43,636

0.0000 0.0000 0

0.75 1.00

431.25 1,098.00 1,529.25

0.28 0.72 1.00

79,948.97 203,557.03 283,506.00

139.0417 185.3889

575 1,098 1,673

39,721 75,849 115,570

69.0800 69.0792

80.3867 80.3867 134,487

266.4893 312.8357 496,725

26.0825 26.0825 43,636

0.0000 0.0000 0

372.9585 419.3049 674,848


Facility Name: Gulfview (Mentor)





Printed on: 6/23/2016 8:41 AM

R/1 & N/M Days

R/1 N/M

58.3676 58.3676

139.0417 185.3889

69.0800 69.0792

266.4893 312.8357


FYE: 07/31/2015





TOTALS

97,649

283,506

115,570

496,725





Gulfview (Mentor)

Ownership: Private





Prior Cost Report


012040300 - 2016/07

RI: 384.92

NM: 425.21

Base Semester

201404

Non-Ambulatory I Medical



2.lnflate Line 1 by Inflation Factor 0.00000000 0.0001 0 0001 0.0001 0.0001 0.0001 0.000

3.Line 1 X 1.4000 X Inflation Factor 0.00000000 0.0001 0.0001 0.0001 0.0001 0.0001 0.000


5.lncentive Basis (line 3 - line 4) 0.0001 0.0001 I 0.0001 0.0001

6.Allowed Current Period Costs (Min of line 3 or 4) 77.8151 260.1471 337.9621 77.8151 300 3671 378.182

?.Incentive Line 5 x Oper 50% Res 50% 0.0001 0.0001 0.0001 0.0001 0 0001 0.000

8.lncentive - Line 4 x Oper 10% Res 3% 0.0001 0 0001 0.0001 0.0001 0.0001 0.000

9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% 0.0001 0.0001 00001 0.0001 0.0001 0.000

10.Final Incentive 00001 0.0001 0.0001 0.0001 0.0001 0.000




14.Total Current Period Base I 363.210 I I 403.430


16.lnterim Rate Component: 0.0001 0.0001 00001 00001 0.0001 0.000

17.NA 0.0001 0.0001 0.0001 00001 0.0001 0.000






I 575

I 1,098



26.Quality Assessment ($21.06) I 21.061 2106

27.Less or Plus: Buy Back - OAF (.001684964) I 0651 0.72


29.

I 0.001 0.00




012073200 - 2016/07

Rl:460.59 / NM:0.00

Suffridge Drive Group Home (Res-Care)

27566 Suffridge Drive

Bonita Springs, FL 33923


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 10/31/2015


New Rate

Effective Date

460.59 7/1/2016

0.00 7/1/2016

X Interim Prospective

X

Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Res-Care, Inc.

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs


10140 Linn Station Road

Louisville, KY 40223

Comments:


Total Prospective


Desk Audited Costs



W.Rydell Samuel






Provider Name: Suffridge Drive Group Home (Res-Care) Cost Report Entered By :




Number of Beds:

Column A Column B

012073200

Pridgeon, Chantelle

July, 2016

12/1/2013 - 10/31/2015

700

6



1. Resident Days 3,503 0 3,503




C. Laundry 1,812


E. Operating Expense Component & Per Diem 132.0619 462,613

3. Resident Care

A. Dietary 55,166

B. Other 0

C. Nursing 103,272


4. Prop Exp & Per Diem 22.7987 79,864

5. ROE/Use Per Diem 0.2498 875


1. Staffing 0.75 1.00



4. Allocation of Direct Care 661,667.00 0.00 661,667.00











5. Total Cost Per Diem 417.0944 0.0000 1,461,082 Printed on: 6/23/2016 8:41 AM. Batch ID: Y7R2F


Facility Name: Suffridge Drive Group Home (Res-Care)





Printed on: 6/23/2016 8:41 AM

No N/M Days

R/1 N/M

45.2292 0.0000

188.8858 0.0000

27.8690 0.0000

261.9840 0.0000


FYE: 10/31/2015





TOTALS

158,438

661,667

97,625

917,730





Suffridge Drive Group Home (Res-Care)

Ownership:Private





Prior Cost Report


012073200 - 2016/07

RI: 460.59

NM: 0.00

Base Semester

201304




2.lnflate Line 1 by Inflation Factor 0.00000000 0.0001 0.0001 00001 0.0001 0.0001 0.000


4.Current Period Cost 132.0621 261 9841 394.0461 0 0001 0.0001 0 000


6.Allowed Current Period Costs (Min of line 3 or 4) 132 0621 261.9841 394 0461 0.0001 0.0001 0.000

?.Incentive Line 5 x Oper 50% Res 50% 0.0001 0 0001 0.0001 0 0001 0.0001 0.000

8.lncentive - Line 4 x Oper 10% Res 3% 0.0001 00001 0.0001 0.0001 0.0001 0.000


1 O.Final Incentive 0.0001 0.0001 0.0001 0.0001 00001 0.000

11.Current Period Base: (line 6 + line 10) 132 0621 261.9841 394.0461 0.0001 0.0001 0.000




15.Prospective Rate: Line 11 x Inflation 1.05498204 139 3231 276.3881 415.7111 0.0001 0.0001 0.000

16.lnterim Rate Component: 00001 0.0001 0.0001 0.0001 0.0001 0.000

17.NA 0.0001 0.0001 0.0001 0.0001 0.0001 0.000






I 3,503

I 0






29.

I 0.001 0.00




012074200 - 2016/07

Rl:358.35 / NM:392.53

Coletta Drive Group Home (Res-Care)

1604 Coletta Drive

Orlando, FL 32807


Level of Care

#7 Institutional



Current Rate


Rate Type:

Provider Number: 01207 4200

Date: 6/23/2016

FYE: 10/31/2015


New Rate

Effective Date

358.35 7/1/2016

392.53 7/1/2016


X

Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Res-Care, Inc.

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Comments:


Total Prospective


Desk Audited Costs



W.Rydell Samuel



Provider Name:

Provider Number:

Audit Status:

Date:




Coletta Drive Group Home (Res-Care) Cost Report Entered By :




Number of Beds:

012074200

Pridgeon, Chantelle

July, 2016

12/1/2013 - 10/31/2015

700

6



1. Resident Days 3,000 1,088 4,088




C. Laundry 742



3. Resident Care

A. Dietary 47,866

B. Other 0

C. Nursing 31,844


4. Prop Exp & Per Diem 21.9680 21.9680 89,805

5. ROE/Use Per Diem 0.4670 0.4670 1,909


1. Staffing 0.75 1.00

2.Total Staffing Required 2,250.00 1,088.00 3,338.00





1. Medicaid Inpatient Days 3,000 1,088 4,088




1. Operating Component 117.2468 117.2468 479,305






Facility Name: Coletta Drive Group Home (Res-Care)

R/1 & N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

19.4985

97.0677

64.0603

180.6265

N/M

19.4985

129.4236

64.0460

212.9681


FYE: 10/31/2015





TOTALS

79,710

432,016

261,863

773,589





Coletta Drive Group Home (Res-Care)

Ownership:Private





Prior Cost Report


012074200 - 2016/07

RI: 358.35

NM: 392.53

Base Semester

201304





3.Line 1 X 1.4000 X Inflation Factor 0.00000000 0.0001 0.0001 0.0001 0.0001 00001 0.000

4.Current Period Cost 117 2471 180 6271 297 8731 117.2471 212 9681 330.215

5.lncentive Basis (line 3 - line 4) 00001 0.0001 I 00001 0.0001


7.lncentive Line 5 x Oper 50% Res 50% 0.0001 0.0001 0 0001 0.0001 0.0001 0.000

8.lncentive - Line 4 x Oper 10% Res 3% 0.0001 0.0001 0.0001 0.0001 0.0001 0.000


1 O.Final Incentive 0.0001 0.0001 0.0001 0 0001 0.0001 0.000






16.lnterim Rate Component: 0.0001 0.0001 0.0001 0.0001 00001 0.000

17.NA 0.0001 0.0001 0.0001 0.0001 0.0001 0.000




21.Plus: Property Interim Rate Component I 0 0001 I 0.000


I 3,000

I 1,088

24.Resident Days 3,000 1,088





29.

I 0.001 0.00




012074800 - 2016/07

Rl:327.81 / NM:361.70

Spring Street Group Home (Res-Care)

1463 Spring Street

Lake City, FL 32052


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 10/31/2015


New Rate

Effective Date

327.81 7/1/2016

361.70 7/1/2016


X

Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Res-Care, Inc.

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Comments:


Total Prospective


Desk Audited Costs



W.Rydell Samuel



Provider Name:

Provider Number:

Audit Status:

Date:




Spring Street Group Home (Res-Care) Cost Report Entered By :




Number of Beds:

012074800

Pridgeon, Chantelle

July, 2016

12/1/2013 - 10/31/2015

700

6


A. Allocation of Exgenses (excluding B & C}

1 . Resident Days 1,986 2,100 4,086




C. Laundry 2,372



3. Resident Care

A. Dietary 46,627

B. Other 0

C. Nursing 30,453


4. Prop Exp & Per Diem 18.0888 18.0888 73,911

5. ROE/Use Per Diem 0.3052 0.3052 1,247


1. Staffing 0.75 1.00
















Facility Name: Spring Street Group Home (Res-Care)

R/1 & N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

18.8644

96.1845

44.4396

159.4885

N/M

18.8644

128.2460

44.4481

191.5585


FYE: 10/31/2015





TOTALS

77,080

460,339

181,598

719,017





Spring Street Group Home (Res-Care)

Ownership:Private





Prior Cost Report


012074800 - 2016/07

RI: 327.81

NM: 361.70

Base Semester

201304





3.Line 1 X 1.4000 X Inflation Factor 0.00000000 0.0001 00001 0 0001 0 0001 0.0001 0.000



6.Allowed Current Period Costs (Min of line 3 or 4) 113.3131 159.4891 272.8011 113.3131 191 5591 304.871


8.lncentive - Line 4 x Oper 10% Res 3% 0.0001 0 0001 0 0001 0 0001 0.0001 0.000


1 a.Final Incentive 0.0001 0.0001 0.0001 0.0001 0.0001 0.000


12.Plus: Property Rate Component I 18 0891 I 18.089




16.lnterim Rate Component: 0.0001 0.0001 0.0001 0.0001 0.0001 0.000

17.NA 0.0001 0.0001 0.0001 0.0001 0.0001 0.000

18.Total Operating & Residential Care Rate 119 5431 168.2581 287.800 I 119 5431 202.0911 321.633

19.Property Rate Component I 18.0891 I 18 089


21.Plus: Property Interim Rate Component I 00001 I 0.000


I 1,986

I 2,100






29.

l 0.001 0.00




012075300 - 2016/07

Rl:382.05 / NM:420.18

Walnut Street Group Home (Res-Care)

102 Alexander Road

Starke, FL 32091


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 10/31/2015


New Rate

Effective Date

382.05 7/1/2016

420.18 7/1/2016


X

Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Res-Care, Inc.

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Comments:


Total Prospective


Desk Audited Costs



W.Rydell Samuel






Provider Name: Walnut Street Group Home (Res-Care) Cost Report Entered By :




Number of Beds:

012075300

Pridgeon, Chantelle

July, 2016

12/1/2013 - 10/31/2015

700

6


A. Allocation of Exi;1enses (excluding B & C)

1. Resident Days 2,800 1,400 4,200




C. Laundry 4,853



3. Resident Care

A. Dietary 49,297

B. Other 0

C. Nursing 43,542


4. Prop Exp & Per Diem 21.0536 21.0536 88,425

5. ROE/Use Per Diem 0.4424 0.4424 1,858

B. Direct Care Exi;1ense

1. Staffing 0.75 1.00





C. Additional Services Exi;1ense











Facility Name: Walnut Street Group Home (Res-Care)

R/1 & N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

22.1045

108.2884

61.0354

191.4283

N/M

22.1045

144.3846

61.0250

227.5141


FYE: 10/31/2015





TOTALS

92,839

505,346

256,334

854,519





Walnut Street Group Home (Res-Care)

Ownership: Private





Prior Cost Report


012075300 - 2016/07

RI: 382.05

NM: 420.18

Base Semester

201304





3.Line 1 X 1.4000 X Inflation Factor 0.00000000 0.0001 0 0001 0.0001 0 0001 0.0001 0.000

4.Current Period Cost 129.7641 191.4281 3211921 129.7641 227.5141 357.278






10.Final Incentive 0 0001 0.0001 0.0001 0.0001 0.0001 0.000






16.lnterim Rate Component: 0.0001 0.0001 0.0001 00001 0.0001 0.000

17.NA 0.0001 0.0001 0.0001 00001 0.0001 0.000

18.Total Operating & Residential Care Rate 136.8981 201 9531 338.8521 136 8981 240.0231 376.922

19.Property Rate Component I 21 0541 I 21.054


21.Plus: Property Interim Rate Component I 0.0001 I 0000


I 2,800

I 1,400






29.

I 0.001 0.00




012075700 - 2016/07

Rl:387.60 / NM:428.78

Bessent Road Group Home (Res-Care)

1329 Bessent Road

Starke, FL 32091


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 10/31/2015


New Rate

Effective Date

387.60 7/1/2016

428.78 7/1/2016


X

Basis

X

Distribution·

Contract Management

DPODS - DCF (4)

Home Office:

Res-Care, Inc.

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Comments:


Total Prospective


Desk Audited Costs



W.Rydell Samuel






Provider Name: Bessent Road Group Home (Res-Care) Cost Report Entered By :




Number of Beds:

012075700

Pridgeon, Chantelle

July, 2016

12/1/2013 - 10/31/2015

700

6



1. Resident Days 2,926 700 3,626




C. Laundry 1,571



3. Resident Care

A. Dietary 42,308

B. Other 0

C. Nursing 40,187


4. Prop Exp & Per Diem 19.4528 19.4528 70,536

5. ROE/Use Per Diem 0.1856 0.1856 673


1. Staffing 0.75 1.00
















Facility Name: Bessent Road Group Home (Res-Care)

R/1 & N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

22.7510

116.8541

56.6808

196.2859

N/M

22.7510

155.8055

56.7000

235.2565


FYE: 10/31/2015





TOTALS

82,495

450,979

205,538

739,012





Bessent Road Group Home (Res-Care)

Ownership:Private





Prior Cost Report


012075700 - 2016/07

RI: 387.60

NM: 428.78

Base Semester

201304



1.Prior Period Base: 0.000 0.000 0000 0.000 0.000 0.000

2.lnflate Line 1 by Inflation Factor 0.00000000 0 0001 0.0001 00001 0.0001 0 0001 0.000

3.Line 1 X 1.4000 X Inflation Factor 0.00000000 00001 0 0001 0.0001 0.0001 0.0001 0.000





8.lncentive - Line 4 x Oper 10% Res 3% 0 0001 0.0001 0.0001 0.0001 0.0001 0.000

9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% 0 0001 0.0001 0.0001 0 0001 0.0001 0.000

10.Final Incentive 0 0001 0.0001 0.0001 0.0001 0.0001 0.000




14.Total Current Period Base I 347.840 I I 386.810


16.lnterim Rate Component: 00001 0 0001 00001 0.0001 0.0001 0.000

17.NA 0.0001 0.0001 00001 0.0001 0.0001 0.000






I 2,926

I 700



26.Quality Assessment ($21.06) I 21 061 21.06



29.

I 0.001 0.00




012075900 - 2016/07

Rl:361.11 / NM:397.79

Frederick Avenue Group Home (Res-Care)

325 N Frederick Avenue

Daytona Beach, FL 32114


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 10/31/2015


New Rate

Effective Date

361.11 7/1/2016

397.79 7/1/2016


X

Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Res-Care, Inc.

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Comments:


Total Prospective


Desk Audited Costs



W.Rydell Samuel



Provider Name:

Provider Number:

Audit Status:

Date:




Frederick Avenue Group Home (Res- Cost Report Entered By : Care)

Rate Semester : 12075900



Number of Beds:

012075900

Pridgeon, Chantelle

July, 2016

12/1/2013 - 10/31/2015

700

6



1. Resident Days 3,500 700 4,200




C. Laundry 1,283



3. Resident Care

A. Dietary 50,255

B. Other 0

C. Nursing 75,527


4. Prop Exp & Per Diem 18.2988 18.2988 76,855

5. ROE/Use Per Diem 0.2129 0.2129 894


1. Staffing 0.75 1.00
















Facility Name: Frederick Avenue Group Home (Res-Care)

R/1 & N/M Days


85 Allocation of D/C Expenses



Printed on: 6/23/2016 8:41 AM

R/1

29.9481

104.0957

52.7654

186.8092

N/M

29.9481

138.7943

52.7771

221.5195


FYE: 10/31/2015





TOTALS

125,782

461,491

221,623

808,896





Frederick Avenue Group Home (Res-Care)

Ownership:Private




I

Current Cost Report 12/1/2013 10/31/2015 Unaudited

Prior Cost Report


012075900 - 2016/07

RI: 361.11

NM: 397.79

Base Semester

201304






4.Current Period Cost 117.3951 186.8091 304.2041 117.3951 221 5201 338.915



?.Incentive Line 5 x Oper 50% Res 50% 0.0001 0.0001 0.0001 0.0001 0 0001 0.000

8.lncentive - Line 4 x Oper 10% Res 3% 0.0001 0 0001 00001 0 0001 0 0001 0.000

9.lncentive - Min of Line 7,8 x Eligibility factor 86.89% 0 0001 0 0001 0 0001 0.0001 0.0001 0.000

1 O.Final Incentive 00001 0.0001 0 0001 0.0001 0.0001 0.000





15.Prospective Rate: Line 11 x Inflation 1.05498204 123.850 I 197.0801 320.9301 123.850 I 233.6991 357.549


17.NA 0.0001 0.0001 0.0001 0.0001 0.0001 0000




21.Plus: Property Interim Rate Component I o.oool I 0.000


I 3,500

I 700






29.

I 0.001 0.00

30.Final Per Diem After Adjustments 361.11 I 397.79



012373500 - 2016/07

Rl:336.07 / NM:368.69

107th Place Group Home (Res-Care)

2233 NW 41 st St Ste 300

Gainesville, FL 32606


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 10/31/2015


New Rate

Effective Date

336.07 7/1/2016

368.69 7/1/2016


X

Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Res-Care, Inc.

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Comments:


Total Prospective


Desk Audited Costs



W.Rydell Samuel



Provider Name:

Provider Number:

Audit Status:

Date:




107th Place Group Home (Res-Care) Cost Report Entered By :




Number of Beds:

012373500

Pridgeon, Chantelle

July, 2016

12/1/2013 - 10/31/2015

700

6



1. Resident Days 2,533 1,400 3,933




C. Laundry 1,879



3. Resident Care

A. Dietary 45,746

B. Other 0

C. Nursing 35,722


4. Prop Exp & Per Diem 19.2024 19.2024 75,523

5. ROE/Use Per Diem 0.2998 0.2998 1,179


1. Staffing 0.75 1.00
















Facility Name: 107th Place Group Home (Res-Care)

R/1 & N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

20.7140

92.5795

53.8152

167.1087

N/M

20.7140

123.4394

53.8236

197.9770


FYE: 10/31/2015





TOTALS

81,468

407,319

211,667

700,454





107th Place Group Home (Res-Care)

Ownership:Private





Prior Cost Report


012373500 - 2016/07

RI: 336.07

NM: 368.69

Base Semester

201304


Operating Resident Care Total Operating Resident Care I Total


2.lnflate Line 1 by Inflation Factor 0.00000000 0.0001 0 0001 0 0001 0.0001 0.0001 0.000

3.Line 1 X 1.4000 X Inflation Factor 0.00000000 0.0001 0.0001 00001 0.0001 0.0001 0.000




?.Incentive Line 5 x Oper 50% Res 50% 0.0001 0.0001 0.0001 0.0001 00001 0.000


9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% 0 0001 0.0001 0.0001 0.0001 0.0001 0.000

10.Final Incentive 0 0001 0.0001 0.0001 0.0001 0.0001 0.000





15.Prospective Rate: Line 11 x Inflation 1.05498204 118.6441 176.2971 294 9401 118.6441 208.8621 327.506


17.NA 0.0001 0.0001 0.0001 0.0001 0.0001 0.000






I 2,533

I 1,400






29.

I 0.001 0.00




012374200 - 2016/07

Rl:376.24 / NM:0.00

Second Street Group Home (Res-Care)

3841 SE 2nd Street

Ocala, FL 34471


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 10/31/2015


New Rate

Effective Date

376.24 7/1/2016

0.00 7/1/2016


X

Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Res-Care, Inc.

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Comments:


Total Prospective


Desk Audited Costs



W.Rydell Samuel






Provider Name: Second Street Group Home (Res-Care) Cost Report Entered By:

Provider Number: 1237 4200 Rate Semester :



Number of Beds:

Column A Column B

012374200

Pridgeon, Chantelle

July, 2016

12/1/2013 - 10/31/2015

700

6







C. Laundry 1,817



3. Resident Care

A. Dietary 43,230

B. Other 0

C. Nursing 38,989


4. Prop Exp & Per Diem 21.0880 79,333

5. ROE/Use Per Diem 0.2759 1,038


1. Staffing 0.75 1.00
















Facility Name: Second Street Group Home (Res-Care)





Printed on: 6/23/2016 8:41 AM

No N/M Days

R/1 N/M

21.8551 0.0000

111.5234 0.0000

56.7132 0.0000

190.0917 0.0000


FYE: 10/31/2015





TOTALS

82,219

419,551

213,355

715,125





Second Street Group Home (Res-Care)

Ownership:Private




I


Prior Cost Report


012374200 - 2016/07

RI: 376.24

NM: 0.00

Base Semester

201304





3.Line 1 X 1.4000 X Inflation Factor 0.00000000 0 0001 0.0001 0.0001 0 0001 0.0001 0.000


5.lncentive Basis (line 3 - line 4) 0.0001 0.0001 I 0.0001 0 0001

6.Allowed Current Period Costs (Min of line 3 or 4) 125.7261 190.0921 3158181 00001 0 0001 0.000









15.Prospective Rate: Line 11 x Inflation 1.05498204 132.6391 200.5431 333 1821 0.0001 0.0001 0.000

16.lnterim Rate Component: 0.0001 0.0001 00001 0.0001 0.0001 0.000

17.NA 0.0001 0.0001 0.0001 0.0001 0.0001 0.000

18.Total Operating & Residential Care Rate 132 6391 200.5431 333.1821 00001 0.0001 0.000





I 3,762

I 0






29.

I 0.001 0.00




012374400 - 2016/07

Rl:370.76 / NM:0.00

Rosewood Avenue Group Home (Res-Care)

71 Rosewood Avenue

Ormond Beach, FL 32174


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 10/31/2015


New Rate

Effective Date

370.76 7/1/2016

0.00 7/1/2016


X

Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Res-Care, Inc.

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Comments:

Printed on: 6/23/2016 3 28 PM.Batch ID: Y7R2F, User ID: FDHC\pridgeoc

Total Prospective


Desk Audited Costs



W.Rydell Samuel





Rate Period ( s) 10/2013 to 7/2016

Provider Name: Rosewood Avenue Group Home (Res- Cost Report Entered By : Care)

Rate Semester : Provider Number: 12374400



Number of Beds:

Column A Column B

012374400

Pridgeon, Chantelle

July, 2016

12/1/2013 - 10/31/2015

700

6







C. Laundry 1,366



3. Resident Care

A. Dietary 45,812

B. Other 0

C. Nursing 71,581


4. Prop Exp & Per Diem 20.1008 80,403



1. Staffing 0.75 1.00





C. Additional Services Ex12ense











Facility Name: Rosewood Avenue Group Home (Res-Care)

No N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

29.3483

114.6803

48.8123

192.8409

N/M

0.0000

0.0000

0.0000

0.0000


FYE: 10/31/2015





TOTALS

117,393

458,721

195,249

771,363





Rosewood Avenue Group Home (Res-Care)

Ownership:Private





Prior Cost Report


012374400 - 2016/07

RI: 370.76

NM: 0.00

Base Semester

201304



1.Prior Period Base: 0.000 0.000 0.000 0 000 0.000 0.000

2.lnflate Line 1 by Inflation Factor 0.00000000 0.0001 0 0001 0.0001 0.0001 0.0001 0.000

3.Line 1 X 1.4000 X Inflation Factor 0.00000000 0.0001 0 0001 0.0001 0 0001 0.0001 0.000




?.Incentive Line 5 x Oper 50% Res 50% 0.0001 00001 0.0001 00001 0.0001 0.000


9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% 0.0001 00001 0.0001 00001 0.0001 0.000

10.Final Incentive 0.0001 0.0001 0.0001 0 0001 0.0001 0.000






16.lnterim Rate Component: 0.0001 0.0001 0 0001 0.0001 00001 0.000

17.NA 0.0001 0.0001 0 0001 0.0001 0.0001 0.000

18.Total Operating & Residential Care Rate 125.1211 2034441 328.5651 00001 0.0001 0.000



21.Plus: Property Interim Rate Component I 0 0001 I 0000


I 4,000

I 0






29.

I 0.001 0.00




012375400 - 2016/07

Rl:374.06 / NM:409.03

19th Street Group Home (Res-Care)

529 NW 19th Street



Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 10/31/2015


New Rate

Effective Date

374.06 7/1/2016

409.03 7/1/2016


X

Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Res-Care, Inc.

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Comments:


Total Prospective


Desk Audited Costs



W.Rydell Samuel



Provider Name:

Provider Number:

Audit Status:

Date:




19th Street Group Home (Res-Care) Cost Report Entered By :




Number of Beds:

012375400

Pridgeon, Chantelle

July, 2016

12/1/2013 - 10/31/2015

700

6



1. Resident Days 2,602 1,066 3,668




C. Laundry 5,624



3. Resident Care

A. Dietary 45,973

B. Other 0

C. Nursing 38,868


4. Prop Exp & Per Diem 24.7759 24.7759 90,878

5. ROE/Use Per Diem 0.4618 0.4618 1,694


1. Staffing 0.75 1.00
















Facility Name: 19th Street Group Home (Res-Care)

R/1 & N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

23.1300

99.3017

55.7590

178.1907

N/M

23.1300

132.4023

55.7533

211.2856


FYE: 10/31/2015





TOTALS

84,841

399,524

204,518

688,883





19th Street Group Home (Res-Care)

Ownership:Private




I


Prior Cost Report


012375400 - 2016/07

RI: 374.06

NM: 409.03

Base Semester

201304




2.lnflate Line 1 by Inflation Factor 0.00000000 I 0.0001 0.0001 00001 0.0001 0.0001 0.000

3.Line 1 X 1.4000 X Inflation Factor 0.00000000 I 0 0001 0.0001 0 0001 0.0001 0.0001 0.000

4.Current Period Cost I 131.8941 178.1911 310.0851 131.8941 211.2861 343.180

5.lncentive Basis (line 3 - line 4) I 0.0001 00001 I 0.0001 0.0001

6.Allowed Current Period Costs (Min of line 3 or 4) I 131.8941 178.1911 310.0851 131.8941 211.2861 343.180

?.Incentive Line 5 x Oper 50% Res 50% I 0.0001 0.0001 0.0001 0.0001 0.0001 0.000

8.lncentive - Line 4 x Oper 10% Res 3% 0.0001 0.0001 00001 0.0001 00001 0.000

9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% 0.0001 0 0001 0.0001 00001 0 0001 0.000

1 O.Final Incentive 0.0001 0 0001 0.0001 0.0001 0 0001 0.000





15.Prospective Rate: Line 11 x Inflation 1.05498204 139.1461 187.9881 327.1341 139. 1461 222.9031 362.048

16.lnterim Rate Component: 0 0001 0.0001 0 0001 0.0001 0 0001 0.000

17.NA 0 0001 0.0001 0.0001 0.0001 00001 0.000

18.Total Operating & Residential Care Rate 1391461 187.9881 327. 1341 139.1461 222.9031 362.048




22.Final Per Diem I 352.371 387.29 23.Medicaid Days I 2,602 I 1,066






29

I 0.001 0.00

30.Final Per Diem After Adjustments 374.osl 409.03



012386400 - 2016/07

Rl:373.54 / NM:0.00

Tunis Street Group Home (Res-Care)

4748 Tunis Street

Jacksonville, FL 32205


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 10/31/2015


New Rate

Effective Date

373.54 7/1/2016

0.00 7/1/2016


X

Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Res-Care, Inc.

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Comments:

Printed on: 6/23/2016 3:28 PM,Batch ID: Y7R2F, User ID: FDHC\pridgeoc

Total Prospective


Desk Audited Costs



W.Rydell Samuel



Provider Name:

Provider Number:

Audit Status:

Date:




Tunis Street Group Home (Res-Care) Cost Report Entered By :




Number of Beds:

Column A Column B

012386400

Pridgeon, Chantelle

July, 2016

12/1/2013 - 10/31/2015

700

6







C. Laundry 1,689



3. Resident Care

A. Dietary 38,075

B. Other 0

C. Nursing 76,782


4. Prop Exp & Per Diem 18.6420 75,500



1. Staffing 0.75 1.00






1. ·Medicaid Inpatient Days 4,050 0 4,050










Facility Name: Tunis Street Group Home (Res-Care)





Printed on: 6/23/2016 8:41 AM

No N/M Days

R/1 N/M

28.3598 0.0000

108.8148 0.0000

62.1751 0.0000

199.3497 0.0000


FYE: 10/31/2015





TOTALS

114,857

440,700

251,809

807,366





Tunis Street Group Home (Res-Care)

Ownership:Private





Prior Cost Report


012386400 - 2016/07

RI: 373.54

NM: 0.00

Base Semester

201304




2.lnflate Line 1 by Inflation Factor 0.00000000 00001 0.0001 00001 0.0001 0.0001 0.000

3.Line 1 X 1.4000 X Inflation Factor 0.00000000 0 0001 0.0001 0 0001 0.0001 0.0001 0.000

4.Current Period Cost 116.1841 199.350 I 315.5331 0.0001 0 0001 0.000


6.Allowed Current Period Costs (Min of line 3 or 4) 116.1841 199.350 I 315.5331 0.0001 0.0001 0.000



9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% 0.0001 00001 0.0001 00001 0.0001 0.000

10.Final Incentive 0.0001 0.0001 00001 0.0001 0.0001 0.000

11.Current Period Base: (line 6 + line 10) 116.1841 199.350 I 315.5331 0.0001 0.0001 0.000






17.NA 0.0001 0.0001 0.0001 00001 0.0001 0.000

18.Total Operating & Residential Care Rate 122.5721 210.3101 332.8821 00001 0.0001 0.000




22.Final Per Diem I 351.851 0.00 23.Medicaid Days I 4,050 I 0

24.Resident Days I 4,050 I 0





29.

I 0.001 0.00




012390800 - 2016/07

Rl:376.00 / NM:0.00

Plaza Oval Group Home (Res-Care)

24 7 Plaza Oval

Casselberry, FL 32707


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 10/31/2015


New Rate

Effective Date

376.00 7/1/2016

0.00 7/1/2016


X

Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Res-Care, Inc.

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Comments:


Total Prospective


Desk Audited Costs



W.Rydell Samuel



Provider Name:

Provider Number:

Audit Status:

Date:



Rate Period( s) 10/2013 to 7/2016

Plaza Oval Group Home (Res-Care) Cost Report Entered By :




Number of Beds:

012390800

Pridgeon, Chantelle

July, 2016

12/1/2013 - 10/31/2015

700

6







C. Laundry 2,156



3. Resident Care

A. Dietary 44,972

B. Other 0

C. Nursing 37,061


4. Prop Exp & Per Diem 16.2893 68,301



1. Staffing 0.75 1.00
















Facility Name: Plaza Oval Group Home (Res-Care)

No N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

19.5643

114.1958

63.7596

197.5197

N/M

0.0000

0.0000

0.0000

0.0000


FYE: 10/31/2015





TOTALS

82,033

478,823

267,344

828,200





Plaza Oval Group Home (Res-Care)

Ownership:Private





Prior Cost Report


012390800 - 2016/07

RI: 376.00

NM: 0.00

Base Semester

201304


Operating I Resident Care I Total Operating Resident Care Total

1.Prior Period Base: 0.0001 0.0001 0.000 0000 0.000 0.000

2.lnflate Line 1 by Inflation Factor 0.00000000 00001 0.0001 0.0001 0.0001 00001 0.000

3.Line 1 X 1.4000 X Inflation Factor 0.00000000 0.0001 0.0001 0 0001 0 0001 0.0001 0.000

4.Current Period Cost 122 3901 197.5201 319.9101 0 0001 0.0001 0.000


6.Allowed Current Period Costs (Min of line 3 or 4) 122.3901 197.5201 319.9101 00001 0.0001 0.000



9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% 0.0001 0.0001 0 0001 0.0001 0.0001 0.000

10.Final Incentive 0.0001 0.0001 0.0001 0.0001 0.0001 0 000

11.Current Period Base: (line 6 + line 10) 122.390 I 197.520 I 319.9101 0.0001 0.0001 0.000






17.NA 0 0001 0 0001 0 0001 0.0001 0.0001 0.000

18.Total Operating & Residential Care Rate 129.1191 208.380 I 337.4991 0 0001 0.0001 0 000

19 .Property Rate Component I 16.2891 I 0.000




I 4,193

I 0





28.Less Rate Cut (0%) Based on Days I 0 001 0.00

29.

l 0 001 0.00

30.Final Per Diem After Adjustments 376.ool 0.00



012392700 - 2016/07

Rl:386.43 / NM:425.30

Claudia Drive Group Home (Res-Care)

140 Claudia Drive



Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 10/31/2015


New Rate

Effective Date

386.43 7/1/2016

425.30 7/1/2016


X

Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Res-Care, Inc.

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Comments:


Total Prospective


Desk Audited Costs



W.Rydell Samuel






Provider Name: Claudia Drive Group Home (Res-Care) Cost Report Entered By :




Number of Beds:

012392700

Pridgeon, Chantelle

July, 2016

12/1/2013 - 10/31/2015

700

6



1. Resident Days 3,500 514 4,014




C. Laundry 1,780



3. Resident Care

A. Dietary 40,999

B. Other 0

C. Nursing 91,446


4. Prop Exp & Per Diem 19.0177 19.0177 76,337

5. ROE/Use Per Diem 0.3737 0.3737 1,500


1. Staffing 0.75 1.00
















Facility Name: Claudia Drive Group Home (Res-Care)

R/1 & N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

32.9958

110.2653

57.1334

200.3945

N/M

32.9958

147.0204

57.1576

237.1738


FYE: 10/31/2015





TOTALS

132,445

461,497

229,346

823,288





Claudia Drive Group Home (Res-Care)

Ownership:Private





Prior Cost Report


012392700 - 2016/07

RI: 386.43

NM: 425.30

Base Semester

201304






4.Current Period Cost 126.9401 200.3951 327.3341 126.940 I 237.1741 364.113




8.lncentive - Line 4 x Oper 10% Res 3% 0.0001 00001 0.0001 00001 0.0001 0.000

9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% 0.0001 0.0001 0.0001 00001 00001 0.000

1 O.Final Incentive 0.0001 0.0001 0.0001 00001 0.0001 0.000


12.Plus: Property Rate Component I 190181 I 19.018

13.Plus: ROE/Use Rate I 0 3741 I 0.374



16.lnterim Rate Component: 0.0001 0 0001 0 0001 0.0001 0.0001 0.000

17.NA 00001 00001 00001 0.0001 0.0001 0.000


19.Property Rate Component I 19 0181 I 19018

20.ROE Component + ROE Interim Component I 03741 I 0.374



I 3,500

I 514





28.Less Rate Cut (0%) Based on Days I o.ool 0.00

29.

I 0.001 0.00




012410100 - 2016/07

Rl:424.98 / NM:0.00

High Dessert Court Group Home (Res-Care)

11818 High Oesset Court



Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 10/31/2015


New Rate

Effective Date

424.98 7/1/2016

0.00 7/1/2016


X

Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Res-Care, Inc.

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Comments:

Printed on: 6/23/2016 3:28 PM.Batch ID: Y7R2F , User ID: FDHC\pridgeoc

Total Prospective


Desk Audited Costs



W.Rydell Samuel





Rate Period( s) 10/2013 to 7/2016

Provider Name: High Dessert Court Group Home (Res- Cost Report Entered By : Care)




Number of Beds:

Column A Column B

012410100

Pridgeon, Chantelle

July, 2016

12/1/2013 - 10/31/2015

700

6


A. Allocation of Ex12enses (excluding B & C)





C. Laundry 1,749



3. Resident Care

A. Dietary 37,202

B. Other 0

C. Nursing 82,234


4. Prop Exp & Per Diem 20.6701 72,056


B. Direct Care Ex12ense

1. Staffing 0.75 1.00
















Facility Name: High Dessert Court Group Home (Res-Care)





Printed on: 6/23/2016 8:41 AM

No N/M Days

R/1 N/M

34.2616 0.0000

123.9897 0.0000

66.7989 0.0000

225.0502 0.0000


FYE: 10/31/2015


84 Allocation of 0/C Expenses



TOTALS

119,436

432,228

232,861

784,525





High Dessert Court Group Home (Res-Care)

Ownership:Private





Prior Cost Report


012410100 - 2016/07

RI: 424.98

NM: 0.00

Base Semester

201304




2.lnflate Line 1 by Inflation Factor 0.00000000 0.0001 0.0001 0.0001 0 0001 0 0001 0.000

3.Line 1 X 1.4000 X Inflation Factor 0.00000000 00001 0.0001 0.0001 0.0001 0.0001 0.000



6.Allowed Current Period Costs (Min of line 3 or 4) 137.1771 225.0501 362.2271 0 0001 0.0001 0.000

?.Incentive Line 5 x Oper 50% Res 50% 0.0001 0.0001 0.0001 0.0001 00001 0.000

8.lncentive - Line 4 x Oper 10% Res 3% 0.0001 0.0001 0 0001 00001 0.0001 0.000

9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% 0 0001 0.0001 0.0001 0 0001 0.0001 0.000


11.Current Period Base: (line 6 + line 10) 137.1771 225.050 I 362.2271 0.0001 0.0001 0.000



14.Total Current Period Base I 383.2931 I 0000


16.lnterim Rate Component: 0.0001 0.0001 0.0001 00001 0.0001 0.000

17.NA 0.0001 0.0001 00001 0.0001 0.0001 0.000






I 3,486

I 0






29.

I 0 001 0.00




028000300 - 2016/07

Rl:293.88 / NM:0.00

Sandy Park Development Center

2975 Garden Street North

Ft. Myers, FL 33917


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 12/31/2014


New Rate

Effective Date

293.88 7/1/2016

0.00 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs


Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel



Provider Name:

Provider Number:

Audit Status:

Date:




Sandy Park Development Center Cost Report Entered By :




Number of Beds:

Column A Column B

028000300

Pridgeon, Chantelle

July, 2016

1/1/2014 - 12/31/2014

365

64



1. Resident Days 23,235 0 23,235




C. Laundry 39,993



3. Resident Care

A. Dietary 457,467

B. Other 0

C. Nursing 154,437


4. Prop Exp & Per Diem 10.6047 246,400



1. Staffing 0.50 1.00
















Facility Name: Sandy Park Development Center





Printed on: 6/23/2016 8:41 AM

No N/M Days

R/1 N/M

26.3354 0.0000

139.7825 0.0000

14.2065 0.0000

180.3244 0.0000


FYE: 12/31/2014





TOTALS

611,904

3,247,847

330,089

4,189,840





Sandy Park Development Center

Ownership:Private







028000300 - 2016/07

RI: 293.88

NM: 0.00

Base Semester

201507




2.lnflate Line 1 by Inflation Factor 1.02030026 62.3171 186.8431 249 1601 00001 0.0001 0.000

3.Line 1 X 1.4000 X Inflation Factor 1.02842036 628131 188.3301 251.1431 0 0001 0.0001 0.000


5.lncentive Basis (line 3 - line 4) 28191 80051 I 0.0001 0 0001



8.lncentive - Line 4 x Oper 10% Res 3% 5.9991 5.410 I 11.4091 0.0001 0.0001 0.000








16.lnterim Rate Component: 0 0001 0.0001 0.0001 0.0001 0.0001 0.000

17.NA 0.0001 0.0001 0.0001 0.0001 0.0001 0.000

18.Total Operating & Residential Care Rate 65.3961 196.3101 261 7061 0.0001 0 0001 0 000


20.ROE Component + ROE Interim Component I 0.0181 I 0.000



I 23,235

I 0






29.

I 0.001 0.00




028018601 - 2016/07

Rl:357.57 / NM:463.40

St. Petersburg Cluster (Sunrise)

1101 102nd Avenue North

St. Petersburg, FL 33716


Level of Care

#7 Institutional



Current Rate


Rate Type:

Provider Number: 028018601 ---------0 ate: 6/23/2016

FYE: 6/30/2015


New Rate

357.57

463.40

Effective Date

7/1/2016

7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs


Sunrise Community, Inc.

9040 Sunset DriveSuite 70-A

Miami, FL 33170

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






028018601

Provider Name: St. Petersburg Cluster {Sunrise) Cost Report Entered By : Pridgeon, Chantelle

Provider Number: 28018601 Rate Semester : July, 2016

Audit Status: Unaudited Cost Report : 7 /1/2014 - 6/30/2015

Date: 6/23/2016 Days In Reporting Period: 365

Number of Beds: 24


A. Allocation of Ex12enses (excluding B & C)

1. Resident Days 1,310 7,076 8,386




C. Laundry 7,984



3. Resident Care

A. Dietary 167,683

B. Other 70,890

C. Nursing 584,880


4. Prop Exp & Per Diem 14.9688 14.9688 125,528

5. ROE/Use Per Diem 2.0055 2.0055 16,818

B. Direct Care Ex12ense

1. Staffing 0.50 1.00

2.Total Staffing Required 655.00 7,076.00 7,731.00


4. Allocation of Direct Care 132,996.26 1,436,765.74 1,569,762.00













Facility Name: St. Petersburg Cluster (Sunrise)

R/1 & N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

98.1938

101.5239

12.3840

212.1017

N/M

98.1938

203.0477

12.3840

313.6255


FYE: 06/30/2015





TOTALS

823,453

1,569,762

103,852

2,497,067





St. Petersburg Cluster (Sunrise)

Ownership:Private







028018601 - 2016/07

RI: 357.57

NM: 463.40

Base Semester

201507





3.Line 1 X 1.4000 X Inflation Factor 1.03366838 88.3591 218.4511 306 810 I 88.3591 317.5331 405.893

4.Current Period Cost 89.1121 2121021 3012141 89 1121 313 6261 402.738

5.lncentive Basis (line 3 - line 4) 00001 6.3491 I 0.0001 3.9081




9.lncentive - Min of Line 7,8 x Eligibility factor 87.43% o oool 2 7751 2.7751 0 0001 1.7081 1.708

1 O.Final Incentive 0 0001 2 7751 2.7751 0 0001 1.7081 1.708



13.Plus: ROE/Use Rate I 2.0061 I 2006




17.NA 0.0001 0.0001 0.0001 o.oool o.oool 0.000

18.Total Operating & Residential Care Rate 92.9321 2259981 318.9301 92.9321 331.6531 424.585





I 1,310

I 7,076



26.Quality Assessment ($21.06) I 21.061 21 06



29.

I 0.001 0.00




028019401 - 2016/07

Rl:467.21 / NM:577.47

Laurel Hill Cluster

2011 Laurel Hill Cluster

Orlando, FL 32818


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 5/31/2014


New Rate

Effective Date

467.21 7/1/2016

577.47 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Quest, Inc.

P.O. Box 531125

Orlando, FL 32853

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs


Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel





028019401


Provider Name: Laurel Hill Cluster



Date: 6/23/2016


1. Resident Days


A. Administration

B. Plant Operation

C. Laundry

D. Housekeeping


3. Resident Care

A. Dietary

B. Other

C. Nursing



5. ROE/Use Per Diem


1. Staffing


3. Staffing Percent














Rate Semester :

Cost Report :


Number of Beds:

Pridgeon, Chantelle

July, 2016

6/1/2013 - 5/31/2014

365

24


0 8,539 8,539

598,699

255,664

62,139

13,953

108.9653 108.9653 930,455

170,394

131,903

1,092,173

163.3060 163.3060 1,394,470

17.8464 17.8464 152,390

2.6851 2.6851 22,928

0.50 1.00

0.00 8,539.00 8,539.00

0.00 1.00 1.00

0.00 1,611,527.00 1,611,527.00

94.3628 188.7255

0 8,539 8,539

0 142,481 142,481

16.6859 16.6859

108.9653 108.9653 930,455

274.3547 368.7174 3,148,478

17.8464 17.8464 152,390

2.6851 2.6851 22,928

403.8515 498.2142 4,254,251


Facility Name: Laurel Hill Cluster





Printed on: 6/23/2016 8:41 AM

Extrapolated R/1

R/1 N/M

163.3060 163.3060

94.3628 188.7255

16.6859 16.6859

274.3547 368.7174


FYE: 05/31/2014





TOTALS

1,394,470

1,611,527

142,481

3,148,478





Laurel Hill Cluster

Ownership:Private







028019401 - 2016/07

RI: 467.21

NM: 577.47

Base Semester

201407






4.Current Period Cost 108 9651 274.3551 383.320 I 108.9651 368.7171 477.683


6.Allowed Current Period Costs (Min of line 3 or 4) 108.9651 274 3551 383.3201 108.9651 368.7171 477.683

?.Incentive Line 5 x Oper 50% Res 50% 7.1441 3.3791 10.5231 7 1441 15.4101 22.554

8.lncentive - Line 4 x Oper 10% Res 3% 10.8971 8.2311 19.1271 10 8971 11.0621 21.958

9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% 7.1441 3.3791 10.5231 71441 11.0621 18.206

1 O.Final Incentive 71441 3.3791 10.5231 7.1441 11.0621 18.206







17.NA 0.0001 0.0001 0.0001 0.0001 0.0001 0.000






l 0

I 8,539




27.Less or Plus: Buy Back - QAF (.001684964) I 0 791 0.97


29.

I 0.001 0.00






028020801 - 2016/07

Rl:332.23 / NM:444.45

McCauley Cluster (Sunrise)

1385 McCauley Road

Tallahassee, FL 32308


Level of Care

#7 Institutional

#8 Non-Ambulatory & #9 Medical

Rate Type:

Interim

Total Interim

Interim Component


Basis

Budget

X Unaudited Costs

Field Audited Costs


Current Rate

313.92

419.32

X


FYE: 6/30/2015


New Rate

332.23

444.45

Effective Date

7/1/2016

7/1/2016

Prospective

X Total Prospective


Desk Audited Costs



W.Rydell Samuel


Distribution: Comments:

Contract Management

DPODS - DCF (4)

Home Office:



Miami, FL 33170






028020801

Provider Name: McCauley Cluster (Sunrise) Cost Report Entered By : Pridgeon, Chantelle


Audit Status: Unaudited Cost Report : 7 /1/2014 - 6/30/2015


Number of Beds: 24


A. Allocation of Exi;ienses (excluding B & C)

1. Resident Days 2,346 5,947 8,293




C. Laundry 9,073



3. Resident Care

A. Dietary 134,540

B. Other 151,253

C. Nursing 496,557


4. Prop Exp & Per Diem 12.6881 12.6881 105,222

5. ROE/Use Per Diem 1.9106 1.9106 15,845

B. Direct Care Exi;iense

1. Staffing 0.50 1.00





C. Additional Services Exi;iense











Facility Name: McCauley Cluster (Sunrise)


B5 Allocation of DIC Expenses



Printed on: 6/23/2016 8:41 AM

R/1 & N/M Days

R/1 N/M

94.3386 94.3386

115.3911 230.7822

6.2136 6.2136

215.9433 331.3344


FYE: 06/30/2015





TOTALS

782,350

1,643,169

51,529

2,477,048





McCauley Cluster (Sunrise)

Ownership:Private




I




028020801 - 2016/07

RI: 332.23

NM: 444.45

Base Semester

201507




2 .Inflate Line 1 by Inflation Factor 1.02404884 I 67.7281 211 1021 278.8291 67.7281 316.6281 384.356

3.Line 1 X 1.4000 X Inflation Factor 1.03366838 I 68.3641 213.0851 281.4491 68.3641 319.6021 387.966


5.lncentive Basis (line 3 - line 4) I 0.0001 0.0001 I 0.0001 0.0001




9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% 0 0001 0.0001 0.0001 0.0001 0.0001 0.000

10.Final Incentive 0 0001 0.0001 0.0001 0 0001 0.0001 0.000






16.lnterim Rate Component: 0.0001 0.0001 0 0001 0.0001 0.0001 0.000

17.NA 0.0001 0.0001 0.0001 0.0001 0.0001 0.000





22.Final Per Diem I 310.61 I 422.64 23.Medicaid Days I 2,346 1 5,947



26.Quality Assessment ($21.06) I 21.06' 21.06



29.

I 0.001 0.00




028028301 - 2016/07

Rl:327.83 / NM:416.68

Greentree Court Cluster (Sunrise)

2160 GreenTree Court

Bartow, FL 33830


Level of Care

#7 Institutional



Current Rate


Rate Type:


FYE: 6/30/2015


New Rate

327.83

416.68

Effective Date

7/1/2016

7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Miami, FL 33170

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






028028301

Provider Name: Greentree Court Cluster (Sunrise) Cost Report Entered By : Pridgeon, Chantelle


Audit Status: Unaudited Cost Report : 7/1/2014 - 6/30/2015


Number of Beds: 24



1. Resident Days 1,460 6,758 8,218




C. Laundry 1,150



3. Resident Care

A. Dietary 113,382

B. Other 122,084

C. Nursing 648,825


4. Prop Exp & Per Diem 13.8799 13.8799 114,065

5. ROE/Use Per Diem 0.8793 0.8793 7,226


1. Staffing 0.50 1.00
















Facility Name: Greentree Court Cluster (Sunrise)

R/1 & N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

107.6042

83.4535

13.2466

204.3043

N/M

107.6042

166.9069

13.2468

287.7579


FYE: 06/30/2015





TOTALS

884,291

1,249,799

108,862

2,242,952





Greentree Court Cluster (Sunrise)

Ownership:Private







028028301 - 2016/07

RI: 327.83

NM: 416.68

Base Semester

201507






4.Current Period Cost 76.2651 204.3041 280.5701 76 2651 287.7581 364.023

5.lncentive Basis (line 3 - line 4) 00001 5.5101 I 00001 7.4851




9.lncentive - Min of Line 7,8 x Eligibility factor 88.80% 0 0001 2.4471 2.4471 0.0001 33231 3.323

1 a.Final Incentive 0 0001 2.4471 2.4471 0.0001 3 3231 3.323


12.Plus: Property Rate Component I 13.880 I I 13.880



15.Prospective Rate: Line 11 x Inflation 1.05175287 74.0101 217.4511 291.460 I 74.0101 306.1451 380.155

16.lnterim Rate Component: 00001 0.0001 00001 00001 00001 0.000

17.NA 0.0001 0.0001 0.0001 00001 0.0001 0.000

18.Total Operating & Residential Care Rate 74.0101 217.4511 291.450 I 74.010 I 306 1451 380.155

19.Property Rate Component I 13.880 I I 13.880




I 1,460

I 6,758






29.

I 0.001 0.00




028029101 - 2016/07

Rl:346.06 / NM:474.36

Mahan Cluster (Sunrise)

2034 Mahan Drive



Level of Care

#7 Institutional



Current Rate


Rate Type:

Provider Number: 028029101 ---------Date: 6/23/2016

FYE: 6/30/2015


New Rate

346.06

474.36

Effective Date

7/1/2016

7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Miami, FL 33170

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






028029101

Provider Name: Mahan Cluster (Sunrise) Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 24



1. Resident Days 2,697 5,615 8,312




C. Laundry 11,132



3. Resident Care

A. Dietary 148,289

B. Other 144,752

C. Nursing 480,076


4. Prop Exp & Per Diem 11.8164 11.8164 98,218

5. ROE/Use Per Diem 1.8920 1.8920 15,726


1. Staffing 0.50 1.00
















Facility Name: Mahan Cluster (Sunrise)





Printed on: 6/23/2016 8:41 AM

R/1 & N/M Days

R/1 N/M

93.0122 93.0122

118.2413 236.4827

7.7438 7.7439

218.9973 337.2388


FYE: 06/30/2015





TOTALS

773,117

1,646,747

64,367

2,484,231





Mahan Cluster (Sunrise)

Ownership:Private







028029101 - 2016/07

RI: 346.06

NM: 474.36

Base Semester

201507


Operating Resident Care Total Operating Resident Care I Total




4.Current Period Cost 67.460 I 218.9971 286.4571 67.4601 337.2391 404.698

5.lncentive Basis (line 3 - line 4) 4 7801 22.5981 I 4.7801 26.1891

6.Allowed Current Period Costs (Min of line 3 or 4) 67.460 I 218.9971 286.4571 67.460 I 337.2391 404.698




1 O.Final Incentive 2 3901 6.5701 8.9601 2.3901 10.1171 12.507







17.NA 0.0001 0.0001 0.0001 0.0001 0.0001 0.000



20.ROE Component + ROE Interim Component I 1.8921 I 1.892



I 2,697

I 5,615






29.

I 0.001 0.00




028030501 - 2016/07

Rl:238.39 / NM:286.99

Lake City Cluster

411 Gwen Lake Boulevard

Lake City, FL 32055


Level of Care

#7 Institutional



Current Rate


Rate Type:


FYE: 6/30/2015


New Rate

238.39

286.99

Effective Date

7/1/2016

7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Res-Care, Inc.

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






Provider Name: Lake City Cluster Cost Report Entered By :




Number of Beds:

028030501

Pridgeon, Chantelle

July, 2016

7/1/2014 - 6/30/2015

365

24



1. Resident Days 0 8,074 8,074




C. Laundry 55,152



3. Resident Care

A. Dietary 146,037

B. Other 0

C. Nursing 285,359


4. Prop Exp & Per Diem 7.9768 7.9768 64,405

5. ROE/Use Per Diem 0.0000 0.0000 0


1. Staffing 0.50 1.00



4. Allocation of Direct Care 0.00 723,148.00 723,148.00



1. Medicaid Inpatient Days 0 8,074 8,074

2. Additional Services 0 220,731 220,731









Facility Name: Lake City Cluster





Printed on: 6/23/2016 8:41 AM

Extrapolated R/1

R/1 N/M

53.4303 53.4303

44.7825 89.5650

27.3385 27.3385

125.5513 170.3338


FYE: 06/30/2015





TOTALS

431,396

723,148

220,731

1,375,275





Lake City Cluster

Ownership:Private







028030501 - 2016/07

RI: 238.39

NM: 286.99

Base Semester

201507




2.lnflate Line 1 by Inflation Factor 1.02404884 I 71.9091 134.2991 206.2081 71.9091 184.1021 256 011

3.Line 1 X 1.4000 X Inflation Factor 1.03366838 I 72.5841 135.560 I 208.1451 72.5841 185.8311 258.416

4.Current Period Cost I 661261 125.5511 191.6781 66.1261 170.3341 236.460

5.lncentive Basis (line 3 - line 4) 6.4581 10 0091 I 6.4581 15.4971

6.Allowed Current Period Costs (Min of line 3 or 4) 66 1261 125.5511 191.6781 66.1261 170.3341 236.460

?.Incentive Line 5 x Oper 50% Res 50% 3.2291 50051 8.2341 3.2291 7.7491 10.978

8.lncentive - Line 4 x Oper 10% Res 3% 66131 3 7671 10.3791 6.6131 5.1101 11. 723

9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% 3.2291 3 7671 6.9961 3.2291 51101 8.339

1 a.Final Incentive 32291 3.7671 6 9961 3.2291 5.1101 8.339







17.NA 0.0001 00001 0.0001 0.0001 0.0001 0.000

18.Total Operating & Residential Care Rate 72.9451 136.010 I 208.9551 72.9451 184.5241 257.468

19.Property Rate Component I 79771 I 7.977



22.Final Per Diem I 216.93i 265.44 23.Medicaid Days

I 0 I 8,074

24.Resident Days 0 I 8,074





29.

I 0.001 0.00




028031301 - 2016/07

Rl:325.99 / NM:408.45

Bayshore Cluster (Sunrise)

2059 Lisenby Avenue

Panama City, FL 32405


Level of Care

#7 Institutional



Current Rate


Rate Type:


FYE: 6/30/2015


New Rate

325.99

408.45

Effective Date

7/1/2016

7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Miami, FL 33170

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel



Provider Name:

Provider Number:

Audit Status:

Date:




Bayshore Cluster (Sunrise) Cost Report Entered By :




Number of Beds:

028031301

Pridgeon, Chantelle

July, 2016

7/1/2014 - 6/30/2015

365

24



1. Resident Days 122 8,443 8,565




C. Laundry 4,543



3. Resident Care

A. Dietary 154,276

B. Other 208,568

C. Nursing 543,994


4. Prop Exp & Per Diem 13.3818 13.3818 114,615

5. ROE/Use Per Diem 1.6674 1.6674 14,281


1. Staffing 0.50 1.00
















Facility Name: Bayshore Cluster (Sunrise)





Printed on: 6/23/2016 8:41 AM

R/1 & N/M Days

R/1 N/M

105.8772 105.8772

75.9863 151.9725

20.3443 20.3464

202.2078 278.1961


FYE: 06/30/2015





TOTALS

906,838

1,292,374

174,267

2,373,479





Bayshore Cluster (Sunrise)

Ownership: Private




I




028031301 - 2016/07

RI: 325.99

NM: 408.45

Base Semester

201507


Operating I Resident Care Total Operating Resident Care I Total

1.Prior Period Base· 67.6781 209.870 277.548 67.678 289.4571 357.135


3.Line 1 X 1.4000 X Inflation Factor 1.03366838 69 9571 216.9361 286.8931 69.9571 299.2021 369.159

4.Current Period Cost 63 6861 202.2081 265.8941 63.6861 278.1961 341.883


6.Allowed Current Period Costs (Min of line 3 or 4) 63.6861 202.2081 265 8941 63 6861 2781961 341.883

?.Incentive Line 5 x Oper 50% Res 50% 3.1351 7.3641 10.499 I 3.1351 10.5031 13.638


9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% 31351 60661 92011 3.1351 8.3461 11.481

10.Final Incentive 3.1351 6.0661 9.2011 31351 8.3461 11.481






16.lnterim Rate Component: 0 0001 0.0001 o.oool 0.0001 0.0001 0.000

17.NA 0 0001 0 0001 0.0001 0.0001 0.0001 0.000




21.Plus: Property Interim Rate Component I ooool I 0.000


I 122

I 8,443






29.

I 0001 0.00




028032101 - 2016/07

Rl:254.88 / NM:308.20

Gainesville 39th Avenue Cluster (Res-Care)

5914 N.W. 39th Avenue



Level of Care

#7 Institutional



Current Rate


Rate Type:


FYE: 6/30/2015


New Rate

254.88

308.20

Effective Date

7/1/2016

7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Res-Care, Inc.

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






Provider Name: Gainesville 39th Avenue Cluster (Res- Cost Report Entered By : Care)




Number of Beds:

028032101

Pridgeon, Chantelle

July, 2016

7/1/2014 - 6/30/2015

365

24



1 . Resident Days 0 8,240 8,240




C. Laundry 4,060


E. Operating Expense Compone,nt & Per Diem 63.0527 63.0527 519,554

3. Resident Care

A. Dietary 130,347

B. Other 0

C. Nursing 447,329


4. Prop Exp & Per Diem 10.4917 10.4917 86,452

5. ROE/Use Per Diem 0.0000 0.0000 0


1. Staffing 0.50 1.00
















Facility Name: Gainesville 39th Avenue Cluster (Res-Care)

Extrapolated R/1





Printed on: 6/23/2016 8:41 AM

R/1

70.1063

49.1348

22.2356

141.4767

N/M

70.1063

98.2695

22.2356

190.6114


FYE: 06/30/2015





TOTALS

577,676

809,741

183,221

1,570,638





Gainesville 39th Avenue Cluster {Res-Care)

Ownership:Private




I




028032101 - 2016/07

RI: 254.88

NM: 308.20

Base Semester

201507









?.Incentive Line 5 x Oper 50% Res 50% 31601 5.1131 8.2731 31601 6.6381 9.798

8.lncentive - Line 4 x Oper 10% Res 3% 6.3051 4.2441 10.550 I 6.3051 5.7181 12.024

9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% 31601 4.2441 7.4051 3.1601 5.7181 8.879






15.Prospective Rate: Line 11 x Inflation 1.05175287 69.6401 153.2621 222 9021 69.6401 205.490 I 276.130

16.lnterim Rate Component: 0.0001 0.0001 00001 0.0001 0.0001 0.000

17.NA 0.0001 0.0001 0.0001 0.0001 0.0001 0.000






l 0 I 8,240






29.

I 0001 0.00




028035600 - 2016/07

Rl:323.60 / NM:501.09

PARC Center Apartments

3190 75th Street North



Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 9/30/2015


New Rate

Effective Date

323.60 7/1/2016

501.09 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs


Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






028035600

Provider Name: PARC Center Apartments Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 48



1. Resident Days 13,438 4,005 17,443




C. Laundry 13,018


E. Operating Expense Component & Per Diem 70.0351 70.0351 1,221,622

3. Resident Care

A. Dietary 195,156

B. Other 0

C. Nursing 470,327


4. Prop Exp & Per Diem 11.7820 11.7820 205,514

5. ROE/Use Per Diem 1.0386 1.0386 18,117


1. Staffing 0.50 1.00



4. Allocation of Direct Care 2,422,350.48 1,443,892.52 3,866,243.00











5. Total Cost Per Diem 312.2492 492.5104 6,168,509 Printed on: 6/23/2016 8:41 AM, Batch 10: Y7R2F


Facility Name: PARC Center Apartments





Printed on: 6/23/2016 8:41 AM

R/1 & N/M Days

R/1 N/M

38.1519 38.1519

180.2612 360.5225

10.9804 10.9803

229.3935 409.6547


FYE: 09/30/2015





TOTALS

665,483

3,866,243

191,530

4,723,256





PARC Center Apartments

Ownership:Private







028035600 - 2016/07

RI: 323.60

NM: 501.09

Base Semester

201507






4.Current Period Cost 70 0351 229.3941 299.4291 70 0351 409.6551 479.690

5.lncentive Basis (line 3 - line 4) 0.0001 0 0001 I 0.0001 0.0001





10.Final Incentive 0.0001 o oool 0.0001 0.0001 0.0001 0.000







17.NA 0.0001 0.0001 0.0001 0.0001 0.0001 0.000

18.Total Operating & Residential Care Rate 62.6431 226.5291 2891721 62.6431 403.7201 466.363





I 13,438

I 4,005




27.Less or Plus: Buy Back - QAF (.001684964) I 0541 0.84


29.

I 0001 0.00




028036401 - 2016/07

Rl:499.94 / NM:616.35

Skipper Road Cluster

2611 E. Bearss Avenue

Tampa, FL 33613


Level of Care

#7 Institutional



Current Rate


Rate Type:


FYE: 5/31/2014


New Rate

499.94

616.35

Effective Date

7/1/2016

7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Quest, Inc.

P.O. Box 531125

Orlando, FL 32853

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs


Comments:

Printed on: 6/23/2016 3 28 PM.Batch ID: Y7R2F, User ID: FDHC\pridgeoc

X Total Prospective


Desk Audited Costs



W.Rydell Samuel






028036401

Provider Name: Skipper Road Cluster Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 24







C. Laundry 40,850



3. Resident Care

A. Dietary 165,216

B. Other 209,195

C. Nursing 1,174,922

D. Resident Care & Per Diem 192.2726 192.2726 1,549,333

4. Prop Exp & Per Diem 18.0031 18.0031 145,069

5. ROE/Use Per Diem 3.1804 3.1804 25,628


1. Staffing 0.50 1.00



4. Allocation of Direct Care 0.00 1,623,834.00 1,623,834.00













Facility Name: Skipper Road Cluster





Printed on: 6/23/2016 8:41 AM

Extrapolated R/1

R/1 N/M

192.2726 192.2726

100.7591 201.5182

12.5055 12.5055

305.5372 406.2963


FYE: 05/31/2014





TOTALS

1,549,333

1,623,834

100,769

3,273,936





Skipper Road Cluster

Ownership:Private







028036401 - 2016/07

RI: 499.94

NM: 616.35

Base Semester

201407


Operating Resident Care Total Operating I Resident Care Total





5.lncentive Basis (line 3 - line 4) 4.4851 3 1071 I 4.4851 11.D?o I 6.Allowed Current Period Costs (Min of line 3 or 4) 114.1961 305.5371 419 7331 114.1961 406.2961 520.492


8.lncentive - Line 4 x Oper 10% Res 3% 11.4201 9.1661 20.5861 11.420 I 12.1891 23.608

9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% 22431 1.5541 3.7961 2.2431 8.5351 10.778






15.Prospective Rate: Line 11 x Inflation 1.07868257 125.600 I 331.2531 456.8531 125.6001 447.4711 573.071

16.lnterim Rate Component: 0.0001 0 0001 0.0001 0.0001 00001 0.000

17.NA 0.0001 0.0001 0.0001 0.0001 0.0001 0.000






I 0

I 8,058






29.

I 0.001 0.00




028037201 - 2016/07

Rl:307.48 / NM:385.80

Pembroke Pines Cluster

871 S.W. Douglas Road

Pembroke Pines, FL 33024


Level of Care

#7 Institutional



Current Rate


Rate Type:


FYE: 6/30/2015


New Rate

307.48

385.80

Effective Date

7/1/2016

7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Ann Storck Center

1790 S.W. 43RD WAY

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs


Ft. Lauderdale, FL 33317

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






028037201

Provider Name: Pembroke Pines Cluster Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 24







C. Laundry 94



3. Resident Care

A. Dietary 154,518

B. Other 0

C. Nursing 536,810


4. Prop Exp & Per Diem 10.8595 10.8595 88,005

5. ROE/Use Per Diem 0.0000 0.0000 0


1. Staffing 0.50 1.00
















Facility Name: Pembroke Pines Cluster





Printed on: 6/23/2016 8:41 AM

Extrapolated R/1

R/1 N/M

85.3070 85.3070

85.9674 171.9348

28.1783 28.1783

199.4527 285.4201


FYE: 06/30/2015





TOTALS

691,328

1,393,360

228,357

2,313,045





Pembroke Pines Cluster

Ownership:Private







028037201 - 2016/07

RI: 307.48

NM: 385.80

Base Semester

201507





3.Line 1 X 1.4000 X Inflation Factor 1.03366838 74.810 I 186.6951 261.5051 74.810 I 261.0381 335.849

4.Current Period Cost 88.4621 199.4531 287.9151 88.4621 285.420 I 373.882


6.Allowed Current Period Costs (Min of line 3 or 4) 74.810 I 186.6951 261.5051 74.8101 261.0381 335.849

?.Incentive Line 5 x Oper 50% Res 50% 0.0001 0.0001 0.0001 o.oool o.oool 0.000


9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% o.oool o.oool 0.0001 o.oool o.oool 0.000

1 O.Final Incentive o.oool o.oool o.oool o.oool o.oool 0.000

11.Current Period Base: (line 6 + line 10) 74.8101 186.6951 261.5051 74.810 I 261.0381 335.849






17.NA o.oool o.oool 0.0001 o.oool o.oool 0.000



20.ROE Component+ ROE Interim Component I o.oool I 0.000

21.Plus: Property Interim Rate Component I o.oool I 0.000


I 0

I 8,104






29.

I 0.001 0.00




028038101 - 2016/07

Rl:244.76 / NM:295.40

Ocala Cluster (Res-Care)

3205 S. E. 17th Street

Ocala, FL 32671


Level of Care

#7 Institutional



Current Rate


Rate Type:


FYE: 6/30/2015


New Rate

244.76

295.40

Effective Date

7/1/2016

7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Res-Care, Inc.

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






028038101

Provider Name: Ocala Cluster (Res-Care) Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 24


A. Allocation of Expenses (excluding B & C}





C. Laundry 49,795



3. Resident Care

A. Dietary 143,783

B. Other 0

C. Nursing 294,727


4. Prop Exp & Per Diem 12.5561 12.5561 109,991

5. ROE/Use Per Diem 0.0000 0.0000 0


1. Staffing 0.50 1.00
















Facility Name: Ocala Cluster (Res-Care)





Printed on: 6/23/2016 8:41 AM

Extrapolated R/1

R/1 N/M

50.0582 50.0582

46.6708 93.3416

25.2285 25.2285

121.9575 168.6283


FYE: 06/30/2015





TOTALS

438,510

817,672

221,002

1,477,184





Ocala Cluster (Res-Care)

Ownership:Private







028038101 - 2016/07

RI: 244.76

NM: 295.40

Base Semester

201507




2.lnflate Line 1 by Inflation Factor 1.02404884 74 0471 129 0421 203.0901 74.0471 178.8631 252.911

3.Line 1 X 1.4000 X Inflation Factor 1.03366838 74 7431 130 2551 204.9981 74.7431 180.5431 255.286


5.lncentive Basis (line 3 - line 4) 0 0001 8.2971 I 0.0001 11.9151

6.Allowed Current Period Costs (Min of line 3 or 4) 74 7431 121 9581 196.7011 74.7431 168.6281 243.371

?.Incentive Line 5 x Oper 50% Res 50% 0 0001 41491 4.1491 0 0001 59581 5.958

8.lncentive - Line 4 x Oper 10% Res 3% 0.0001 3.6591 3.6591 00001 50591 5.059

9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% 0 0001 3.6591 36591 0.0001 5.0591 5.059

10.Final Incentive 0.0001 3.6591 3.6591 0.0001 5.0591 5.059



13 Plus: ROE/Use Rate I 0.0001 I 0.000


15.Prospective Rate: Line 11 x Inflation 1.05175287 78.6111 132.1171 210.7281 78.6111 182 6761 261.287

16.lnterim Rate Component: 00001 0.0001 0.0001 0.0001 0.0001 0.000

17.NA 0.0001 0.0001 0.0001 0.0001 0.0001 0.000






I 0

I 8,760






29.

I 0.001 0.00




028040201 - 2016/07

Rl:478.06 / NM:608.59

Williams Road Cluster

1923 Sarah Louise Drive

Brandon, FL 33510


Level of Care

#7 Institutional



Current Rate


Rate Type:


FYE: 5/31/2014


New Rate

478.06

608.59

Effective Date

7/1/2016

7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Quest, Inc.

P. 0. Box 531125

Orlando, FL 32853

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs


Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






028040201

Provider Name: Williams Road Cluster Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 24



1 . Resident Days 358 7,979 8,337




C. Laundry 48,327



3. Resident Care

A. Dietary 155,431

B. Other 199,939



4. Prop Exp & Per Diem 21.7244 21.7244 181,116

5. ROE/Use Per Diem 2.5606 2.5606 21,348


1. Staffing 0.50 1.00
















Facility Name: Williams Road Cluster





Printed on: 6/23/2016 8:41 AM

R/1 & N/M Days

R/1 N/M

185.8619 185.8619

101.1311 202.2622

12.8883 12.8906

299.8813 401.0147


FYE: 05/31/2014





TOTALS

1,549,531

1,650,055

107,468

3,307,054





Williams Road Cluster

Ownership:State Cluster







028040201 - 2016/07

RI: 478.06

NM: 608.59

Base Semester

201407




2.lnflate Line 1 by Inflation Factor 1.01827004 113.3901 285.6451 399.0361 113.390 I 413.0181 526.409


4.Current Period Cost 111.2131 299.8811 411.0941 111.2131 401 0151 512.227

5.lncentive Basis (line 3 - line 4) 2.9921 o.oool I 2.9921 14.9681


?.Incentive Line 5 x Oper 50% Res 50% 1.4961 0 0001 1.4961 1.4961 7.4841 8.980

8.lncentive - Line 4 x Oper 10% Res 3% 11 1211 0.0001 11.1211 11.1211 12.0301 23.152


10.Final Incentive 1.4961 o.oool 1.4961 1.4961 7.4841 8.980





15.Prospective Rate: Line 11 x Inflation 1.07868257 121.5761 310.3321 431 9081 121 5761 440.6401 562.217

16.lnterim Rate Component: 0.0001 0.0001 0.0001 00001 0 0001 0.000

17.NA 0 0001 0.0001 0.0001 0.0001 0.0001 0.000

18.Total Operating & Residential Care Rate 121 5761 3103321 431.9081 121.5761 440.6401 562.217





I 358

I 7,979



26.0uality Assessment ($21.06) I 21 061 21.06



29.

I 0.001 0.00




028041101-2016/07

Rl:396.26 / NM:494.40

MCP 80th Street

11750 S.W. 80th Street

Miami, FL 33183


Level of Care

#7 Institutional



Current Rate


Rate Type:


FYE: 6/30/2015


New Rate

396.26

494.40

Effective Date

7/1/2016

7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

UCP Of Miami

1411 NW 14th Ave

Miami, FL 33125

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs


Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel





028041101


Provider Name: MCP 80th Street



Date: 6/23/2016


1. Resident Days


A. Administration

B. Plant Operation

C. Laundry

D. Housekeeping


3. Resident Care

A. Dietary

B. Other

C. Nursing



5. ROE/Use Per Diem


1. Staffing


3. Staffing Percent














Rate Semester :

Cost Report :


Number of Beds:

Pridgeon, Chantelle

July, 2016

7/1/2014 - 6/30/2015

365

24


0 8,746 8,746

424,165

295,400

36,409

43,049

91.3587 91.3587 799,023

168,230

0

826,448

113.7295 113.7295 994,678

43.0122 43.0122 376,185

2.6501 2.6501 23,178

0.50 1.00

0.00 8,746.00 8,746.00

0.00 1.00 1.00

0.00 1,603,386.00 1,603,386.00

91.6640 183.3279

0 8,746 8,746

0 98,345 98,345

11.2446 11.2446

91.3587 91.3587 799,023

216.6381 308.3020 2,696,409

43.0122 43.0122 376,185

2.6501 2.6501 23,178

353.6591 445.3230 3,894,795


Facility Name: MCP 80th Street





Printed on: 6/23/2016 8:41 AM

Extrapolated R/1

R/1 N/M

113.7295 113.7295

91.6640 183.3279

11.2446 11.2446

216.6381 308.3020


FYE: 06/30/2015





TOTALS

994,678

1,603,386

98,345

2,696,409





MCP 80th Street

Ownership:Private







028041101 - 2016/07

RI: 396.26

NM: 494.40

Base Semester

201507








6.Allowed Current Period Costs (Min of line 3 or 4) 91.3591 216.6381 307 9971 91.3591 308.3021 399.661



9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% 0.8751 3.8151 4.6901 08751 5.3111 6.187

1 O.Final Incentive 0.8751 3 8151 4.6901 0.8751 5.3111 6.187





15.Prospective Rate: Line 11 x Inflation 1.05175287 97.0081 231.8621 328.8691 97 0081 329.8431 426.851

16.lnterim Rate Component: 00001 0.0001 o.oool 0 0001 0 0001 0.000

17.NA 0 0001 o.oool 0.0001 0.0001 0.0001 0.000

18.Total Operating & Residential Care Rate 97 0081 231.8621 328.8691 97.0081 329.8431 426.851





I 0

I 8,746






29.

I 0.001 0.00




028045301 - 2016/07

Rl:425.12 / NM:525.80

MCP Braddock

14400 SW 32nd Street

Miami,, FL 33175


Level of Care

#7 Institutional



Current Rate


Rate Type:


FYE: 6/30/2015


New Rate

425.12

525.80

Effective Date

7/1/2016

7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

UCP Of Miami

1411 NW 14th Ave

Miami, FL 33125

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs


Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel





028045301


Provider Name: MCP Braddock



Date: 6/23/2016


1. Resident Days


A. Administration

B. Plant Operation

C. Laundry

D. Housekeeping


3. Resident Care

A. Dietary

B. Other

C. Nursing



5. ROE/Use Per Diem


1. Staffing


3. Staffing Percent














Rate Semester :

Cost Report :


Number of Beds:

Pridgeon, Chantelle

July, 2016

7/1/2014 - 6/30/2015

365

24


0 8,550 8,550

435,690

298,743

38,644

29,398

93.8567 93.8567 802,475

132,997

0

989,839

131.3258 131.3258 1,122,836

45.9098 45.9098 392,529

2.0779 2.0779 17,766

0.50 1.00

0.00 8,550.00 8,550.00

0.00 1.00 1.00

0.00 1,664,288.00 1,664,288.00

97.3268 194.6536

0 8,550 8,550

0 100,387 100,387

11.7412 11.7412

93.8567 93.8567 802,475

240.3938 337.7206 2,887,511

45.9098 45.9098 392,529

2.0779 2.0779 17,766

382.2382 479.5650 4,100,281


Facility Name: MCP Braddock





Printed on: 6/23/2016 8:41 AM

Extrapolated R/1

R/1 N/M

131.3258 131.3258

97.3268 194.6536

11.7412 11.7412

240.3938 337.7206


FYE: 0613012015





TOTALS

1,122,836

1,664,288

100,387

2,887,511





MCP Braddock

Ownership:Private




I




028045301 - 2016/07

RI: 425.12

NM: 525.80

Base Semester

201507







5.lncentive Basis (line 3 - line 4) 0.0001 9.5211 I 0.0001 59991


7.lncentive Line 5 x Oper 50% Res 50% 00001 4.7611 4.7611 0.0001 2.9991 2.999

8.lncentive - Line 4 x Oper 10% Res 3% 0 0001 72121 7.2121 00001 10.1321 10.132







15.Prospective Rate: Line 11 x Inflation 1.05175287 97.5131 257 8421 355.3551 97.5131 358.3531 455.866


17.NA 0.0001 0.0001 0.0001 0.0001 0.0001 0.000




21.Plus: Property Interim Rate Component I 0.0001 I 0 000


I 0

I 8,550






29.

l 0.001 0.00




028046101 - 2016/07

Rl:419.58 / NM:518.20

MCP 2nd Street

11801 NW Second Street

Miami, Fl., FL 33182


Level of Care

#7 Institutional



Current Rate


Rate Type:


FYE: 6/30/2015


New Rate

419.58

518.20

Effective Date

7/1/2016

7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

UCP Of Miami

1411 NW 14th Ave

Miami, FL 33125

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs


Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel





028046101


Provider Name: MCP 2nd Street



Date: 6/23/2016


1. Resident Days


A. Administration

B. Plant Operation

C. Laundry

D. Housekeeping


3. Resident Care

A. Dietary

B. Other

C. Nursing



5. ROE/Use Per Diem


1. Staffing


3. Staffing Percent














Rate Semester :

Cost Report :


Number of Beds:

Pridgeon, Chantelle

July, 2016

7/1/2014 - 6/30/2015

365

24


0 8,635 8,635

433,937

287,460

37,041

36,594

92.0709 92.0709 795,032

163,730

0

994,851

134.1727 134.1727 1,158,581

43.7604 43.7604 377,871

2.5511 2.5511 22,029

0.50 1.00

0.00 8,635.00 8,635.00

0.00 1.00 1.00

0.00 1,628,276.00 1,628,276.00

94.2835 188.5670

0 8,635 8,635

0 95,386 95,386

11.0464 11.0464

92.0709 92.0709 795,032

239.5026 333.7861 2,882,243

43.7604 43.7604 377,871

2.5511 2.5511 22,029

377.8850 472.1685 4,077,175


Facility Name: MCP 2nd Street





Printed on: 6/23/2016 8:41 AM

Extrapolated R/1

R/1 N/M

134.1727 134.1727

94.2835 188.5670

11.0464 11.0464

239.5026 333.7861


FYE: 06/30/2015





TOTALS

1,158,581

1,628,276

95,386

2,882,243





MCP 2nd Street

Ownership:Private







028046101 - 2016/07

RI: 419.58

NM: 518.20

Base Semester

201507


Operating I Resident Care Total Operating Resident Care I Total

1.Prior Period Base: 892191 236.656 325.875 89.219 326.5521 415.771

2.lnflate Line 1 by Inflation Factor 1.02404884 I 91 3651 242.3471 333.7121 91.3651 334.4051 425.770



5.lncentive Basis (line 3 - line 4) I 0 1521 5 1211 I 0.1521 3.7601



8.lncentive - Line 4 x Oper 10% Res 3% I 92071 7.1851 16.3921 9.2071 10.0141 19.221

9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% I 0.0761 2.5601 2.6371 00761 1.8801 1.956

10.Final Incentive I 0.0761 2.5601 2.6371 0.0761 1.8801 1.956


12.Plus: Property Rate Component I I 43.7601 I 43.760

13.Plus: ROE/Use Rate I I 2.5511 I 2.551

14.Total Current Period Base I I 380.5221 I 474.125

15.Prospective Rate: Line 11 x Inflation 1.05175287 I 96.9161 254.590 I 351.5061 96.9161 353 0381 449.954

16.lnterim Rate Component: I 0.0001 00001 0.0001 o.oool 0.0001 0.000

17.NA I 00001 0.0001 0.0001 0.0001 0.0001 0.000

18.Total Operating & Residential Care Rate I 96.9161 254.5901 351.5061 96.9161 353.0381 449.954

19.Property Rate Component I I 43.7601 I 43.760

20.ROE Component+ ROE Interim Component I I 2.5511 I 2.551

21.Plus: Property Interim Rate Component

I I 0 0001 I 0.000

22.Final Per Diem 397.821 496.27 23.Medicaid Days

I 0

I 8,635






29.

I 0.001 0.00




028048801 • 2016/07

Rl:399.52 / NM:507.11

MCP Sunset

7100 S.W. 122nd. Avenue

Miami, FL 33183


Level of Care

#7 Institutional



Current Rate


Rate Type:


FYE: 6/30/2015


New Rate

399.52

507.11

Effective Date

7/1/2016

7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

UCP Of Miami

1411 NW 14th Ave

Miami, FL 33125

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs


Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel





028048801


Provider Name: MCP Sunset



Date: 6/23/2016

A. Allocatioo of ExRenses (excluding B & C)

1 . Resident Days


A. Administration

B. Plant Operation

C. Laundry

D. Housekeeping


3. Resident Care

A. Dietary

B. Other

C. Nursing



5. ROE/Use Per Diem

B. Direct Care ExRense

1. Staffing


3. Staffing Percent



C. Additioni;!I Services ExRense











Rate Semester :

Cost Report :


Number of Beds:

Pridgeon, Chantelle

July, 2016

7/1/2014 - 6/30/2015

365

24


0 8,640 8,640

422,737

289,624

36,636

33,250

90.5378 90.5378 782,247

150,414

0

914,727

123.2802 123.2802 1,065,141

40.5014 40.5014 349,932

2.2843 2.2843 19,736

0.50 1.00

0.00 8,640.00 8,640.00

0.00 1.00 1.00

0.00 1,582,652.00 1,582,652.00

91.5887 183.1773

0 8,640 8,640

0 121,849 121,849

14.1029 14.1029

90.5378 90.5378 782,247

228.9718 320.5604 2,769,642

40.5014 40.5014 349,932

2.2843 2.2843 19,736

362.2953 453.8839 3,921,557


Facility Name: MCP Sunset





Printed on: 6/23/2016 8:41 AM

Extrapolated R/1

R/1 N/M

123.2802 123.2802

91.5887 183.1773

14.1029 14.1029

228.9718 320.5604


FYE: 06/30/2015

A3D Allowable Resident Care !Exp




TOTALS

1,065,141

1,582,652

121,849

2,769,642





MCP Sunset

Ownership:Private







028048801 - 2016/07

RI: 399.52

NM: 507.11

Base Semester

201507







5.lncentive Basis (line 3 - line 4) 0.8201 0.000 I 08201 18.2631

6.Allowed Current Period Costs (Min of line 3 or 4) 90.5381 227.568 318.1061 90 .. 5381 320.5601 411.098

?.Incentive Line 5 x Oper 50% Res 50% 0.4101 0.000 0.41 o I 0.41 o I 9.1311 9.541


9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% 0.41 o I 0.000 0.4101 0.41 o I 9.1311 9.541

10.Final Incentive 0.41 o I 0.000 0.4101 0.4101 9.1311 9.541


12.Plus: Property Rate Component 40.5011 I 40.501

13.Plus: ROE/Use Rate 2.2841 I 2.284



16.lnterim Rate Component: 0.0001 0.000 o.oool o.oool o.oool 0.000

17.NA 0.0001 0.000 o.oool 0.0001 o.oool 0.000

18.Total Operating & Residential Care Rate 95.6541 239.345 335.oool 95.6541 346.7541 442.409



21.Plus: Property Interim Rate Component o.oool I 0.000

22.Final Per Diem I 377.791 485.19 -----~~--- -- - - - -- --- -----

23.Medicaid Days

I 0

I 8,640




27.Less or Plus: Buy Back- QAF (.001684964) I 0.671 0.85


29.

I o.ool 0.00




028049601 • 2016/07

Rl:342.98 / NM:462.19

Dorchester Cluster (Sunrise)

3201 Ginger Drive



Level of Care

#7 Institutional



Current Rate


Rate Type:


FYE: 6/30/2015


New Rate

342.98

462.19

Effective Date

7/1/2016

7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Miami, FL 33170

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






028049601

Provider Name: Dorchester Cluster (Sunrise) Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 24



1. Resident Days 1,672 6,233 7,905




C. Laundry 7,738



3. Resident Care

A. Dietary 136,209

B. Other 188,136

C. Nursing 505,427


4. Prop Exp & Per Diem 13.2940 13.2940 105,089

5. ROE/Use Per Diem 1.6832 1.6832 13,306


1. Staffing 0.50 1.00





C. Addition§! Services ExQense











Facility Name: Dorchester Cluster (Sunrise)





Printed on: 6/23/2016 8:41 AM

R/1 & N/M Days

R/1 N/M

104.9680 104.9680

113.6560 227.3121

7.2207 7.2204

225.8447 339.5005


FYE: 06/30/2015





TOTALS

829,772

1,606,869

57,078

2,493,719





Dorchester Cluster (Sunrise)

Ownership:Private







028049601 - 2016/07

RI: 342.98

NM: 462.19

Base Semester

201507


















16.lnterim Rate Component: o.oool 0.000 0.0001 0.0001 o.oool 0.000

17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000



20.ROE Component + ROE Interim Component 1.6831 I 1.683


22.Final Per Diem I 321.351 440.35 ~---~----~--- ---- -- ---- -- - ----

23.Medicaid Days

I 1,672

I 6,233






29.

I o.ool 0.00




028059300 - 2016/07

Rl:240.75 / NM:0.00

146th Place Grp Home #10 (Sunrise)

10521 S.W. 146th Place

Miami, FL 33186


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 6/30/2015


New Rate

Effective Date

240.75 7/1/2016

0.00 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Miami, FL 33170

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel



Provider Name:

Provider Number:

Audit Status:

Date:




146th Place Grp Home #10 {Sunrise) Cost Report Entered By :




Number of Beds:

Column A Column B

028059300

Pridgeon, Chantelle

July, 2016

7 /1/2014 - 6/30/2015

365

6


A. Allocation of l;;xRenses (excluding B & C)




8. Plant Operation 28,259

C. Laundry 631

D. Housekeeping 803


3. Resident Care

A. Dietary 14,913

8. Other 52,221

C. Nursing 3,060


4. Prop Exp & Per Diem 13.5566 29,689



1. Staffing 0.75 1.00





C. Additional Services ExRense











Facility Name: 146th Place Grp Home #10 (Sunrise)





Printed on: 6/23/2016 8:41 AM

No N/M Days

R/1 N/M

32.0521 0.0000

113.8192 0.0000

4.9644 0.0000

150.8357 0.0000


FYE: 06/30/2015





TOTALS

70,194

249,264

10,872

330,330





146th Place Grp Home #10 (Sunrise)

Ownership:Private







028059300 - 2016/07

RI: 240.75

NM: 0.00

Base Semester

201507












10.Final Incentive 1.2241 4.525 5.7491 0.0001 0.0001 0.000







17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000





22.Final Per Diem I 219.281 0.00 ~-~-- -~ --- -- -- - ---- ·-· - -

23.Medicaid Days

I 2,190

l 0






29. I 0.001 0.00




028062300 - 2016/07

Rl:246.51 / NM:287.59

119th Street Grp Home #11 (Sunrise)


Miami, FL 33186


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 6/30/2015


New Rate

Effective Date

246.51 7/1/2016

287.59 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Miami, FL 33170

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






028062300

Provider Name: 119th Street Grp Home #11 (Sunrise) Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 6



1. Resident Days 1,460 730 2,190




C. Laundry 314



3. Resident Care

A. Dietary 15,089

B. Other 53,816

C. Nursing 7,471


4. Prop Exp & Per Diem 15.3507 15.3507 33,618

5. ROE/Use Per Diem 0.5128 0.5128 1,123


1. Staffing 0.75 1.00
















Facility Name: 119th Street Grp Home #11 (Sunrise)

R/1 & N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

34.8749

120.7282

2.2308

157.8339

N/M

34.8749

160.9710

2.2315

198.0774


FYE: 0613012015





TOTALS

76,376

293,772

4,886

375,034





119th Street Grp Home #11 (Sunrise)

Ownership:Private







028062300 - 2016/07

RI: 246.51

NM: 287.59

Base Semester

201507


















16.lnterim Rate Component: 0.0001 0.000 o.oool 0.0001 0.0001 0.000

17.NA 0.0001 0.000 o.oool 0.0001 0.0001 0.000





22.Final Per Diem I 225.041 266.05 -· -------·- -- - - -- -. -- - -

23.Medicaid Days

I 1,460

I 730






29.

I 0.001 0.00






028065800 - 2016/07

Rl:238.59 / NM:0.00

22nd Street Grp Home #6 (Sunrise)

444 N.W. 22nd Street

Homestead, FL 33030


Level of Care

#7 Institutional


Rate Type:

Interim

Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Miami, FL 33170

Current Rate

231.75

0.00


Date: 6/23/2016

FYE: 6/30/2015


New Rate

Effective Date

238.59 7/1/2016

0.00 7/1/2016

X Prospective

X Total Prospective


Desk Audited Costs



W.Rydell Samuel


Comments:



Provider Name:

Provider Number:

Audit Status:

Date:




22nd Street Grp Home #6 (Sunrise) Cost Report Entered By :




Number of Beds:

Column A Column B

028065800

Pridgeon, Chantelle

July, 2016

7/1/2014 - 6/30/2015

365

6


A. AlloQation of Exi;ienses (excluding B & C)





C. Laundry 285



3. Resident Care

A. Dietary 16,823

B. Other 54,360

C. Nursing 0


4. Prop Exp & Per Diem 9.6776 20,352



1. Staffing 0.75 1.00
















Facility Name: 22nd Street Grp Home #6 (Sunrise)





Printed on: 6/23/2016 8:41 AM

No NIM Days

R/1 N/M

33.8483 0.0000

114.2777 0.0000

2.8050 0.0000

150.9310 0.0000


FYE: 0613012015





TOTALS

71,183

240,326

5,899

317,408





22nd Street Grp Home #6 (Sunrise)

Ownership:Private







028065800 - 2016/07

RI: 238.59

NM: 0.00

Base Semester

201507




2.lnflate Line 1 by Inflation Factor 1.02404884 I 45.4321 155.336 200.7691 0.0001 0.0001 0.000





7.lncentive Line 5 x Oper 50% Res 50% I 2.9671 2.932 5.8991 0.0001 0.0001 0.000

8.lncentive - Line 4 x Oper 10% Res 3% I 3.9931 4.528 8.5201 0.0001 0.0001 0.000

9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% I 2.9671 2.932 5.8991 0.0001 0.0001 0.000






15.Prospective Rate: Line 11 x Inflation 1.05175287 I 45.1121 161.826 206.9381 0.0001 0.0001 0.000

16.lnterim Rate Component: I 0.0001 0.000 0.0001 0.0001 0.0001 0.000

17.NA I 0.0001 0.000 0.0001 0.0001 0.0001 0.000





22.Final Per Diem 217.131 0.00 ------------ --- ---- --- ---

I I 23.Medicaid Days 2,103 0




27.Less or Plus: Buy Back- OAF (.001684964) I 0.401 0.00


29.

I 0.001 0.00

JO.Final Per Diem After Adjustments 238.591 0.00



028427100 - 2016/07

Rl:261.82 / NM:340.80

Fern Park Developmental Center

230 Fern Park Boulevard

Fern Park, FL 32730


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 2/28/2015


New Rate

Effective Date

261.82 7/1/2016

340.80 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

DDMS

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs


5050 Poplar Avenue Suite 2000Suite 718

Memphis, TN 38157

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






028427100

Provider Name: Fern Park Developmental Center Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 64


~- Allocation of ExRenses (excluding B & C)

1. Resident Days 5,443 17,702 23,145




C. Laundry 47,780



3. Resident Care

A. Dietary 425,669

B. Other 0

C. Nursing 924,313


4. Prop Exp & Per Diem 23.8579 23.8579 552,192

5. ROE/Use Per Diem 0.1672 0.1672 3,869


1. Staffing 0.50 1.00



4. Allocation of Direct Care 415,252.38 2,701,009.62 3, 116,262.00













Facility Name: Fern Park Developmental Center

R/1 & N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

58.3272

76.2911

8.9429

143.5612

N/M

58.3272

152.5822

8.9429

219.8523


FYE: 0212812015





TOTALS

1,349,982

3,116,262

206,983

4,673,227





Fern Park Developmental Center

Ownership:Private







028427100 - 2016/07

RI: 261.82

NM: 340.80

Base Semester

201507









7.lncentive Line 5 x Oper 50% Res 50% 1.8231 0.000 1.8231 1.8231 0.0001 1.823










17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000


19. Property Rate Component 23.8581 I 23.858



22.Final Per Diem I 240.321 319.17 -·-·-·-·------ -------- ·- -

23.Medicaid Days

I 5,443

I 17,702





28.Less Rate Cut (0%) Based on Days I o.ooj 0.00

29.

I o.ool 0.00




028500500 - 2016/07

Rl:216.22 / NM:0.00

Naranja Group Home (Sunrise)

15190 S.W. 272nd Street

Naranja, FL 33032


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 6/30/2015


New Rate

Effective Date

216.22 7/1/2016

0.00 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Miami, FL 33170

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel



Provider Name:

Provider Number:

Audit Status:

Date:




Naranja Group Home (Sunrise) Cost Report Entered By :




Number of Beds:

Column A Column B

028500500

Pridgeon, Chantelle

July, 2016

7/1/2014 - 6/30/2015

365

12


A. Allocation of l;;xgenses (excluding B & C)

1 . Resident Days 4,380 0 4,380




C. Laundry 558



3. Resident Care

A. Dietary 35,473

B. Other 131,694

C. Nursing 28,228


4. Prop Exp & Per Diem 8.9639 39,262



1. Staffing 0.50 1.00
















Facility Name: Naranja Group Home (Sunrise)


85 Allocation of DIC Expenses



Printed on: 6/23/2016 8:41 AM

No N/M Days

R/1 N/M

44.6107 0.0000

93.3151 0.0000

2.0584 0.0000

139.9842 0.0000


FYE: 06/30/2015





TOTALS

195,395

408,720

9,016

613,131





Naranja Group Home {Sunrise)

Ownership:Private







028500500 - 2016/07

RI: 216.22

NM: 0.00

Base Semester

201507










a.Incentive - Line 4 x Oper 10% Res 3% 3.3921 4.200 7.5921 0.0001 0.0001 0.000


10.Final Incentive 0.6651 0.969 1.6341 0.0001 0.0001 0.000







17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000




21.Plus: Property Interim Rate Component o.oooj I 0.000

22.Final Per Diem I 194.791 0.00 ~------~·- ---- --- -- ------ -- -- -

23.Medicaid Days

I 4,380

I 0






29.

I 0.001 0.00




028501300 - 2016/07

Rl:319.76 / NM:398.45

Sunrise - Main Facility

9040 Sunset Drive

Miami, FL 33173


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 6/30/2015


New Rate

Effective Date

319.76 7/1/2016

398.45 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Miami, FL 33170

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






028501300

Provider Name: Sunrise • Main Facility Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 120


A. Allocation of l;;xgenses (excluding B & C)

1 . Resident Days 25,557 17,592 43,149


A. Administration 1,738,163

B. Plant Operation 1,038,029

C. Laundry 14,021



3. Resident Care

A. Dietary 1,548,966

B. Other 954,267



4. Prop Exp & Per Diem 10.7526 10.7526 463,966

5. ROE/Use Per Diem 1.8929 1.8929 81,677


1. Staffing 0.50 1.00
















Facility Name: Sunrise - Main Facility





Printed on: 6/23/2016 8:41 AM

R/1 & NIM Days

R/1 N/M

109.1902 109.1902

71.8644 143.7289

15.9639 15.9639

197.0185 268.8830


FYE: 06/30/2015





TOTALS

4,711,446

4,365,118

688,826

9,765,390





Sunrise - Main Facility

Ownership:Private







028501300 - 2016/07

RI: 319.76

NM: 398.45

Base Semester

201507




2. Inflate Line 1 by Inflation Factor 1.02404884 69.2431 205.558 274.8011 69.2431 284.7251 353.968



5.lncentive Basis (line 3- line 4) 1.3631 10.470 I 1.3631 18.5171





10.Final Incentive 0.6821 5.235 5.9171 0.6821 8.0661 8.748







17.NA o.oool 0.000 0.0001 0.0001 0.0001 0.000


19. Property Rate Component 10.7531 I 10.753


21.Plus: Property Interim Rate Component o.oooj I 0.000

22.Final Per Diem I. 298.16j 376.72 ~--------- ------- - .. ·-- - - ----

23.Medicaid Days I 25,557 I 17,592






29.

I 0.001 0.00




028505600 • 2016/07

Rl:312.59 / NM:476.05

PARC Cottage

3101 76th Way North



Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 9/30/2015


New Rate

Effective Date

312.59 7/1/2016

476.05 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs


Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel





028505600


Provider Name: PARC Cottage



Date: 6/23/2016


1 . Resident Days


A. Administration

B. Plant Operation

C. Laundry

D. Housekeeping


3. Resident Care

A. Dietary

B. Other

C. Nursing



5. ROE/Use Per Diem


1. Staffing


3. Staffing Percent














Rate Semester :

Cost Report :


Number of Beds:

Pridgeon, Chantelle

July, 2016

10/1/2014 - 9/30/2015

365

16


3,285 2,555 5,840

342,900

67,551

6,298

14,332

73.8152 73.8152 431,081

125,199

0

168,256

50.2491 50.2491 293,455

5.5755 5.5755 32,561

1.0570 1.0570 6,173

0.50 1.00

1,642.50 2,555.00 4,197.50

0.39 0.61 1.00

499,854.92 777,552.08 1,277,407.00

152.1628 304.3257

3,285 2,555 5,840

42,000 32,666 74,666

12.7854 12.7851

73.8152 73.8152 431,081

215.1973 367.3599 1,645,528

5.5755 5.5755 32,561

1.0570 1.0570 6,173

295.6450 447.8076 2,115,343


Facility Name: PARC Cottage





Printed on: 6/23/2016 8:41 AM

R/1 & N/M Days

R/1 N/M

50.2491 50.2491

152.1628 304.3257

12.7854 12.7851

215.1973 367.3599


FYE: 09/30/2015





TOTALS

293,455

1,277,407

74,666

1,645,528





PARC Cottage

Ownership:Private







028505600 - 2016/07

RI: 312.59

NM: 476.05

Base Semester

201507












10.Final Incentive 0.0001 0.000 0.0001 0.0001 0.0001 0.000

11. Current Period Base: (line 6 + line 10) 65.2291 206.845 272.0741 65.2291 362.9641 428.193






17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000





22.Final Per Diem I 291.01 I 454.19 ~·-~·--~- --- ---- --- -- - -- -

23.Medicaid Days

I 3,285

I 2,555






29.

I 0.001 0.00




028512900 - 2016/07

Rl:278.95 / NM:0.00

MACtown, Inc.

151 NE 62nd Street

Miami, FL 33138


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 9/30/2014


New Rate

Effective Date

278.95 7/1/2016

0.00 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs


Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






Provider Name: MACtown, Inc. Cost Report Entered By :




Number of Beds:

028512900

Pridgeon, Chantelle

July, 2016

10/1/2013 - 9/30/2014

365

56


A. Allocation of Expenses (excluding B & Q)

1. Resident Days 20,114 0 20,114




C. Laundry 0

D. Housekeeping 0


3. Resident Care

A. Dietary 0

B. Other 0

C. Nursing 0

D. Resident Care & Per Diem 0.0000 0

4. Prop Exp & Per Diem 12.2289 245,973


B. Direct Qare Expense

1. Staffing 0.50 1.00







2. Additional Services 0 0 0









Facility Name: MACtown, Inc.





Printed on: 6/23/2016 8:41 AM

No N/M Days

R/1 N/M

0.0000 0.0000

186.7510 0.0000

0.0000 0.0000

186.7510 0.0000


FYE: 09/30/2014





TOTALS

0

3,756,309

0

3,756,309





MACtown, Inc.

Ownership:Private







028512900 - 2016/07

RI: 278.95

NM: 0.00

Base Semester

201407










8.lncentive - Line 4 x Oper 10% Res 3% 0.0001 5.603 5.6031 0.0001 o.oool 0.000

9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% 0.0001 5.603 5.6031 0.0001 o.oool 0.000

10.Final Incentive 0.0001 5.603 5.6031 0.0001 0.0001 0.000





15.Prospective Rate: Line 11 x Inflation 1.07155360 38.8001 206.117 244.9171 0.0001 o.oool 0.000

16.lnterim Rate Component: 0.0001 0.0001 0.0001 o.oool 0.0001 0.000

17.NA o.oool 0.000 0.0001 o.oool 0.0001 0.000

18.Total Operating & Residential Care Rate 38.8001 206.117 244.9171 o.oooj o.oooj 0.000




22.Final Per Diem I 257.421 0.00 r-·--~~~-------- - -- --- --- ---- -

23.Medicaid Days

I 20,114

I 0






29.

I o.ool 0.00




028513700 - 2016/07

Rl:293.99 / NM:353.89

New Horizons of NW Florida, Inc.

10050 Hillview Road

Pensacola, FL 32514


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 9/30/2015


New Rate

Effective Date

293.99 7/1/2016

353.89 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs


Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






028513700

Provider Name: New Horizons of NW Florida, Inc. Cost Report Entered By : Pridgeon, Chantelle


Audit Status: Unaudited Cost Report : 10/1/2014- 9/30/2015


Number of Beds: 30


A. Allocation of Exi;ienses (excluding 6 & C)

1 . Resident Days 3,011 7,635 10,646




C. Laundry 48,511



3. Resident Care

A. Dietary 257,743

B. Other 68,122

C. Nursing 554,303


4. Prop Exp & Per Diem 5.0299 5.0299 53,548

5. ROE/Use Per Diem 1.5766 1.5766 16,784


1. Staffing 0.50 1.00



4. Allocation of Direct Care 186,121.67 943,898.33 1, 130,020.00


C. Additional Services Exi;iense











Facility Name: New Horizons of NW Florida, Inc.

R/1 & N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

82.6759

61.8139

18.4092

162.8990

N/M

82.6759

123.6278

21.6620

227.9657


FYE: 0913012015





TOTALS

880,168

1,130,020

220,819

2,231,007





New Horizons of NW Florida, Inc.

Ownership:Private







028513700 - 2016/07

RI: 293.99

NM: 353.89

Base Semester

201507







5.lncentive Basis (line 3 - line 4) 0.0001 10.162 I o.oool 0.0001


7.lncentive Line 5 x Oper 50% Res 50% o.oool 5.081 5.0811 o.oool 0.0001 0.000

8.lncentive - Line 4 x Oper 10% Res 3% 0.0001 4.887 4.8871 o.oool o.oool 0.000

9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% o.oool 4.887 4.8871 0.0001 o.oool 0.000

10.Final Incentive 0.0001 4.887 4.8871 o.oool o.oool 0.000






16. Interim Rate Component: 0.0001 0.000 0.0001 0.0001 o.oool 0.000

17.NA o.oool 0.000 0.0001 o.oool o.oool 0.000


19.Property Rate Component 5.o3oj I 5.030



22.Final Per Diem I 272.431 332.23 ~--~----- --- -- ---- --- -- -- ---- --

23.Medicaid Days

I 3,011

I 7,635






29.

I o.ool 0.00




028519600 - 2016/07

Rl:354.25 / NM:0.00

BARC Housing, Inc.

10250 N.W. 53rd Street

Sunrise, FL 33351


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 9/30/2014


New Rate

Effective Date

354.25 7/1/2016

0.00 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs


Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






Provider Name: BARC Housing, Inc. Cost Report Entered By :




Number of Beds:

Column A Column B

028519600

Pridgeon, Chantelle

July, 2016

10/1/2013 - 9/30/2014

365

36



1 . Resident Days 12,721 0 12,721




C. Laundry 4,493



3. Resident Care

A. Dietary 264,215

B. Other 488,718

C. Nursing 243,237


4. Prop Exp & Per Diem 15.7531 200,395



1. Staffing 0.50 1.00
















Facility Name: BARG Housing, Inc.





Printed on: 6/23/2016 8:41 AM

No NIM Days

R/1 N/M

78.3091 0.0000

115.2009 0.0000

10.2027 0.0000

203.7127 0.0000


FYE: 0913012014





TOTALS

996,170

1,465,471

129,789

2,591,430


028520000 • 2016/07

Rl:241.83 / NM:328.89

Pensacola Developmental Center

One Villa Drive

Pensacola, FL 32506


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 9/30/2015


New Rate

Effective Date

241.83 7/1/2016

328.89 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

DDMS

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs



Memphis, TN 38157

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel







BARC Housing, Inc.

Ownership:Private







028519600 · 2016/07

RI: 354.25

NM: 0.00

Base Semester

201407







5.lncentive Basis (line 3 - line 4) I 1.1311 0.000 I 0.0001 o.oool 6.Allowed Current Period Costs (Min of line 3 or 4) I 94.6561 200.289 294.9441 0.0001 0.0001 0.000

?.Incentive Line 5 x Oper 50% Res 50% I 0.5651 0.000 0.5651 0.0001 o.oool 0.000

8.lncentive - Line 4 x Oper 10% Res 3% I 9.4661 0.000 9.4661 0.0001 0.0001 0.000









17.NA I 0.0001 0.000 0.0001 0.0001 0.0001 0.000





I 0.000 I 0.000

22.Final Per Diem 332.591 0.00 ~ --··--·-- ---- - - ---- ------ ------ -

23.Medicaid Days

I 12,721

I 0






29.

I 0.001 0.00






028520000

Provider Name: Pensacola Developmental Center Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 63



1. Resident Days 13,542 16,842 30,384




C. Laundry 5,057



3. Resident Care

A. Dietary 517,001

B. Other 0

C. Nursing 936,899


- 4. Prop Exp & Per Diem 14.2983 14.2983 434,439

5. ROE/Use Per Diem 0.2009 0.2009 6,103


1. Staffing 0.50 1.00
















Facility Name: Pensacola Developmental Center

R/1 & NIM Days





Printed on: 6/23/2016 8:41 AM

R/1

47.8508

82.7325

8.6781

139.2614

N/M

47.8508

165.4650

8.6781

221.9939


FYE: 0913012015





TOTALS

1,453,900

3,907,124

263,676

5,624,700





Pensacola Developmental Center

Ownership:Private







028520000 · 2016/07

RI: 241.83

NM: 328.89

Base Semester

201507







5.lncentive Basis (line 3 - line 4) o.oool 2.182 I o.oool 2.3311


7.lncentive Line 5 x Oper 50% Res 50% o.oool 1.0911 1.0911 0.0001 1.1661 1.166

a.Incentive - Line 4 x Oper 10% Res 3% o.oool 4.178 4.1781 0.0001 6.6601 6.660


10.Final Incentive 0.0001 1.091 1.0911 0.0001 1.1661 1.166


12. Plus: Property Rate Component 14.2981 I 14.298





17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000





22.Final Per Diem I 220.361 307.28 ~----------- - --- -- ---- -- -- --

I I 23.Medicaid Days 13,542 16,842






29.

I o.ool 0.00




028521800 • 2016/07

Rl:310.32 / NM:391.07

Ann Storck Center, Inc.

1790 S.W. 43rd Way



Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 9/30/2015


New Rate

Effective Date

310.32 7/1/2016

391.07 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Ann Storck Center

1790 S.W. 43RD WAY

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs



Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






028521800

Provider Name: Ann Storck Center, Inc. Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 48


A. Allocation of Exgenses (exclyding 6 & C)

1. Resident Days 0 17,350 17,350




C. Laundry 42,648



3. Resident Care

A. Dietary 352,895

B. Other 0



4. Prop Exp & Per Diem 6.6083 6.6083 114,654

5. ROE/Use Per Diem 0.0000 0.0000 0


1. Staffing 0.50 1.00
















Facility Name: Ann Storck Center, Inc.





Printed on: 6/23/2016 8:41 AM

Extrapolated R/1

R/1 N/M

81.1301 81.1301

74.8837 149.7674

34.3704 34.3704

190.3842 265.2679


FYE: 09/30/2015





TOTALS

1,407,607

2,598,464

596,327

4,602,398





Ann Storck Center, Inc.

Ownership:Private







028521800 - 2016/07

RI: 310.32

NM: 391.07

Base Semester

201507









7 .Incentive Line 5 x Oper 50% Res 50% 6.3451 8.502 14.8471 6.3451 10.8411 17.185

8.lncentive - Line 4 x Oper 10% Res 3% 6.7491 5.712 12.450 I 6.7491 7.9581 14.707


10.Final Incentive 6.3451 5.712 12.0561 6.3451 7.9581 14.303







17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000





22.Final Per Diem I 288.741 369.36 ~~------ ------ ---- ---- - . -- ----

23.Medicaid Days

I 0

I 17,350






29.

I 0.001 0.00




028522600 • 2016/07

Rl:266.97 / NM:352.77

Tallahassee Developmental Center

455 Appleyard Drive



Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 9/30/2015


New Rate

Effective Date

266.97 7/1/2016

352.77 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

DDMS

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs



Memphis, TN 38157

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






028522600

Provider Name: Tallahassee Developmental Center Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 63


A. AllocatiQD of ExRenses (excluding B & C)

1. Resident Days 8,698 17,477 26,175




C. Laundry 10,500



3. Resident Care

A. Dietary 526,539

B. Other 0

C. Nursing 993,609


4. Prop Exp & Per Diem 19.5015 19.5015 510,452

5. ROE/Use Per Diem 1.6555 1.6555 43,334


1. Staffing 0.50 1.00





C. Additional S~rvices ExRense











Facility Name: Tallahassee Developmental Center

R/1 & N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

58.0763

95.2938

10.1931

163.5632

N/M

58.0763

190.5876

10.1932

258.8571


FYE: 09/30/2015





TOTALS

1,520,148

4,159,765

266,807

5,946,720





Tallahassee Developmental Center

Ownership:Private







028522600 - 2016/07

RI: 266.97

NM: 352.77

Base Semester

201507












10.Final Incentive 0.0001 0.000 0.0001 0.0001 0.0001 0.000







17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000





22.Final Per Diem I 245.461 331.12 f----------------- -- - --- -- - --- ---

I l 23.Medicaid Days 8,698 17,477

24.Resident Days 8,698 I 17,477





29.

I 0.001 0.00

30.Final Per Diem After Adjustments 266.97i 352.77



028524200 - 2016/07

Rl:252.75 / NM:355.81

Ft. Walton Beach Developmental Ctr.

1045 Mar Walt Drive

Ft. Walton Beach, FL 32547


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 9/30/2015


New Rate

Effective Date

252.75 7/1/2016

355.81 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

DDMS

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs



Memphis, TN 38157

Comments:

Printed on: 6/23/2016 3:28 PM,Batch ID: Y7R2F , User ID: FDHC\pridgeoc

X Total Prospective


Desk Audited Costs



W. Rydell Samuel






028524200

Provider Name: Ft. Walton Beach Developmental Ctr. Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 63


A. Allocation of Ex1;1enses (excluding B & C)

1. Resident Days 18,652 10,361 29,013


A. Administration 1,007,185

8. Plant Operation 599,406

C. Laundry 4,550



3. Resident Care

A. Dietary 499,804

B. Other 0

C. Nursing 834,278


4. Prop Exp & Per Diem 9.4029 9.4029 272,807

5. ROE/Use Per Diem 2.0355 2.0355 59,057

B. Direct Care Ex1;1ense

1. Staffing 0.50 1.00





C. Additional Services Ex1;1ense











Facility Name: Ft. Walton Beach Developmental Ctr.

R/1 & N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

45.9822

99.9625

11.5817

157.5264

N/M

45.9822

199.9251

11.5816

257.4889


FYE: 09/30/2015





TOTALS

1,334,082

3,935,925

336,018

5,606,025





Ft. Walton Beach Developmental Ctr.

Ownership:Private







028524200 - 2016/07

RI: 252.75

NM: 355.81

Base Semester

201507












10.Final Incentive 0.0001 0.0001 0.0001 0.0001 0.0001 0.000







17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000





22.Final Per Diem I 231.261 334.15 -~--~- -~--- -- --·----- -- ---- - -

23.Medicaid Days

I 18,652

I 10,361






29.

l 0.001 0.00




028526900 - 2016/07

Rl:243.30 / NM:323.38

Panama City Developmental Center

1407 Lincoln DriveP.O. Box 456

Panama City, FL 32401


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 9/30/2015


New Rate

Effective Date

243.30 7/1/2016

323.38 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

DDMS

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs



Memphis, TN 38157

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






028526900

Provider Name: Panama City Developmental Center Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 64


A. Allocation of Expenses (excluding B ~ C)

1. Resident Days 3,200 24,676 27,876




C. Laundry 5,153



3. Resident Care

A. Dietary 540,012

B. Other 0

C. Nursing 942,251


4. Prop Exp & Per Diem 13.0640 13.0640 364,172

5. ROE/Use Per Diem 0.7087 0.7087 19,756


1. Staffing 0.50 1.00










1. Operating Component 61.8359 61.8359 1,723,738






Facility Name: Panama City Developmental Center

R/1 & N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

53.1734

80.8929

7.5453

141.6116

N/M

53.1734

161.7858

7.5453

222.5045


FYE: 09/30/2015





TOTALS

1,482,263

4,251,084

210,332

5,943,679





Panama City Developmental Center

Ownership:Private







028526900 - 2016/07

RI: 243.30

NM: 323.38

Base Semester

201507



1.Prior Period Base:

2.lnflate Line 1 by Inflation Factor 1.02772568

3.Line 1 X 1.4000 X Inflation Factor 1.03881595

4.Current Period Cost

5.lncentive Basis (line 3 - line 4)

6.Allowed Current Period Costs (Min of line 3 or 4)

?.Incentive Line 5 x Oper 50% Res 50%

8.lncentive - Line 4 x Oper 10% Res 3%

9.lncentive - Min of Line 7,8 x Eligibility factor 100.00%

10.Final Incentive

11.Current Period Base: (line 6 + line 10)

12.Plus: Property Rate Component

13.Plus: ROE/Use Rate

14.Total Current Period Base

15.Prospective Rate: Line 11 x Inflation 1.04958219

16.lnterim Rate Component:

17.NA

18.Total Operating & Residential Care Rate

19.Property Rate Component

20.ROE Component+ ROE Interim Component


22.Final Per Diem 23.Medicaid Days

24.Resident Days

25.Medicaid Utilization

26.Quality Assessment ($21.06)

27.Less or Plus: Buy Back- QAF (.001684964)

28.Less Rate Cut (0%) Based on Days

29.

30.Final Per Diem After Adjustments


I I I

I I

I

56.782

58.3561

58.9861

61.8361

0.0001

58.9861

0.0001

0.0001

0.0001

0.0001

58.9861

61.9101

0.0001

0.0001

61.9101

134.043

137.759

139.246

141.612

0.000

139.246

0.000

0.000

0.000

0.000

139.246

146.150

0.000

0.000

146.150

3,200

3,200

190.824

196.1151

198.2311

203.4481

I 198.2311

0.0001

0.0001

0.0001

0.0001

198.2311

13.0641

0.7091

212.0041

208.0601

0.0001

0.0001

208.0601

13.0641

0.709

0.0001

221.831

I 100.00% I

21.061

0.411

0.001

0.001

243.301

56.782

58.3561

58.9861

61.8361

0.0001

58.9861

0.0001

0.0001

0.0001

0.0001

58.9861

61.9101

0.0001

0.0001

61.9101

207.366

213.1161

215.4151

222.5051

0.0001

215.4151

0.0001

0.0001

0.0001

0.0001

215.4151

I

I 226.0961

0.0001

0.0001

226.0961

I I

24,676

24,676

100.00%

264.148

271.472

274.401

284.340

274.401

0.000

0.000

0.000

0.000

274.401

13.064

0.709

288.174

288.007

0.000

0.000

288.007

13.064

0.709

0.000

301.78

21.06

0.54

0.00

0.00

323.38


028530700 - 2016/07

Rl:222.04 / NM:297.12

Hillsborough County Developmental Ctr

14219 Bruce B Downs Boulevard

Tampa, FL 33613


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 9/30/2015


New Rate

Effective Date

222.04 7/1/2016

297.12 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

DDMS

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs



Memphis, TN 38157

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel



Provider Name:




Hillsborough County Developmental Ctr Cost Report Entered By:




Number of Beds:

028530700

Pridgeon, Chantelle

July, 2016

6/1/2014 - 9/30/2015

487

64


A. Allocation of !;xRenses (excluding B & C)

1 . Resident Days 7,382 23,052 30,434




C. Laundry 1,229



3. Resident Care

A. Dietary 516,902

B. Other 0



4. Prop Exp & Per Diem 4.6934 4.6934 142,838

5. ROE/Use Per Diem 0.7234 0.7234 22,015


1. Staffing 0.50 1.00
















Facility Name: Hillsborough County Developmental Ctr

R/1 & N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

50.1996

72.3713

9.4170

131.9879

N/M

50.1996

144.7427

9.4170

204.3593


FYE: 09/30/2015





TOTALS

1,527,774

3,870,853

286,596

5,685,223





Hillsborough County Developmental Ctr

Ownership:Private

Incentive Rating: Eligible from 05/01/2015- 04/30/2016 Days Eligible: 366 of 366






028530700 - 2016/07

RI: 222.04

NM: 297.12

Base Semester

201507







5.lncentive Basis (line 3 - line 4) I 0.0001 0.0001 I 0.0001 o.oooj 6.Allowed Current Period Costs (Min of line 3 or 4) I 54.0151 131.959 185.9741 54.0151 203.3711 257.386

7 .Incentive Line 5 x Oper 50% Res 50% I 0.0001 0.000 0.0001 0.0001 0.0001 0.000

8.lncentive - Line 4 x Oper 10% Res 3% I 0.0001 0.000 o.oool 0.0001 0.0001 0.000


10.Final Incentive I 0.0001 0.000 o.oool 0.0001 0.0001 0.000






16.lnterim Rate Component: I o.oool 0.000 o.oool o.oool o.oool 0.000

17.NA I o.oool 0.000 o.oool o.oool 0.0001 0.000





I o.oool I 0.000

22.Final Per Diem 200.611 275.56 ~---~----· ---- ----- ---- - -- ----

23.Medicaid Days

I 7,382

I 23,052






29.

I 0.001 0.00




028531500 • 2016/07

Rl:366.80 / NM:443.03

Woodhouse, Inc

1001 N.E. 3rd Avenue

Pompano Beach, FL 33060


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 6/30/2015


New Rate

Effective Date

366.80 7/1/2016

443.03 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs


Comments:


X Total Prospective


Desk Audited Costs



W. Rydell Samuel





028531500


Provider Name: Woodhouse, Inc



Date: 6/23/2016

~- Allocation of ExQenses (excludiog B & C)

1 . Resident Days


A. Administration

B. Plant Operation

C. Laundry

D. Housekeeping


3. Resident Care

A. Dietary

B. Other

C. Nursing



5. ROE/Use Per Diem


1. Staffing


3. Staffing Percent














Rate Semester :

Cost Report :


Number of Beds:

Pridgeon, Chantelle

July, 2016

7/1/2014 - 6/30/2015

365

24


1,825 6,694 8,519

566,076

317,177

700

93,760

114.7685 114.7685 977,713

195,496

0

487,180

80.1357 80.1357 682,676

17.3090 17.3090 147,455

1.7824 1.7824 15,184

0.50 1.00

912.50 6,694.00 7,606.50

0.12 0.88 1.00

128,190.87 940,394.13 1,068,585.00

70.2416 140.4831

1,825 6,694 8,519

85,275 312,784 398,059

46.7260 46.7260

114.7685 114.7685 977,713

197.1033 267.3448 2,149,320

17.3090 17.3090 147,455

1.7824 1.7824 15,184

330.9632 401.2047 3,289,672


Facility Name: Woodhouse, Inc





Printed on: 6/23/2016 8:41 AM

R/1 & N/M Days

R/1 N/M

80.1357 80.1357

70.2416 140.4831

46.7260 46.7260

197.1033 267.3448


FYE: 0613012015





TOTALS

682,676

1,068,585

398,059

2,149,320





Woodhouse, Inc

Ownership:Private







028531500 - 2016/07

RI: 366.80

NM: 443.03

Base Semester

201507









7.lncentive Line 5 x Oper 50% Res 50%



10.Final Incentive







17.NA






24.Resident Days



27.Less or Plus: Buy Back- OAF (.001684964)


29.



I

I

I I

I

103.492

105.9811

106.9771

114.7691

0.0001

106.9771

0.0001

0.0001

0.0001

0.0001

106.9771

112.5131

0.0001

0.0001

112.5131

203.605

208.501

210.460

197.103

13.357

197.103

6.678

5.9131

5.913

5.913

203.016

213.523

0.000

0.000

213.523

1,825

1,825

307.097

314.4831

317.4371

311.8721

I 304.0801

6.6781

5.9131

5.9131

5.9131

309.9931

17.3091

1.7821

329.0851

326.0361

0.0001

0.0001

326.0361

17.3091

1.7821

o.oool 345.131

I 100.00% I

21.061

0.621

0.001

0.001

366.sol

103.492

105.9811

106.9771

114.7691

0.0001

106.9771

0.0001

0.0001

0.0001

0.0001

106.9771

112.5131

0.0001

0.0001

112.5131

278.352

285.0461

287.7241

267.3451

20.3791

267.3451

10.1901

a.0201

8.0201

a.0201

275.3651

I I

289.6161

0.0001

0.0001

289.6161

I

I 6,694

6,694

100.00%

381.845

391.027

394.701

382.113

374.321

10.190

8.020

8.020

8.020

382.342

17.309

1.782

401.433

402.129

0.000

0.000

402.129

17.309

1.782

0.000

421.22

21.06

0.75

0.00

0.00

443.03


028533100 - 2016/07

Rl:318.86 / NM:405.28

Cape Coral Cluster (Sunrise)

2821 Pine Island Road, S.W.

Cape Coral, FL 33991


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 6/30/2015


New Rate

Effective Date

318.86 7/1/2016

405.28 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Miami, FL 33170

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel ~ Medicaid Cost Reimbursement Analysis




Rate Period{s) 07/2016 to 7/2016

028533100

Provider Name: Cape Coral Cluster (Sunrise) Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 24


A. Allocation of Expenses (excluding B 8! C)

1. Resident Days 1,825 6,918 8,743




C. Laundry 2,626



3. Resident Care

A. Dietary 135,720

B. Other 132,562

C. Nursing 448,405


4. Prop Exp & Per Diem 20.9961 20.9961 183,569

5. ROE/Use Per Diem 3.4279 3.4279 29,970


1. Staffing 0.50 1.00
















Facility Name: Cape Coral Cluster (Sunrise)





Printed on: 6/23/2016 8:41 AM

R/1 & N/M Days

R/1 N/M

81.9727 81.9727

79.6314 159.2629

11.3540 11.3541

172.9581 252.5897


FYE: 0613012015





TOTALS

716,687

1,247,108

99,269

2,063,064





Cape Coral Cluster (Sunrise)

Ownership:Private







028533100 - 2016/07

RI: 318.86

NM: 405.28

Base Semester

201507












10.Final Incentive







17.NA



20.ROE Component + ROE Interim Component


22.Final Per Diem 23. Medicaid Days

24.Resident Days





29.



I

I

I

I I

I I I I I I I

78.624

80.5151

81.2711

83.3921

0.0001

81.2711

0.0001

0.0001

0.0001

0.0001

81.2711

85.4771

0.0001

0.0001

85.4771

180.847

185.197

186.936

172.958

13.978

172.958

6.989

5.189

5.189

5.189

178.147

187.366

0.000

0.000

187.366

1,825

1,825

259.472

265.7121

268.2081

256.3511

I 254.2301

6.9891

5.1891

5.1891

5.1891

259.4181

20.9961

3.4281

283.8421

272.8441

0.0001

0.0001

272.8441

20.9961

3.4281

o.oool 297.211

I 100.00% I

21.061

0.541

0.001

0.001

318.861

78.624

80.5151

81.2711

83.3921

0.0001

81.2711

0.0001

0.0001

0.0001

0.0001

81.2711

85.4771

0.0001

0.0001

85.4771

270.491

276.9961

279.5981

252.5901

27.0081

252.5901

13.5041

7.5781

7.5781

7.5781

260.1671

I 273.6321

0.0001

0.0001

273.6321

I 6,918

6,918

100.00%

349.115

357.511

360.869

335.982

333.861

13.504

7.578

7.578

7.578

341.439

20.996

3.428

365.863

359.109

0.000

0.000

359.109

20.996

3.428

0.000

383.53

21.06

0.68

0.00

0.00

405.28


028536600 - 2016/07

Rl:245.28 / NM:273.45

Squire Court Community Home (Res-Care)

95 Squire Court

Dunedin, FL 34698


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 6/30/2015


New Rate

Effective Date

245.28 7/1/2016

273.45 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Res-Care, Inc.

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel



Provider Name:

Provider Number:

Audit Status:

Date:




Squire Court Community Home (Res- Cost Report Entered By : Care)




Number of Beds:

028536600

Pridgeon, Chantelle

July, 2016

7/1/2014 - 6/30/2015

365

6



1. Resident Days 1,460 730 2,190




C. Laundry 508



3. Resident Care

A. Dietary 20,279

B. Other 0

C. Nursing 20,218


4. Prop Exp & Per Diem 12.6849 12.6849 27,780

5. ROE/Use Per Diem 0.7557 0.7557 1,655


1. Staffing 0.75 1.00





C. Additional Servic~s ExQense











Facility Name: Squire Court Community Home (Res-Care)

R/1 & N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

18.4918

77.9022

55.5014

151.8954

N/M

18.4918

103.8696

55.4932

177.8546


FYE: 06/30/2015





TOTALS

40,497

189,562

121,542

351,601





Squire Court Community Home (Res-Care)

Ownership: Private







028536600 - 2016/07

RI: 245.28

NM: 273.45

Base Semester

201507









7 .Incentive Line 5 x Oper 50% Res 50%



10.Final Incentive







17.NA






24.Resident Days



27.Less or Plus: Buy Back - QAF (.001684964)


29.



I

I I I I I I I I

I

42.144

43.1571

43.5631

52.0301

0.0001

43.5631

0.0001

0.0001

0.0001

0.0001

43.5631

45.8171

o.oool 0.0001

45.8171

158.158

161.961

163.483

151.895

11.587

151.895

5.794

4.557

4.557

4.557

156.452

164.549

0.000

0.000

164.549

1,460

1,460

200.301

205.1181

207.0451

203.9261

I 195.4581

5.7941

4.5571

4.5571

4.5571

200.0151

12.6851

0.7561

213.4551

210.3661

0.0001

0.0001

210.3661

12.6851

0.7561

o.oool 223.81 I

I 100.00% I

21.061

0.411

0.001

0.001

245.281

42.144

43.1571

43.5631

52.0301

0.0001

43.5631

0.0001

0.0001

0.0001

0.0001

43.5631

45.8171

0.0001

0.0001

45.8171

188.372

192.9021

194.7141

177.8551

16.8591

177.8551

8.4301

5.3361

5.3361

5.3361

183.1901

I I

192.6711

0.0001

0.0001

192.6711

I

I 730

730

100.00%

230.516

236.059

238.277

229.885

221.417

8.430

5.336

5.336

5.336

226.753

12.685

0.756

240.193

238.488

0.000

0.000

238.488

12.685

0.756

0.000

251.93

21.06

0.46

0.00

0.00

273.45


028537400 - 2016/07

Rl:271.93 / NM:0.00

Bayview Community Home (Res-Care)

3438 S.R. 580

Safety Harbor, FL 34695


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 6/30/2015


New Rate

Effective Date

271.93 7/1/2016

0.00 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Res-Care, Inc.

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






Provider Name: Bayview Community Home (Res-Care) Cost Report Entered By :

Provider Number: 28537 400 Rate Semester :



Number of Beds:

Column A Column B

028537400

Pridgeon, Chantelle

July, 2016

7/1/2014 - 6/30/2015

365

6


A. Allocation of ExRenses (excluding B & C)

1 . Resident Days 2,190 0 2,190




C. Laundry 475



3. Resident Care

A. Dietary 19,614

B. Other 0

C. Nursing 15,703


4. Prop Exp & Per Diem 16.3630 35,835



1. Staffing 0.75 1.00
















Facility Name: Bayview Community Home (Res-Care)





Printed on: 6/23/2016 8:41 AM

No N/M Days

R/1 N/M

16.1265 0.0000

103.8753 0.0000

51.4772 0.0000

171.4790 0.0000


FYE: 06/30/2015





TOTALS

35,317

227,487

112,735

375,539





Bayview Community Home (Res-Care)

Ownership:Private







028537 400 - 2016/07

RI: 271.93

NM: 0.00

Base Semester

201507












10.Final Incentive 0.0001 2.336 2.3361 0.0001 0.0001 0.000







17.NA I 0.0001 0.000 o.oool 0.0001 0.0001 0.000





I 0.000 I 0.000

22.Final Per Diem 250.41 I 0.00 ~ ----·· ---- - -- -----

23.Medicaid Days

I 2,190

I 0






29.

I 0.001 0.00




028539100 - 2016/07

Rl:418.82 / NM:503.87 2727 Mahan Drive - Mail Stop 23

Hendricks

95146 Hendricks Rd, Bldg D

Fernandina Beach, FL 32034-1474

Provider Type: ICF/llD

Level of Care

#7 Institutional


Current Rate


Rate Type:


Date: 6/23/2016

FYE: 5/31/2015


New Rate

Effective Date

418.82 7/1/2016

503.87 7/1/2016

Interim x Prospective

Basis

x

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs





Comments:

Printed on : 6/23/2016 3:28 PM.Batch ID: Y7R2F , User ID: FDHC\pridgeoc

x Total Prospective


Desk Audited Costs



W.Rydell Samuel



Florida Agency For Health Care Administration


ICF/llD Profile Sheet


028539100

Provider Name: Hendricks Cost Report Entered By : Pridgeon, Chantelle Provider Number: 28539100


Date: 6/23/2016


1. Resident Days


A. Administration

B. Plant Operation

C. Laundry

D. Housekeeping


3. Resident Care

A. Dietary

B. Other

C. Nursing



5. ROE/Use Per Diem


1. Staffing


3. Staffing Percent













Rate Semester : July, 2016

Cost Report : 6/1/2014 - 5/31/2015

Days In Reporting Period: 365

Number of Beds: 24


T

1,460 7,300 8,760

622,213

406,275

52,285

76,858

132.1497 132.1497 1,1 57,631

286,313

0

388,084

76.9860 76.9860 674,397

59.2622 59.2622 519,137

3.2669 3.2669 28,618

0.50 1.00

730.00 7,300.00 8,030.00

0.09 0.91 1.00

110,792.36 1, 107,923.64 1,218,716.00

75.8852 151 .7704

1,460 7,300 8,760

44,430 222,149 266,579

30.4315 30.4314

132.1497 132.1497 1,1 57,631

183.3027 259.1878 2,1 59,692

59.2622 59.2622 519,137

3.2669 3.2669 28,618 - -

377.9815 453.8666 3,865,078


Facility Name: Hendricks





Printed on: 6/23/2016 8:41 AM

-

R/1 & N/M Days

R/I N/M

76.9860 76.9860

75.8852 151.7704

30.4315 30.4314

183.3027 259.1878


FYE: 0513112015





TOTALS

674,397

1,218,716

266,579

2,159,692

Hendricks

Ownership: Private







Fiscal Year Begin Fis.cal Year End Audit Status

I Current Cost Report 6/1/2014 5/31/2015 Unaudited Prior Cost Report 6/1/2013 5/31/2014 Unaudited


028539100 - 2016/07

RI: 418.82

NM: 503.87

Base Semester

201507

Non-Ambulatory I Medical Operating Resident Care Total Operating Resident Care Total

1.Prior Period Base: 137.937 174.368 312.304 137.937 253.769 391 .706

2.lnflate Line 1 by Inflation Factor 1.02343244 -1- 141 .1691 178.4531 319.6221 141 .1691 259.7161 400.885


4.Current Period Cost I 132.1501 183.3031 315.4521 132.1501 259.1881 391 .338

5.lncentive Basis (line 3 - line 4) - I 10.3121 o.oool I 10.3121 2.9071

6.Allowed Current Period Costs (Min of line 3 or 4) 132.1501 180.0881 312 .2371 132.1501 259.1881 391 .338

?.Incentive Line 5 x Oper 50% Res 50% - 1 5.1561 o.oool 5.1561 5.1561 1.4531 6.609

8.lncentive - Line 4 x Oper 10% Res 3% I 13.2151 o.oool 13.2151 13.2151 7.7761 20.991

9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% I 5.1561 o.oool 5.1561 5.1561 1.4531 6.609

10.Final Incentive I 5.1561 o.oool 5.1561 5.1561 1.4531 6.609 - --

11 .Current Period Base: (line 6 +line 10) I 137.3061 180.0881 317 .3931 137.3061 260.6411 397.947

12.Plus: Property Rate Component -- I I- 59.2621 I 59.262

13.Plus: ROE/Use Rate - 1 3.2671 I 3.267

14.Total Current Period Base -1 I 379.9231 I 460.476

15.Prospective Rate: Line 11 x Inflation 1.05398512 -1- 144.7181 189.8101 334.5281 144.7181 274.7121 419.430


17.NA - - 1 - 0.0001 o.oool o.oool 0.0001 0.0001 0.000


19.Property Rate Component I I 59.2621 I 59.262

20.ROE Component + ROE Interim Component

=-' I- 3.2671 I- 3.267

21 .Plus: Property Interim Rate Component o.oool 0.000

22.Final Per Diem 397.06 481.96 23.Medicaid Days 1,460 7,300

24.Resident Days -_I 1,460 I 7,300 ---- - I 25.Medicaid Utilization 100.00% 100.00%

26.Quality Assessment ($21 .06) I 21.061 21 .06


28.Less Rate Cut (0%) Based on Days - I o.ool 0.00 ----

29. 0.001 0.00




028541200 - 2016/07


Twin Lane Community Home (Res-Care)

2281 Twin Lane Drive

Dundedun, FL 34698


Level of Care

#7 Institutional


Current Rate


Rate Type:


Date: 6/23/2016

FYE: 6/30/2015


New Rate

Effective Date

273.78 7/1/2016

310.78 7/1/2016


Basis

x

Distribution:

Contract Management

DPODS - DCF (4)

Home Office :

Res-Care, Inc.

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Comments:

Printed on : 6/23/2016 3:28 PM, Batch ID: Y7R2F , User ID: FDHC\pridgeoc

x Total Prospective


Desk Audited Costs



W.Rydell Samuel






028541200

Provider Name:

Provider Number:

Twin Lane Community Home (Res-Care) Cost Report Entered By:


Pridgeon, Chantelle

July, 2016 Audit Status: Unaudited

Date: 6/23/2016


1. Resident Days


A. Administration

B. Plant Operation

C. Laundry

D. Housekeeping


3. Resident Care

A. Dietary

B. Other

C. Nursing



5. ROE/Use Per Diem


1. Staffing


3. Staffing Percent













Cost Report :


7/1/2014 - 6/30/2015

365

Number of Beds: 6

Column A Column B Residential Non-Ambulatory Medical Institutional

1,008 1

57.9591 1

19.2815

15.1545

0.9522

0.75

756.00

0.43

105,001 .29

104.1679

1,008

52,935

52.5149

57.9591

175.9643

15.1545

0.9522

250.0301

999

57.9591

19.2815

15.1545

0.9522

1.00

999.00

0.57

138,751 .71

138.8906

999

52,471

52.5235

57.9591

210.69561

15.1545

0.9522

284.7614

Column C Total

2,007

90,668

22,312

509

2,835

116,324

20,539

0

18, 159

38,698

30,415

1,911

1,755.00

1.00

243,753.00

2,007

105,406

116,324

387,857

30,415

1,911

536,507


Facility Name: Twin Lane Community Home (Res-Care)

~------





Printed on: 6/23/2016 8:41 AM

R/I & N/M Days

R/I N/M

19.2815 19.2815

104.1679 138.8906 \

52.5149 52.5235

175.9643 210.6956


FYE: 06/30/2015

A3D Allowable ~esident Care Exp




TOTALS

38,698

243,753

105,406

387,857



ICF/llD Calculation Sheet


Twin Lane Community Home (Res-Care)

Ownership: Private

Incentive Rating: Eligible from 05/01 /2015 - 04/30/2016 Days Eligible: 366 of 366






028541200 - 2016/07

RI: 273.78

NM: 310.78

Base Semester

201507




2.lnflate Line 1 by Inflation Factor 1.02404884 - - I 3.Line 1 X 1.4000 X Inflation Factor 1.03366838 -==I[ 4.Current Period Cost





I I I I

9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% I

---1= 10.Final Incentive

11.Current Period Base: (line 6 +line 10)

12.Plus: Property Rate Component - 1

----1 15.Prospective Rate: Line 11 x Inflation 1.05175287 - 1




17.NA




21 .Plus: Property Interim Rate Component


I I I

__ I

- I

43.869

44.9241

45.3461

57.9591

0.0001

45.3461

0.0001

0.0001

0.0001

0.0001

45.3461

47.6931

0.0001

0.0001

47.6931

176.476

180.7201

182.4181

175.9641

6.453

175.9641

3.2271

5.2791

3.2271

3.2271

179.1911

I 1-

188.4651

0.0001

0.0001

188.4651

I

~-I -------- --------

24.Resident Days I 1,008

1,008

220.345

225.64~ 227.7641

233.9231

I 221 .3111

3.2271

5.2791

3.2271

3.2271

224.5371

15.1551

0.9521

240.6441

236.1581

0.0001

0.0001

236.1581

15.1551

0.9521

0.0001

252.26

25.Medicaid Utilization - --- - - --1 100.00%

·1 I

26.Quality Assessment ($21.06) - -----1

27.Less or Plus: Buy Back- QAF (.001684964) I 28.Less Rate Cut (0%) Based on Days _ ---- __ 11~ _____ -----

29.



21 .061

0.461

0.001

0.001

273.78

43.869

44.9241

45.3461

57.9591

0.0001

45.3461

0.0001

0.0001

0.0001

0.0001

45.3461

47.6931

0.0001

0.0001

47.6931

210.812

215.8821

217 .9101

210.6961

7.2141

210.6961

3.6071

6.3211

3.6071

3.6071

214.3031

I I I

225.3931

0.0001

0.0001

225.3931

I

I=-999

999

100.00%

254.681

260.806

263.256

268.655

256.042

3.607

6.321

3.607

3.607

259.649

15.155

0.952

275.756

273.086

0.000

0.000

273.086

15.155

0.952

0.000

289.19

21.06

0.52

0.00

0.00

310.78


028547100 - 2016/07


62nd Place Grp Home #17 (Sunrise)

19963 N.W. 62nd Place

Miami Lakes, FL 33015


Level of Care

#7 Institutional


Current Rate


Rate Type:


Date: 6/23/2016

FYE: 6/30/2015


New Rate

Effective Date

212.95 7/1/2016

0.00 7/112016


Basis

x

Distribution :

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Miami, FL 33170

Comments:

Printed on: 6/23/2016 3:28 PM, Batch ID: Y7R2F , User ID: FDHC\pridgeoc

x Total Prospective


Desk Audited Costs



W.Rydell Samuel



Provider Name:

Provider Number:

Audit Status:

Date:




62nd Place Grp Home #17 (Sunrise) Cost Report Entered By :




Number of Beds:

028547100

Pridgeon, Chantelle

July, 2016

7/1/2014 - 6/30/2015

365

6

Column A Column B Column C Total


1. Resident Days


A. Administration

B. Plant Operation

C. Laundry

D. Housekeeping


3. Resident Care

A. Dietary

B. Other

C. Nursing



5. ROE/Use Per Diem


1. Staffing


3. Staffing Percent













---

r

r I

.L

T

I L--l

Residential Non-Ambulatory Medical Institutional

0

32.7366

31 .9113 1

13.3288 1

0.3205

T

0.75 1.00

1,614.75 0.00

1.00 0.00

221,982.00 0.00

103.1036 0.0000

2,153 0

7871

0

0.3655 0.0000

32.7366 0.0000

135.3804 1 0.0000

13.3288 0.0000

0.3205 0.0000 ---

181.7663 0.0000 -~~

2,153

51,289

16,503

571

2,119

70,482

21 ,023

34,765

12,917

68,705

28,697

690

1,614.75

1.00

221 ,982.00

2,1 53

787

70,482

291,474

28,697

690

391,343


Facility Name: 62nd Place Grp Home #17 (Sunrise)


BS Allocation of DIC Expenses



Printed on : 6/23/2016 8:41 AM

-

No NIM Days

R/I N/M

31 .9113 0.0000

103.1036 0.0000

0.3655 0.0000

135.3804 0.0000


FYE: 0613012015





TOTALS

68,705

221 ,982

787

291,474





62nd Place Grp Home #17 (Sunrise)

Ownership: Private







028547100 - 2016/07

RI: 212.95

NM: 0.00

Base Semester

201507



1.Prior Period Base: 41 .162 128.785 169.947 0.000 0.000 0.000

2.lnflate Line 1 by Inflation Factor 1.02404884 I 42.1521 131 .8821 174.0341 0.0001 0.0001 0.000


4.Current Period Cost -----1- 32.7371 135.3801 168.1171 0.0001 0.0001 0.000


6.Allowed Current Period Costs (Min of line 3 or 4) - I 32.7371 133.1211 165.8571 0.0001 0.0001 0.000


8.lncentive - Line 4 x Oper 10% Res 3% I- 3.2741 0.000 3.2741 0.0001 0.0001 0.000



11.Current Period Base: (line 6 +line 10) I 36.0101 133.121 169.1311 0.0001 0.0001 0.000

12.Plus: Property Rate Component I I- 13.3291 I - 0.000

13.Plus: ROE/Use Rate I 0.3211 1- 0.000

14.Total Current Period Base I I 182.7801 I 0.000



17.NA I_ 0.0001 0.0001 0.0001 0.0001 0.0001 0.000

18.Total Operating & Residential Care Rate ~ 1 37.8741 140.010 177.8841 0.0001 0.0001 0.000


20.ROE Component+ ROE Interim Component I I

0.3211 I-- 0.000

21 .Plus: Property Interim Rate Component I 0.0001 0.000

22.Final Per Diem 191.53 0.00 23.Medicaid Days 2,153 0

--- -- - --- I 24.Resident Days 2,153 0 - -----

25.Medicaid Utilization 100.00% I 0.00% -- ---- ------26.Quality Assessment ($21.06) 21.061 0.00

27.Less or Plus: Buy Back- QAF (.001684964) 0.361 0.00

28.Less Rate Cut (0%) Based on Days 0.001 0.00 --~-~

29. 0.001 0.00




028548000 - 2016/07

Rl:239.94 / NM:282.60

138th Court Grp Home #16 (Sunrise)

3210 S.W. 138th Court

Miami, FL 33175


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 6/30/2015


New Rate

Effective Date

239.94 7/1/2016

282.60 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Miami, FL 33170

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






028548000

Provider Name: 138th Court Grp Home #16 (Sunrise) Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 6


A. AllocatiQn of ExRenses (excluding B & C)

1. Resident Days 1,384 730 2,114




C. Laundry 401



3. Resident Care

A. Dietary 13,928

B. Other 27,488

C. Nursing 4,006


4. Prop Exp & Per Diem 14.8936 14.8936 31,485

5. ROE/Use Per Diem 0.5151 0.5151 1,089


1. Staffing 0.75 1.00
















Facility Name: 138th Court Grp Home #16 (Sunrise)

R/1 & N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

21.4863

126.3852

4.1192

151.9907

N/M

21.4863

168.5136

4.1192

194.1191


FYE: 06/30/2015





TOTALS

45,422

297,932

8,708

352,062






Ownership:Private







028548000 - 2016/07

RI: 239.94

NM: 282.60

Base Semester

201507



















17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000





22.Final Per Diem I 218.471 261.06 ---------- ----- ------ -----







29.

I 0.001 0.00




028552800 - 2016/07

Rl:224.24 / NM:262.07

26th Terrace Grp Home #12 (Sunrise)

1219 26th Terrace

Cape Coral, FL 33904


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 6/30/2015


New Rate

Effective Date

224.24 7/1/2016

262.07 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Miami, FL 33170

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






028552800

Provider Name: 26th Terrace Grp Home #12 (Sunrise) Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 6



1. Resident Days 1,454 730 2,184




C. Laundry 94



3. Resident Care

A. Dietary 17,630

B. Other 32,313

C. Nursing 0


4. Prop Exp & Per Diem 10.2747 10.2747 22,440

5. ROE/Use Per Diem 1.0778 1.0778 2,354


1. Staffing 0.75 1.00





C. Additional Servic1;1s Expense











Facility Name: 26th Terrace Grp Home #12 (Sunrise)

R/1 & N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

22.8677

116.7565

3.9993

143.6235

N/M

22.8677

155.6754

4.0000

182.5431


FYE: 0613012015





TOTALS

49,943

283,407

8,735

342,085





26th Terrace Grp Home #12 (Sunrise)

Ownership:Private







028552800 - 2016/07

RI: 224.24

NM: 262.07

Base Semester

201507



















17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000



20.ROE Component+ ROE Interim Component 1.0781 I 1.Q78


22.Final Per Diem I 202.sol 240.57 ~- - ---------- ----- ---------

23. Medicaid Days

I 1,454

I 730






29.

l 0.001 0.00




028553600 - 2016/07

Rl:289.67 / NM:0.00

Country Meadows Grp Home #13 (Sunrise)

1950 Country Meadows Circle

Sarasota, FL 34235


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 6/30/2015


New Rate

Effective Date

289.67 7/1/2016

0.00 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Miami, FL 33170

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel



Provider Name:

Provider Number:

Audit Status:

Date:




Country Meadows Grp Home #13 Cost Report Entered By : (Sunrise)




Number of Beds:

Column A Column B

028553600

Pridgeon, Chantelle

July, 2016

7/1/2014 - 6/30/2015

365

6







C. Laundry 332

D. Housekeeping 753


3. Resident Care

A. Dietary 16,927

B. Other 45,416

C. Nursing 0


4. Prop Exp & Per Diem 15.9301 34,887



1. Staffing 0.75 1.00
















Facility Name: Country Meadows Grp Home #13 (Sunrise)

No N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

28.4671

136.8461

11.6685

176.9817

N/M

0.0000

0.0000

0.0000

0.0000


FYE: 0613012015





TOTALS

62,343

299,693

25,554

387,590





Country Meadows Grp Home #13 (Sunrise)

Ownership:Private







028553600 • 2016/07

RI: 289.67

NM: 0.00

Base Semester

201507












10.Final Incentive 5.1861 5.309 10.4961 0.0001 0.0001 0.000







17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000





22.Final Per Diem I 268.131 0.00 - -------- - -- -- - --

I 23.Medicaid Days

I 2,190 0






29.

I 0.001 0.00




028557900 • 2016/07

Rl:221.74 / NM:0.00



Miami, FL 33185


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 6/30/2015


New Rate

Effective Date

221.74 7/1/2016

0.00 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Miami, FL 33170

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel



Provider Name:

Provider Number:

Audit Status:

Date:




148th Court Grp Home #20 (Sunrise) Cost Report Entered By :




Number of Beds:

Column A Column B

028557900

Pridgeon, Chantelle

July, 2016

7/1/2014 - 6/30/2015

365

6







C. Laundry 597



3. Resident Care

A. Dietary 14,108

B. Other 61,167

C. Nursing 1,254


4. Prop Exp & Per Diem 10.8868 23,842



1. Staffing 0.75 1.00

















No NIM Days





Printed on: 6/23/2016 8:41 AM

R/1

34.9447

98.7452

3.1845

136.8744

N/M

0.0000

0.0000

0.0000

0.0000


FYE: 0613012015





TOTALS

76,529

216,252

6,974

299,755






Ownership:Private







028557900 - 2016/07

RI: 221.74

NM: 0.00

Base Semester

201507












10.Final Incentive 3.0321 4.106 7.1381 0.0001 0.0001 0.000







17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000





22.Final Per Diem I 200.301 0.00 ·- -----------

23.Medicaid Days

I 2,190

I 0






29.

l 0.001 0.00






028558700 • 2016/07

Rl:226.48 / NM:0.00

Sunrise Oakmont

19420 W. Oakmont Drive



Level of Care

#7 Institutional


Rate Type:

Interim

Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Miami, FL 33170

Current Rate

219.97

0.00


Date: 6/23/2016

FYE: 6/30/2015


New Rate

Effective Date

226.48 7/1/2016

0.00 7/1/2016

X Prospective

X Total Prospective


Desk Audited Costs



W.Rydell Samuel


Comments:






Provider Name: Sunrise Oakmont Cost Report Entered By :




Number of Beds:

Column A Column B

028558700

Pridgeon, Chantelle

July, 2016

7/1/2014 - 6/30/2015

365

6







C. Laundry 1,169



3. Resident Care

A. Dietary 19,496

B. Other 40,235

C. Nursing 364


4. Prop Exp & Per Diem 14.9110 31,835



1. Staffing 0.75 1.00
















Facility Name: Sunrise Oakmont





Printed on: 6/23/2016 8:41 AM

No N/M Days

R/1 N/M

28.1475 0.0000

109.1958 0.0000

0.1311 0.0000

137.4744 0.0000


FYE: 0613012015





TOTALS

60,095

233,133

280

293,508





Sunrise Oakmont

Ownership:Private







028558700 - 2016/07

RI: 226.48

NM: 0.00

Base Semester

201507












10.Final Incentive







17.NA





22.Final Per Diem --~-----~" - - ------------

23.Medicaid Days

24.Resident Days





29.

JO.Final Per Diem After Adjustments


I

I I I I

40.028

40.9901

41.3751

37.9481

3.4271

37.9481

1.7141

3.7951

1.7141

1.7141

39.6621

41.7141

0.0001

0.0001

41.7141

139.781

143.143

144.488

137.474

7.013

137.474

3.507

4.124

3.507

3.507

140.981

148.277

0.000

0.000

148.277

2,135

2,135

179.809

184.1331

185.8631

175.4221

I 175.4221

5.2201

7.9191

5.2201

5.2201

180.6431

14.9111

0.1401

195.6931

189.9911

0.0001

0.0001

189.9911

14.9111

0.1401

0.0001

205.041

100.00% I 21.061

0.381

0.001

0.001

226.481

0.000

0.0001

0.0001

0.0001

0.0001

0.0001

0.0001

0.0001

0.0001

0.0001

0.0001

0.0001

0.0001

0.0001

0.0001

0.000

0.0001

0.0001

0.0001

0.0001

0.0001

0.0001

0.0001

0.0001

0.0001

0.0001

I 0.0001

0.0001

0.0001

0.0001

I 0

0

0.00%

0.000

0.000

0.000

0.000

0.000

0.000

0.000

0.000

0.000

0.000

0.000

0.000

0.000

0.000

0.000

0.000

0.000

0.000

0.000

0.000

0.00

0.00

0.00

0.00

0.00

0.00


028559500 - 2016/07

Rl:237.53 / NM:0.00

53rd Court Grp Home #9 (Sunrise)

10228 S.W. 53rd Court

Cooper City, FL 33328


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 6/30/2015


New Rate

Effective Date

237.53 7/1/2016

0.00 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Miami, FL 33170

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel



Provider Name:

Provider Number:

Audit Status:

Date:




53rd Court Grp Home #9 (Sunrise) Cost Report Entered By :




Number of Beds:

Column A Column B

028559500

Pridgeon, Chantelle

July, 2016

7/1/2014 - 6/30/2015

365

6







C. Laundry 610



3. Resident Care

A. Dietary 22,658

B. Other 42,043

C. Nursing 3,929


4. Prop Exp & Per Diem 14.1658 31,023



1. Staffing 0.75 1.00
















Facility Name: 53rd Court Grp Home #9 (Sunrise)

No N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

31.3379

132.0091

0.5648

163.9118

N/M

0.0000

0.0000

0.0000

0.0000


FYE: 06/30/2015





TOTALS

68,630

289,100

1,237

358,967





53rd Court Grp Home #9 (Sunrise)

Ownership:Private







028559500 - 2016/07

RI: 237.53

NM: 0.00

Base Semester

201507












10.Final Incentive 1.0091 0.000 1.0091 0.0001 0.0001 0.000







17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000





22.Final Per Diem I 216.071 0.00 -







29.

I 0.001 0.00




028560900 • 2016/07

Rl:235.77 / NM:0.00



Davie, FL 33320


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 6/30/2015


New Rate

Effective Date

235.77 7/1/2016

0.00 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Miami, FL 33170

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel



Provider Name:

Provider Number:

Audit Status:

Date:




55th Court Grp Home #15 (Sunrise) Cost Report Entered By :




Number of Beds:

Column A Column B

028560900

Pridgeon, Chantelle

July, 2016

7/1/2014 - 6/30/2015

365

6


A. Allocation of Expeoses (excluding B & C)





C. Laundry 673



3. Resident Care

A. Dietary 18,081

B. Other 42,816

C. Nursing 7,051


4. Prop Exp & Per Diem 8.8397 19,359



1. Staffing 0.75 1.00

















No N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

31.0265

123.9475

0.4603

155.4343

N/M

0.0000

0.0000

0.0000

0.0000


FYE: 06/30/2015





TOTALS

67,948

271,445

1,008

340,401






Ownership:Private







028560900 - 2016/07

RI: 235.77

NM: 0.00

Base Semester

201507












10.Final Incentive 1.9971 0.000 1.9971 0.0001 0.0001 0.000







17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000





22.Final Per Diem I 214.311 0.00 ---- ----- --------------

23.Medicaid Days

I 2,190

I 0






29.

I 0.001 0.00




028561700 - 2016/07

Rl:247.47 / NM:0.00

Wentworth Drive Grp Home #18 (Sunrise)

18711 Wentworth Drive



Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 6/30/2015


New Rate

Effective Date

247.47 7/1/2016

0.00 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Miami, FL 33170

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel



Provider Name:

Provider Number:

Audit Status:

Date:




Wentworth Drive Grp Home #18 Cost Report Entered By : (Sunrise)




Number of Beds:

Column A Column B

028561700

Pridgeon, Chantelle

July, 2016

7/1/2014 - 6/30/2015

365

6







C. Laundry 762



3. Resident Care

A. Dietary 20,551

B. Other 39,463

C. Nursing 498


4. Prop Exp & Per Diem 11.9819 24,503



1. Staffing 0.75 1.00
















Facility Name: Wentworth Drive Grp Home #18 (Sunrise)

No N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

29.5902

133.9423

0.4249

163.9574

N/M

0.0000

0.0000

0.0000

0.0000


FYE: 06/30/2015





TOTALS

60,512

273,912

869

335,293





Wentworth Drive Grp Home #18 (Sunrise)

Ownership:Private







028561700 - 2016/07

RI: 247.47

NM: 0.00

Base Semester

201507







5.lncentive Basis (line 3 - line 4) 1.5561 0.084 I 0.0001 o.oool 6.Allowed Current Period Costs (Min of line 3 or 4) 38.5031 163.957 202.4611 0.0001 o.oool 0.000



9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% 0.7781 0.042 0.8201 o.oool o.oool 0.000

10.Final Incentive 0.7781 0.042 0.8201 0.0001 o.oool 0.000

11.Current Period Base: (line 6 + line 10) 39.2811 163.999 203.2801 o.oool 0.0001 0.000





16.lnterim Rate Component: 0.0001 0.000 o.oool 0.0001 o.oool 0.000

17.NA o.oool 0.000 o.oool 0.0001 0.0001 0.000





22.Final Per Diem I 226.001 0.00 ---- ·- -- --------

23.Medicaid Days

I 2,045

I 0






29.

I 0.001 0.00




028565000 • 2016/07

Rl:328.98 / NM:401.09

Lakeview Court

920 W. Kennedy Blvd

Orlando, FL 32810

Provider Type: ICF/110

Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 11/30/2014


New Rate

Effective Date

328.98 7/1/2016

401.09 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

OSI

P.O. BOX 2064

Winter Park, FL 32790

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs


Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel





028565000


Provider Name: Lakeview Court



Date: 6/23/2016


1. Resident Days


A. Administration

B. Plant Operation

C. Laundry

D. Housekeeping


3. Resident Care

A. Dietary

B. Other

C. Nursing



5. ROE/Use Per Diem


1. Staffing


3. Staffing Percent














Rate Semester :

Cost Report :


Number of Beds:

Pridgeon, Chantelle

July, 2016

12/1/2013 - 11/30/2014

365

64


10,900 12,319 23,219

1,332,953

358,117

45,205

19,589

75.6219 75.6219 1,755,864

598,496

56,511

851,388

64.8777 64.8777 1,506,395

19.5577 19.5577 454,110

0.1006 0.1006 2,335

0.50 1.00

5,450.00 12,319.00 17,769.00

0.31 0.69 1.00

715,429.28 1,617,132.72 2,332,562.00

65.6357 131.2714

10,900 12,319 23,219

645,223 729,221 1,374,444

59.1948 59.1948

75.6219 75.6219 1,755,864

189.7082 255.3439 5,213,401

19.5577 19.5577 454,110

0.1006 0.1006 2,335

284.9884 350.6241 7,425,710


Facility Name: Lakeview Court





Printed on: 6/23/2016 8:41 AM

R/1 & N/M Days

R/1 N/M

64.8777 64.8777

65.6357 131.2714

59.1948 59.1948

189.7082 255.3439


FYE: 1113012014





TOTALS

1,506,395

2,332,562

1,374,444

5,213,401





Lakeview Court

Ownership:Private







028565000 - 2016/07

RI: 328.98

NM: 401.09

Base Semester

201507












10.Final Incentive 2.5021 1.752 4.2551 2.5021 3.5651 6.068







17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000





22.Final Per Diem I 307.371 379.35 -- -- -----------

23.Medicaid Days

I 10,900

I 12,319






29.

I 0.001 0.00




028566800 - 2016/07

Rl:323.64 / NM:387.10

Washington Square

1401 North U.S. Highway 1

Titusville, FL 32796

Provider Type: ICF/110

Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 11/30/2014


New Rate

Effective Date

323.64 7/1/2016

387.10 7/1/2016


Basis

X

Distribution·

Contract Management

DPODS - DCF (4)

Home Office:

OSI

P.O. BOX 2064


Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs


Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel





028566800


Provider Name: Washington Square



Date: 6/23/2016


1. Resident Days


A. Administration

B. Plant Operation

C. Laundry

D. Housekeeping


3. Resident Care

A. Dietary

B. Other

C. Nursing



5. ROE/Use Per Diem


1. Staffing


3. Staffing Percent














Rate Semester :

Cost Report :


Number of Beds:

Pridgeon, Chantelle

July, 2016

12/1/2013 - 11/30/2014

365

64


5,212 18,014 23,226

1,342,539

380,036

52,038

20,132

77.2731 77.2731 1,794,745

581,988

66,239

887,378

66.1158 66.1158 1,535,605

17.9098 17.9098 415,973

0.0897 0.0897 2,084

0.50 1.00

2,606.00 18,014.00 20,620.00

0.13 0.87 1.00

312,000.75 2,156,708.25 2,468,709.00

59.8620 119.7240

5,212 18,014 23,226

304,365 1,051,962 1,356,327

58.3970 58.3969

77.2731 77.2731 1,794,745

184.3748 244.2367 5,360,641

17.9098 17.9098 415,973

0.0897 0.0897 2,084

279.6474 339.5093 7,573,443


Facility Name: Washington Square





Printed on: 6/23/2016 8:41 AM

R/1 & NIM Days

R/1 N/M

66.1158 66.1158

59.8620 119.7240

58.3970 58.3969

184.3748 244.2367


FYE: 1113012014





TOTALS

1,535,605

2,468,709

1,356,327

5,360,641





Washington Square

Ownership:Private







028566800 - 2016/07

RI: 323.64

NM: 387.10

Base Semester

201507












10.Final Incentive 1.3751 3.120 4.4951 1.3751 2.6231 3.999







17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000





22.Final Per Diem I 302.041 365.39 ~-~--- -·-- --- -------- - - -- - ------- --

23.Medicaid Days

I 5,212

I 18,014






29.

I 0.001 0.00




028567600 - 2016/07

Rl:321.54 / NM:382.86

Howell Branch Court

3664 Howell Branch Road



Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 11/30/2014


New Rate

Effective Date

321.54 7/1/2016

382.86 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

OSI

P.O. BOX 2064


Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs


Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel





028567600


Provider Name: Howell Branch Court



Date: 6/23/2016


1. Resident Days


A. Administration

B. Plant Operation

C. Laundry

D. Housekeeping


3. Resident Care

A. Dietary

B. Other

C. Nursing



5. ROE/Use Per Diem


1. Staffing


3. Staffing Percent














Rate Semester :

Cost Report :


Number of Beds:

Pridgeon, Chantelle

July, 2016

12/1/2013 - 11/30/2014

365

64


3,216 19,493 22,709

1,324,120

370,091

48,679

26,566

77.9187 77.9187 1,769,456

575,723

80,063

876,795

67.4878 67.4878 1,532,581

18.4328 18.4328 418,591

0.1073 0.1073 2,436

0.50 1.00

1,608.00 19,493.00 21,101.00

0.08 0.92 1.00

185,158.83 2,244,590.17 2,429,749.00

57.5743 115.1485

3,216 19,493 22,709

196,048 1,188,298 1,384,346

60.9602 60.9602

77.9187 77.9187 1,769,456

186.0223 243.5965 5,346,676

18.4328 18.4328 418,591

0.1073 0.1073 2,436

282.4811 340.0553 7,537,159


Facility Name: Howell Branch Court





Printed on: 6/23/2016 8:41 AM

R/1 & NIM Days

R/1 N/M

67.4878 67.4878

57.5743 115.1485

60.9602 60.9602

186.0223 243.5965


FYE: 1113012014





TOTALS

1,532,581

2,429,749

1,384,346

5,346,676





Howell Branch Court

Ownership:Private







028567600 - 2016/07

RI: 321.54

NM: 382.86

Base Semester

201507












10.Final Incentive 0.0001 0.306 0.3061 0.0001 0.0851 0.085







17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000





22.Final Per Diem I 299.941 361.15 ---------

23.Medicaid Days

I 3,216

I 19,493






29.

I 0.001 0.00






028568400 - 2016/07

Rl:257.77 / NM:0.00

157th Terrace (Sunrise)

9790 S. W. 157th Terrace

Miami, FL 33157


Level of Care

#7 Institutional


Rate Type:

Interim

Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Miami, FL 33170

Current Rate

242.04

0.00


Date: 6/23/2016

FYE: 6/30/2015


New Rate

Effective Date

257.77 7/1/2016

0.00 7/1/2016

X Prospective

X Total Prospective


Desk Audited Costs



W.Rydell Samuel


Comments:



Provider Name:

Provider Number:

Audit Status:

Date:




157th Terrace (Sunrise) Cost Report Entered By :




Number of Beds:

Column A Column B

028568400

Pridgeon, Chantelle

July, 2016

7/1/2014 - 6/30/2015

365

6



1 . Resident Days 2,110 0 2,110




C. Laundry 977

D. Housekeeping 816


3. Resident Care

A. Dietary 15,193

B. Other 55,968

C. Nursing 6,232


4. Prop Exp & Per Diem 15.0924 31,845



1. Staffing 0.75 1.00
















Facility Name: 157th Terrace (Sunrise)





Printed on: 6/23/2016 8:41 AM

No N/M Days

R/1 N/M

36.6791 0.0000

130.3147 0.0000

5.9555 0.0000

172.9493 0.0000


FYE: 06/30/2015





TOTALS

77,393

274,964

12,566

364,923





157th Terrace (Sunrise)

Ownership:Private







028568400 - 2016/07

RI: 257.77

NM: 0.00

Base Semester

201507












10.Final Incentive 0.0001 0.000 0.0001 0.0001 0.0001 0.000







17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000





22.Final Per Diem I 236.281 0.00 ~- -------- --------- - - --

23.Medicaid Days

I 2,110

I 0






29.

I 0.001 0.00




028569200 • 2016/07

Rl:294.62 / NM:342.98

145th Street Group Home (Sunrise)


Miami, Fl 33196


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 6/30/2015


New Rate

Effective Date

294.62 7/1/2016

342.98 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Miami, FL 33170

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






028569200

Provider Name: 145th Street Group Home (Sunrise) Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 6



1. Resident Days 365 1,706 2,071




C. Laundry 467



3. Resident Care

A. Dietary 14,056

B. Other 50,510

C. Nursing 18,707


4. Prop Exp & Per Diem 18.7721 18.7721 38,877

5. ROE/Use Per Diem 2.6499 2.6499 5,488


1. Staffing 0.75 1.00
















Facility Name: 145th Street Group Home (Sunrise)

R/1 & N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

40.2091

135.1303

5.9260

181.2654

NIM

40.2091

180.1738

5.9273

226.3102


FYE: 0613012015





TOTALS

83,273

356,699

12,275

452,247





145th Street Group Home (Sunrise)

Ownership:Private







028569200 - 2016/07

RI: 294.62

NM: 342.98

Base Semester

201507



















17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000





22.Final Per Diem I 273.061 321.34 ----~-~~--

I I 23.Medicaid Days 365 1,706




27.Less or Plus: Buy Back - QAF (.001684964) I a.sol 0.58


29.

I 0.001 0.00




031256800 - 2016/07

Rl:387.35 / NM:454.35

Avon Park Cluster (Mentor)

55 East College Drive

Avon Park, FL 33825


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 5/31/2014


New Rate

Effective Date

387.35 7/1/2016

454.35 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Tampa, FL 33619

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






031256800

Provider Name: Avon Park Cluster (Mentor) Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 24







C. Laundry 0



3. Resident Care

A. Dietary 145,280

B. Other 0

C. Nursing 991,943


4. Prop Exp & Per Diem 8.9422 8.9422 77,538

5. ROE/Use Per Diem 0.5825 0.5825 5,051


1. Staffing 0.50 1.00
















Facility Name: Avon Park Cluster (Mentor)





Printed on: 6/23/2016 8:41 AM

Extrapolated R/1

R/1 N/M

131.1525 131.1525

60.2044 120.4087

26.3875 26.3875

217.7444 277.9487


FYE: 05/31/2014





TOTALS

1,137,223

1,044,064

228,806

2,410,093





Avon Park Cluster (Mentor)

Ownership:Private







031256800 - 2016/07

RI: 387.35

NM: 454.35

Base Semester

201407









?.Incentive Line 5 x Oper 50% Res 50% o.oool 6.682 6.6821 o.oool 21.5411 21.541

8.lncentive - Line 4 x Oper 10% Res 3% o.oool 6.532 6.5321 o.oool 8.3381 8.338


10.Final Incentive 0.0001 6.532 6.5321 0.0001 8.3381 8.338







17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000





22.Final Per Diem I 365.641 432.53 ~ ------- --------- - -

23.Medicaid Days

I 0

I 8,671






29.

I o.ool 0.00




031257600 - 2016/07

Rl:399.29 / NM:495.73

Eagle Watch Cluster {Mentor)

1725 Fifth Street

Daytona Beach, FL 32117


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 5/31/2014


New Rate

Effective Date

399.29 7/1/2016

495.73 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Tampa, FL 33619

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






031257600

Provider Name: Eagle Watch Cluster (Mentor) Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 24


A. Allocation of Exi;ienses (excluding B & C)

1. Resident Days 2,531 6,213 8,744




C. Laundry 0



3. Resident Care

A. Dietary 220,637

B. Other 0

C. Nursing 657,123


4. Prop Exp & Per Diem 11.4999 11.4999 100,555

5. ROE/Use Per Diem 1.0336 1.0336 9,038


1. Staffing 0.50 1.00
















Facility Name: Eagle Watch Cluster (Mentor)





Printed on: 6/23/2016 8:41 AM

R/1 & N/M Days

R/1 N/M

100.3843 100.3843

87.2081 174.4161

21.4097 21.4091

209.0021 296.2095


FYE: 05/31/2014





TOTALS

877,760

1,304,371

187,203

2,369,334





Eagle Watch Cluster (Mentor)

Ownership:Private







031257600 - 2016/07

RI: 399.29

NM: 495.73

Base Semester

201407












10.Final Incentive 0.0001 4.900 4.9001 0.0001 6.9441 6.944


12.Plus: Property Rate Component 11.500 I I 11.500




16.lnterim Rate Component: * 0.0001 26.453 26.4531 0.0001 26.4531 26.453

17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000



20.ROE Component + ROE Interim Component * 1.034 I 1.034

21.Plus: Property Interim Rate Component * 0.000 I 0.000

22.Final Per Diem I 377.56 473.84 ·---~ ----------- ---- --

23.Medicaid Days

I 2,531 6,213

24.Resident Days 2,531 I 6,213





29.

I 0.001 0.00

30.Final Per Diem After Adjustments 399.29i 495.73

* See Attachment


Health Insurance IRR #267 IRR# - Eagle Watch Cluster (Mentor)- Provider #0312576-00 Other Interim Rate Analysis - ICF/110 Plan Section IV.G.

Effective Date 1/1/2015 - Rate Semester 7/1/2016 Residential/Institutional (Level of Care 7)

Resident

Residential/Institutional IRR Effective 1/1/2015 $ 26.45 Operating Care Property ROE

Description Component Component Component Component Totals

Prospective Rate (Line 15) 107.843 230.732 11.500 1.034 351.11

Prospective Rate w/o ROE 107.843 230.732 11.500 0.000 350.07

Allocation of IRR 0.000 26.453 0.000 0.000 26.45

Final Per Diem (Line 22) 107.843 257.185 11.500 1.034 377.56

L22. Final Per Diem Rate - LOC 7 377.56

L26. Quality Assessment ($21.06) 21.06

L27. Less or Plus: Buy Back - OAF (.001684964) 0.67

L28. Less Rate Cut (0%) Based on Days 0.00

L29. 0.00

L30. Final Per Diem After Adjustments 399.29

Non - Ambulatory/Medical (Level of Care 8, 9)

Resident

Non-Ambulatory/Medical IRR Effective 1/1/2015 $ 26.45 Operating Care Property ROE




Allocation of I RR 0.000 26.453 0.000 0.000 26.45


L22. Final Per Diem Rate - LOC 8, 9 473.84




L29. 0.00


Printed on: 6/23/2016 8:48 AM, Batch ID: Y7R2F


031258400 - 2016/07

Rl:383.17 / NM:482.70

Point West Cluster (Mentor)

4550 Ricker Road



Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 5/31/2014


New Rate

Effective Date

383.17 7/1/2016

482.70 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Tampa, FL 33619

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






031258400

Provider Name: Point West Cluster (Mentor) Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 24



1 . Resident Days 925 7,312 8,237




C. Laundry 0



3. Resident Care

A. Dietary 157,958

B. Other 0

C. Nursing 670,656


4. Prop Exp & Per Diem 10.3465 10.3465 85,224

5. ROE/Use Per Diem 1.6383 1.6383 13,495


1. Staffing 0.50 1.00
















Facility Name: Point West Cluster (Mentor)





Printed on: 6/23/2016 8:41 AM

R/1 & N/M Days

R/1 N/M

100.5966 100.5966

89.7706 179.5412

23.3514 23.3515

213.7186 303.4893


FYE: 0513112014





TOTALS

828,614

1,395,843

192,346

2,416,803





Point West Cluster (Mentor)

Ownership:Private







031258400 - 2016/07

RI: 383.17

NM: 482.70

Base Semester

201407









?.Incentive Line 5 x Oper 50% Res 50% o.oool 6.035 6.0351 o.oool 10.2271 10.227

a.Incentive - Line 4 x Oper 10% Res 3% o.oool 6.412 6.4121 o.oool 9.1051 9.105

9.lncentive - Min of Line 7,8 x Eligibility factor 76.23% o.oool 4.600 4.6001 o.oool 6.9401 6.940

10.Final Incentive 0.0001 4.600 4.6001 0.0001 6.9401 6.940







17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000





22.Final Per Diem I 361.471 460.83 ~- -- ---- - ---

23.Medicaid Days

I 925 I 7,312






29.

I o.ool 0.00




031259200 - 2016/07

Rl:355.59 / NM:439.77

Hodges Cluster (Mentor)

3615 Hodges Boulevard



Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 5/31/2014


New Rate

Effective Date

355.59 7/1/2016

439.77 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Tampa, FL 33619

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






031259200

Provider Name: Hodges Cluster (Mentor) Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 24



1 . Resident Days 365 8,029 8,394




C. Laundry 0



3. Resident Care

A. Dietary 100,508

B. Other 0

C. Nursing 764,682


4. Prop Exp & Per Diem 9.1853 9.1853 77,101

5. ROE/Use Per Diem 2.0658 2.0658 17,340


1. Staffing 0.50 1.00
















Facility Name: Hodges Cluster (Mentor)





Printed on: 6/23/2016 8:41 AM

R/1 & NIM Days

R/1 N/M

103.0724 103.0724

76.6025 153.2049

12.1836 12.1825

191.8585 268.4598


FYE: 0513112014





TOTALS

865,190

1,258,042

102,260

2,225,492





Hodges Cluster (Mentor)

Ownership:Private







031259200 - 2016/07

RI: 355.59

NM: 439.77

Base Semester

201407











9.lncentive - Min of Line 7,8 x Eligibility factor 57.10% 0.0001 3.287 3.2871 o.oool 4.5991 4.599

10.Final Incentive o.oool 3.287 3.2871 0.0001 4.5991 4.599







17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000





22.Final Per Diem I 333.931 417.97 ----- ------ -·---

23.Medicaid Days

I 365

I 8,029






29.

I 0.001 0.00




031260600 • 2016/07

Rl:355.62 / NM:435.74

Kinkaid Cluster (Mentor)

5808 Kinkaid Road



Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 9/30/2015


New Rate

Effective Date

355.62 7/1/2016

435.74 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Tampa, FL 33619

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






031260600

Provider Name: Kinkaid Cluster (Mentor) Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 24



1. Resident Days 1,278 9,447 10,725




C. Laundry 0



3. Resident Care

A. Dietary 186,167

B. Other 0

C. Nursing 880,675


4. Prop Exp & Per Diem 15.2040 15.2040 163,063

5. ROE/Use Per Diem 1.2524 1.2524 13,432


1. Staffing 0.50 1.00
















Facility Name: Kinkaid Cluster (Mentor)





Printed on: 6/23/2016 8:41 AM

R/1 & N/M Days

R/1 N/M

99.4724 99.4724

75.9130 151.8259

21.0571 21.0571

196.4425 272.3554


FYE: 0913012015





TOTALS

1,066,842

1,531,316

225,837

2,823,995





Kinkaid Cluster (Mentor)

Ownership:Private







031260600 - 2016/07

RI: 355.62

NM: 435.74

Base Semester

201507












10.Final Incentive 1.9741 2.189 4.1631 1.9741 2.4801 4.454







17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000





22.Final Per Diem I 333.961 413.94 -- -- ---------------- ----

23.Medicaid Days

I 1,278

I 9,447






29.

I 0.001 0.00




031261400 - 2016/07

Rl:377.58 / NM:470.74

Flamingo Drive Cluster (Mentor)

1285 Flamingo Drive

Lantana, FL 33462


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 5/31/2014


New Rate

Effective Date

377.58 7/1/2016

470.74 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Tampa, FL 33619

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






031261400

Provider Name: Flamingo Drive Cluster (Mentor) Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 24







C. Laundry 0



3. Resident Care

A. Dietary 105,806

B. Other 0

C. Nursing 765,386


4. Prop Exp & Per Diem 11.1514 11.1514 92,869

5. ROE/Use Per Diem 3.6206 3.6206 30,152


1. Staffing 0.50 1.00
















Facility Name: Flamingo Drive Cluster (Mentor)

Extrapolated R/1





Printed on: 6/23/2016 8:41 AM

R/1

104.6100

72.9647

28.6164

206.1911

N/M

104.6100

145.9293

28.6164

279.1557


FYE: 0513112014





TOTALS

871,192

1,215,299

238,317

2,324,808





Flamingo Drive Cluster (Mentor)

Ownership:Private







031261400 - 2016/07

RI: 377.58

NM: 470.74

Base Semester

201407












10.Final Incentive 0.0001 6.186 6.1861 0.0001 8.3751 8.375






16.lnterim Rate Component: * 0.0001 0.000 o.oool o.oool 11.940 I 11.940

17.NA 0.0001 0.000 0.0001 o.oool o.oool 0.000



20.ROE Component+ ROE Interim Component *

I 3.6211 I 3.621

21.Plus: Property Interim Rate Component * o.oool I 0.000

22.Final Per Diem I 355.881 448.89 f--------- ---- - - -

I 23.Medicaid Days 0

I 8,328






29.

I 0.001 0.00


* See Attachment


1 :1 Staffing IRR# - Flamingo Drive Cluster (Mentor)- Provider #0312614-00 Staffing Interim Rate Analysis - ICF/IID Plan Section IV.G.


Resident











L29. 0.00


Non • Ambulatory/Medical (Level of Care 8, 9)

Resident











L29. 0.00




031262200 • 2016/07

Rl:380.76 / NM:0.00

Barranger Group Home (Mentor)

9513 Barranger Drive

Pensacola, FL 32514


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 5/31/2014


New Rate

Effective Date

380.76 7/1/2016

0.00 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Tampa, FL 33619

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel



Provider Name:

Provider Number:

Audit Status:

Date:




Barranger Group Home (Mentor) Cost Report Entered By :




Number of Beds:

Column A Column B

031262200

Pridgeon, Chantelle

July, 2016

6/1/2013 - 5/31/2014

365

6







C. Laundry 0



3. Resident Care

A. Dietary 19,295

B. Other 0

C. Nursing 30,535


4. Prop Exp & Per Diem 18.2927 38,689



1. Staffing 0.75 1.00
















Facility Name: Barranger Group Home (Mentor)

No N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

23.5603

150.9314

8.7248

183.2165

N/M

0.0000

0.0000

0.0000

0.0000


FYE: 0513112014





TOTALS

49,830

319,220

18,453

387,503





Barranger Group Home (Mentor)

Ownership:Private







031262200 - 2016/07

RI: 380.76

NM: 0.00

Base Semester

201407












10.Final Incentive 0.0001 5.496 5.4961 0.0001 0.0001 0.000






16.lnterim Rate Component: * 0.0001 63.390 63.3901 0.0001 0.0001 0.000

17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000



20.ROE Component + ROE Interim Component . 0.0001 I 0.000

21.Plus: Property Interim Rate Component * 0.0001 I 0.000

22.Final Per Diem I 359.061 0.00 -- - --------- - -------

23.Medicaid Days

I 2,115

I 0






29.

I 0.001 0.00


* See Attachment


Staffing IRR IRR #264 - Barranger Group Home (Mentor)- Provider #0312622-00 Staffing Interim Rate Analysis - ICF/IID Plan Section IV.G.


Resident









L27. Less or Plus: Buy Back - QAF (.001684964) 0.64


L29. 0.00



Resident











L29. 0.00




031263100 - 2016/07

Rl:272.28 / NM:0.00

Greenridge Group Home (Mentor)

222 Greenridge Road

Pensacola, FL 32514


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 5/31/2014


New Rate

Effective Date

272.28 7/1/2016

0.00 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Tampa, FL 33619

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel



Provider Name:

Provider Number:

Audit Status:

Date:




Greenridge Group Home (Mentor) Cost Report Entered By :




Number of Beds:

Column A Column B

031263100

Pridgeon, Chantelle

July, 2016

6/1/2013 - 5/31/2014

365

6







C. Laundry 0



3. Resident Care

A. Dietary 18,966

B. Other 0

C. Nursing 13,677


4. Prop Exp & Per Diem 14.9581 32,504



1. Staffing 0.75 1.00
















Facility Name: Greenridge Group Home (Mentor)

No N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

15.0221

126.4211

8.2181

149.6613

N/M

0.0000

0.0000

0.0000

0.0000


FYE: 0513112014





TOTALS

32,643

274,713

17,858

325,214





Greenridge Group Home (Mentor)

Ownership:Private







031263100 - 2016/07

RI: 272.28

NM: 0.00

Base Semester

201407












10.Final Incentive 0.0001 4.490 4.4901 0.0001 0.0001 0.000







17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000





22.Final Per Diem I 250.761 0.00 ·- -------

23.Medicaid Days

I 2,173

I 0






29.

I 0.001 0.00




031264900 • 2016/07

Rl:357.61 / NM:431.42

Pensacola Cluster {Mentor)

9460 S. University Parkway

Pensacola, FL 32515


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 5/31/2014


New Rate

Effective Date

357.61 7/1/2016

431.42 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Tampa, FL 33619

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






031264900

Provider Name: Pensacola Cluster (Mentor) Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 24







C. Laundry 0



3. Resident Care

A. Dietary 131,177

B. Other 0

C. Nursing 720,363


4. Prop Exp & Per Diem 6.8534 6.8534 58,405

5. ROE/Use Per Diem 1.0812 1.0812 9,214


1. Staffing 0.50 1.00



4. Allocation of Direct Care 0.00 1, 130,308.00 1,130,308.00













Facility Name: Pensacola Cluster (Mentor)





Printed on: 6/23/2016 8:41 AM

Extrapolated R/1

R/1 N/M

99.9226 99.9226

66.3171 132.6341

21.9774 21.9774

188.2171 254.5341


FYE: 0513112014





TOTALS

851,540

1,130,308

187,291

2,169,139





Pensacola Cluster (Mentor)

Ownership:Private







031264900 - 2016/07

RI: 357.61

NM: 431.42

Base Semester

201407











9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% o.oool 5.647 5.6471 0.0001 7.6361 7.636

10.Final Incentive 0.0001 5.647 5.6471 0.0001 7.6361 7.636







17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000





22.Final Per Diem I 335.951 409.63 - --- ---------- ---- - -·

23.Medicaid Days

I 0

I 8,522






29.

I o.ool 0.00





031265700 • 2016/07

Rl:286.97 / NM:0.00

Caprona Group Home (Mentor)

111 N.E Caprona Avenue

Port St. Lucie, FL 34983


Level of Care

#7 Institutional


Current Rate


Rate Type:


Date: 6/23/2016

FYE: 5/31/2014


New Rate

Effective Date

286.97 7/1/2016

0.00 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Tampa, FL 33619

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel



Provider Name:

Provider Number:

Audit Status:

Date:




Caprona Group Home (Mentor) Cost Report Entered By :




Number of Beds:

Column A Column B

031265700

Pridgeon, Chantelle

July, 2016

6/1/2013 - 5/31/2014

365

6


A. Allogation of Expeoses (excluding B & C)





C. Laundry 0



3. Resident Care

A. Dietary 24,006

B. Other 0

C. Nursing 58,105


4. Prop Exp & Per Diem 19.4890 42,681



1. Staffing 0.75 1.00
















Facility Name: Caprona Group Home (Mentor)





Printed on: 6/23/2016 8:41 AM

No N/M Days

R/1 N/M

37.4936 0.0000

107.5612 0.0000

9.8352 0.0000

154.8900 0.0000


FYE: 0513112014





TOTALS

82,111

235,559

21,539

339,209





Caprona Group Home (Mentor)

Ownership:Private







031265700 - 2016/07

RI: 286.97

NM: 0.00

Base Semester

201407



















17.NA 0.0001 0.000 0.0001 0.0001 0.0001 0.000





22.Final Per Diem I 265.431 0.00 ·--~ -- --------- - ---- ·--

23.Medicaid Days

I 2,190

I 0






29.

I 0.001 0.00




031266500 - 2016/07

Rl:237.80 / NM:269.58

Rich Street Group Home (Mentor)

2318 S.E. Rich Street

Port St. Lucie, FL 34984


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 9/30/2015


New Rate

Effective Date

237.80 7/1/2016

269.58 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Tampa, FL 33619

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






031266500

Provider Name: Rich Street Group Home (Mentor) Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 6



1 . Resident Days 1,849 1,035 2,884




C. Laundry 0



3. Resident Care

A. Dietary 30,682

B. Other 0

C. Nursing 33,621


4. Prop Exp & Per Diem 16.3998 16.3998 47,297

5. ROE/Use Per Diem 0.0000 0.0000 0


1. Staffing 0.75 1.00
















Facility Name: Rich Street Group Home (Mentor)

R/1 & N/M Days





Printed on: 6/23/2016 8:41 AM

R/1

22.2965

106.0517

11.7144

140.0626

N/M

22.2965

141.4023

11.7140

175.4128


FYE: 0913012015





TOTALS

64,303

342,441

33,784

440,528





Rich Street Group Home (Mentor)

Ownership:Private







031266500 - 2016/07

RI: 237.80

NM: 269.58

Base Semester

201507










a.Incentive - Line 4 x Oper 10% Res 3% I 0.0001 0.000 0.0001 0.0001 0.0001 0.000








16.lnterim Rate Component: . I 0.0001 15.573 15.5731 0.0001 14.1551 14.155

17.NA I 0.0001 0.000 0.0001 0.0001 0.0001 0.000



20.ROE Component + ROE Interim Component . I 0.0001 I 0.000

21.Plus: Property Interim Rate Component . l

0.0001 I 0.000

22.Final Per Diem 216.341 248.07 ----- - ---- -- --

23.Medicaid Days

I 1,849

I 1,035






29.

I 0.001 0.00

30.Final Per Diem After Adjustments 237.8ol 269.58

* See Attachment


Staffing #282 IRR# - Rich Street Group Home (Mentor)- Provider #0312665-00 Staffing Interim Rate Analysis - ICF/IID Plan Section IV.G.


Resident







L22. Final Per Diem Rate - LOG 7 216.34




L29. 0.00



Resident







L22. Final Per Diem Rate - LOG 8, 9 248.07




L29. 0.00




031267300 - 2016/07

Rl:327.46 / NM:399.92

Sandpiper Cluster (Mentor)

1000 East 14th Street

Stuart, FL 33496


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 9/30/2015


New Rate

Effective Date

327.46 7/1/2016

399.92 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs




Tampa, FL 33619

Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel






031267300

Provider Name: Sandpiper Cluster (Mentor) Cost Report Entered By : Pridgeon, Chantelle




Number of Beds: 24


A. Allocation of ExReoses (excluding B & C)

1. Resident Days 2,117 9,407 11,524




C. Laundry 0



3. Resident Care

A. Dietary 203,561

B. Other 0

C. Nursing 962,312


4. Prop Exp & Per Diem 14.8468 14.8468 171,095

5. ROE/Use Per Diem 0.6572 0.6572 7,573


1. Staffing 0.50 1.00





C. Additional Service§ ExRense











Facility Name: Sandpiper Cluster (Mentor)





Printed on: 6/23/2016 8:41 AM

R/1 & N/M Days

R/1 N/M

101.1691 101.1691

73.3826 146.7652

20.3788 20.3791

194.9305 268.3134


FYE: 0913012015





TOTALS

1,165,873

1,535,971

234,848

2,936,692





Sandpiper Cluster (Mentor)

Ownership:Private







031267300 - 2016/07

RI: 327.46

NM: 399.92

Base Semester

201507







5.lncentive Basis (line 3 - line 4) o.oool 0.526 I o.oool o.oool


?.Incentive Line 5 x Oper 50% Res 50% o.oool 0.263 0.2631 o.oool o.oool 0.000

8.lncentive - Line 4 x Oper 10% Res 3% o.oool 5.848 5.8481 o.oool o.oool 0.000

9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% o.oool 0.263 0.2631 o.oool 0.0001 0.000

1 O.Final Incentive o.oool 0.263 0.2631 o.oool o.oool 0.000






16.lnterim Rate Component: 0.0001 0.000 o.oool 0.0001 o.oool 0.000

17.NA 0.0001 0.000 o.oool 0.0001 0.0001 0.000





22.Final Per Diem I 305.851 378.18 --- ---- ---- ---- -

23.Medicaid Days

I 2,117

I 9,407




27.Less or Plus: Buy Back- QAF (.001684964) I o.551 0.67


29.

I o.ool 0.00




031345900 - 2016/07

Rl~402.03 / NM:0.00

New Horizons Village

1275 N. Rainbow Loop

Lecanto, FL 34461


Level of Care

#7 Institutional



Current Rate


Rate Type:


Date: 6/23/2016

FYE: 11/30/2015


New Rate

Effective Date

402.03 7/1/2016

0.00 7/1/2016


Basis

X

Distribution:

Contract Management

DPODS - DCF (4)

Home Office:

Total Interim

Interim Component


Budget

Unaudited Costs

Field Audited Costs


Comments:


X Total Prospective


Desk Audited Costs



W.Rydell Samuel



Provider Name:

Provider Number:

Audit Status:

Date:




New Horizons Village Cost Report Entered By :




Number of Beds:

Column A Column B

031345900

Pridgeon, Chantelle

July, 2016

12/1/2014 - 11/30/2015

365

48



1. Resident Days 17,431 0 17,431




C. Laundry 37,470



3. Resident Care

A. Dietary 514,501

B. Other 0

C. Nursing 662,798

D. Resident Care & Per Diem 67.5405 1,177,299

4. Prop Exp & Per Diem 25.8044 449,797

5. ROE/Use Per Diem 1.1552 20,137


1. Staffing 0.50 1.00
















Facility Name: New Horizons Village





Printed on: 6/23/2016 8:41 AM

No NIM Days

R/1 NIM

67.5405 0.0000

130.7463 0.0000

32.0659 0.0000

230.3527 0.0000


FYE: 1113012015





TOTALS

1,177,299

2,279,038

558,940

4,015,277





New Horizons Village

Ownership:Private







031345900 - 2016/07

RI: 402.03

NM: 0.00

Base Semester

201507





3 .Line 1 X 1.4000 X Inflation Factor 1.05070957 I 110.2401 238.751 348.9911 0.0001 0.0001 0.000




?.Incentive Line 5 x Oper 50% Res 50% 5.3701 4.199 9.5691 o.oool o.oool 0.000

a.Incentive - Line 4 x Oper 10% Res 3% 9.9501 6.911 16.8611 o.oool o.oool 0.000

9.lncentive - Min of Line 7,8 x Eligibility factor 100.00% 5.3701 4.199 9.5691 o.oool 0.0001 0.000

10.Final Incentive 5.3701 4.199 9.5691 o.oool o.oool 0.000

11.Current Period Base: (line 6 + line 10) 104.8701 234.552 339.4221 o.oool 0.0001 0.000




15.Prospective Rate: Line 11 x Inflation 1.04097721 109.1671 244.163 353.3301 o.oool o.oool 0.000


17.NA o.oool 0.000 0.0001 0.0001 0.0001 0.000

18.Total Operating & Residential Care Rate 109.1671 244.163 353.3301 0.0001 o.oool 0.000




22.Final Per Diem I 380.291 0.00 ---·-- ·-- ---- ---- ---- ----

23.Medicaid Days

I 17,431

I 0






29.

l 0.001 0.00


Printed on: 6/23/2016 8:43 AM Balch ID: Y7R2F

Documents

Florida Agency For Health Care Administration 000169300 -2016… › ... › ICF_Not_Public_July_2016.pdf · 2016-07-07 · Florida Agency For Health Care Administration Office of