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Florida Agency For Health Care Administration--O_2_8_00_3_8_0_0_-_2_01_1_I_I0-j Office of Medicaid Cost Reimbursement Planning and Analysis ---_R_I_2_6_2_5_6__N_l_f_3_9_2_8_1-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND MARIANNA 1 3700 Williams Drive Marianna FL 32446
Provider Number Date FYE
Audit Status
028003800 091082011 063012010 Unaudited [3]
Provider Type ICFMR-DD
Level of Care 7 Institutional
8 Non-Ambulatory amp 9 Medical
Current Rate
25925
38781
New Rate
26256
39281
Effective Date
100112011
100112011
Rate Type- -~~~--
Interim
Total Interim Interim Component
Settlement Based on Costs
x Prospective
X Total Prospective
Prospective Adjusted for New Cost
Budget Desk Audited Costs
X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion Field Audit - Interim Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS DCF (2) Home Office
For Information only - No Change in rate
Printp1 nn OQ()RIJm 1 ltIt ORmiddot J -I R TTdna VPNnn 1 1 hv 17111 RMrh TD-F7GVI
Florida Agency For Health Care Administrationll---__O_28_0_0_3_8_0_0__ Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name SUNLAND MARIAc~NA 1 Cost Report Entered by Squire Yashica Provider Numbel 28003800 Rate Semester October 2011 Audit Status Unaudited (3] Cost R~port 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 115
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componen1
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
328046 328046
1109059 31369
605699 605699 43234 43234
00000
100 281000
130406534 69945318
2489157
2810 81313
289370
328046 328046 2139654 3384226
43234 43234 00000
~-- shy2510933 3755506
1299691 2440119
174172 0
2154800 10000
536363600
40286 1165779
1321565 8969534
174172 0
Florida Agency For Health Care Administration I 028003800 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 26256
ICFMR-DD Calculation Sheet NM 39281 Rates Effective 10101120 II through 033112012
SUNLAND MARIANNA 1 OwnershipState[l]
~Fj~al y e~-B-gi~-- -fu~~l-Y~~~-E~-d- --A~dit Statu --IBase Semester 1 Current Cost Repoifr--- 070172009 06302010 UriauditedN--------------~---i
Prior Cost Report I ~________________ L_ _____ _ _ __ _ __ ___________~
---------shy ~----------------------~------- ------j---~~~+__~~~__t_~~_______I----t_~~~__t~--____j
Inflation Factor 000000000
3 Line 1 x i--=-------=~-=- --=----------------------------------------+----f-----+-----------t------------- ----+---------------r------------l
4 Current Period Cost 32805 213965 32805 338423
0000 0000 00005 Incentive Basis (line 3 -line 4) --~------------~--+----+---------
0000
32805 213965 2467706 Allowed Current Period Costs ~~==~~~o~==-~~~~--r-~~~-~~~~~~+_
32805 338423 371227
7 Incentive Line 5 x 0000 0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
ase 15 Prospective Rate Line II x Inflation (104648267)
~~1--6----In--te~r~im~R__at_e----E~~___ _ ___________~~___+I-______O_O_O_O+-_____--+--____~____+------ -0--0_0_0---------------------- ____-------_------1
I-_N_A__~_______~______~_____~_________--+_----=OO~O--=--O+- 0000 0000 0000 ----i--~---------------_I
18 Total amp Residential Care Rate ==~-=~~~~-~--~-
19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component ~------------------------------ -------------shy
--------shy
25 Medicaid Utilization 10000
000 000
000
26256 39281
-- --------- ---- --f----------- ----------- -------------------t------------~--------
2810 -----~- -----+---------------~-=__=-______---------- -f-------------------------- ----shy
inted on 090812011 at 0851 18 Using version 41 by 17111 Batch IDFZGV J
--l
Florida Agency For Health Care Administration 028004600 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis --_R_I_2_5_9_6_2_I_N_M_3_9_0_9_1
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 1 1621 NE Waldo Road Gainesville FL 32609
Provider Number 028004600 Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Provider Type ICFMR-DD
Level of Care 7 Institutional
8 Non-Ambulatory amp 9 Medical
Current New Rate Rate
25632 25962
38592 39091
E
10
101
ffective Date
0112011
0112011
Interim
Total Interim Interim Component
x Prospective
X Total Prospective Prospective Adjusted for New Cost
Settlement Based on Costs -~-------------------
Budget Desk Audited Costs
X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit Prospective Portion
Field Audit - Interim Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (3) Home Office
For Information only - No Change in rate
Florida Agency For Health Care AdministrationL-1___0_2_8_00_4_6_0_0__-- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 042011 to 102011
Provider Name TACACHALE 1 Cost Report Entered by Squire Yashica Provider Numbel 28004600 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 071012009 - 063012010 Date 982011 Days In Reporting Period 365
Number of Beds 112
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem j ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additiona] Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
ColumnA Column C Total Residential Institutional
302] 7 38380
1078781 539053
8163
o __~9~2J_
1657761
878394 1256078
431934
o 2134472
29630 556142
1137]9 00000 o
100 3021700 3429850 881000627 10000
729914482 828506200 2415576
38096 916394
30197 1119140
303472
431934 431934 1657761 2020603 3275] 89 11538674
29630 29630 113719 00000 0
__ ___2~8-21-6~-- ==c== cc_=c=37=3=6=7=53~ c=_=c=_=_13312_~~5~_==
Florida Agency For Health Care Administration I 028004600 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RJ 25962
ICFMR-DD Calculation Sheet NM 39091 Rates Effective 1 I120 II through 033112012
TACACHALE 1 OwnershipState[l]
000000000
327519
9677
000
000
Jrinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
I
028006200 - 2011110 Florida Agency For Health Care Administration RI25693 1 NM39517 shyOffice of Medicaid Cost Reimbursement Planning and Analysis
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 2
1621 N E Waldo Road Gainesville FL 32609
Provider Type ICFMR-DD
Level of Care 7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
25368
028006200 0910812011 06302010 Unaudited [3]
New Effective Rate Date
25693 100112011
39014 39517 100112011
Interim x Prospective
Total Interim Interim Component
X Total Prospective Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
X Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Di stribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit Prospective Portion
w Rydell Samuel r Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
Florida Agency For Health Care AdministrationL-r___0_2_8_00_6_2_0_0___ Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 10201]
Provider Name TACACHALE 2 Cost Report Entered by Squire Yashica Provider Numbel 28006200 Rate Semester October 20 II Audit Status Unaudited [3] Cost Report 07012009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 90
I
Column C Total
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem i ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
18449
461030 38424 00000
050 922450
356605779 239302912
1297105
18436 439401
16643
422004
461030 38424 00000
100 1664300 643394221
431754388 2594210
16543 433774
262210
873770 565260
o 41
1480898
804464 813384
o-______shy
1617848 134836
o
2586750 10000
1057300
34979 873175
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
422004 1996474
38424 00000
422004 3317451
38424
1480898 9201596
134836 o
------------~ --------~
5 Total Cost Per Diem 2456902 _7Zmiddot_879 ~_0817~31L__
Florida Agency For Health Care Administration I 028006200 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25693
ICFMR-DD Calculation Sheet NM 39517 Rates Effective 1001120 II through 033112012
TACACHALE 2 OwnershipState[l]
i ~~~~~t~ie~~~of~~~~~II~~~~~~~1~ndt~nau~it~~~n~-f~~ s~m~~q c_~___ ~_____________ ~_________~~_~-~_~~~~_~~~~__~~~_~_~__~_~--~_~_~___ _____ _______ ~_____ _
1 Prior Period Base
Inflation Factor 000000000 r-=-=C-==-----==---=-~Lc_________________________________J___________---shy___________________J___
4 Current Period Cost
5 Incentive Basis line 3 - line 4) 0000 bull ~----- -shy ------------t----------r-~-----------
6 Allowed~urrentJgtefl()d Costs~___~___________~~__________r__shy _--4=220=-0+_------shy___-=---__ shy __ +shy ____________ 1 -------=-=----If---=-------=-~r_-------=----I
r~~~___~==~~_~~_~~~~=~~_________f---~O~O-~O~O+_---~-~-~----~O~O~OO--f--~~~-~-----~---~~---+----~~-~ 0000 0000
15 Prospective Rate Line I I x Inflation (104648267) -----+----~-+-
-16 Interim Rate
17 NA
-158-_~-~~IL1l~~_c-~l~l~ ~~~ Rate 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
18449 16643 ~~- -----~-------~---- -----~----~---------~
9993 9940
000
000
rinted on 090820 I I at 085118 Using version 41 by 17111 Batch TDFZGVJ
000
Florida Agency For Health Care Administrationr--0_2_8_00_9_7_0_0_-_2_0_11_I_l0_--I Office of Medicaid Cost Reimbursement Planning and Analysis --_R_I_4_2_6_4_3_I_N_M__6_9_2_8_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND MARIANNA 2 Provider Number 028009700 ---------------shy3700 Williams Drive Date 09082011
Marianna FL 32446 FYE 06302010 Audit Status Unaudited [3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date
7 Institutional 42106 42643 100112011
8 Non-Ambulatory amp 9 Medical 68404 69283 100112011
~~-- ----~--- ~
iRate Type I Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs _~_bull_ __~_ ~_bull J
Budget Desk Audited Costs
X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit Interim Portion ~~-~--~ ~------~bull - ~---- - ---~- - -------- - ~------__ __---__
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Florida Agency For Health Care AdministrationL-I___O_2_8_00_9_7_0_0__---l
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
RatePeriod(s) 042011 to 102011
Provider Name SUNLAND MARIANNA 2 Provider Numbel 28009700 Audit Status Unaudited [3] Date 982011
~-~~~~~~-~----- ~- ~~---- ~~ --~- shy
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 121
~~--~-column-B-~-~COIU=~TotalColumnA Residential II Non-Ambulatory Medical Institutional
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
~~-~~+---3-1-4-2-2l1 ~- 057-shy - - -- shy 32479
636490
515567 82350 00000
050 1571100
936963263 799847029
2545500
30327 905763
298666
636490 3359733
82350 00000
4078574
636490
515567 82350 00000
100 105700 63036737
53811871 5691000
1057 31589
298855
636490 5905423
82350
6624263
1075906 904102
o ~~_~~l4
2067257
951057 48171
__~675~2_ 1674511
267466 o
1676800 10000
853658900
31384 937352
2067257 11148452
267466 o
13483175
Florida Agency For Health Care Administration I 028009700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 42643
ICFMR-DD Calculation Sheet NM 69283 Rates Effective 1010 l20 11 through 033112012
SUNLAND MARIANNA 2 OvvnershipState[l]
Inflation Factor 000000000
---~-shy
6
31422 9652
63649 590542 654191
0000 0000
63649 i 590542 654191
0000 0000 0000
0000 0000 0000
1057-shy ----- -------~~- -
10000
000 000
000
~inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
--
Florida Agency For Health Care Administrationl-0_28Ol_19OO_-2Ol1lO=-j
Office ofMedicaid Cost Reimbursement Planning and Analysis I-_R_I_2_4_4_0-7_I-N--M~3--7-976--1 2727 Mahan Drive-Mail Stop 21
Tallahassee Florida 32308
TACACHALE 3 Provider Number 028011900 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 06302010
Audit Status Unaudited [3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date
7 Institutional 24099 24407 10012011
8 Non-Ambulatory amp 9 Medical 37493 37976 100112011
r=--c~--~-- - --- ---- ---------- -------- ~----~-- - ---- ------shy
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
i-BaSIS I Budget
X Unaudited Costs
Field Audited Costs Field Audit - Interiin Portion
Distribution Contract Management DPODS - DCF (3) Home Office
Desk Audited Costs
Desk Audit - Interim Portion
Desk Audit - Prospective Portion
w Rydell SueJ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
_______
Florida Agency For Health Care Administrationll-__O_28_0_1_1_9_00__---l
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 3 Provider NumbeJ 28011900 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
5 ROEUse Per Diem
B Direct Care Expense 1 Staffing
2 Total Staffmg Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
j C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 49
ColumnA ColumnB Residential Non-Ambulatory Medical Institutional
11503 6962
Column C Total
18465
430542 276993
o 05~
394287
368227 37137 00000
050 575150
452393125 149587089
1300418
11503 269061
233905 __-------
394287 1902551
37137 00000
2333974
394287
368227 37137 00000
100 696200
547606875 181070211
2600836
6950 159916
230095
394287 3199159
37137
3630582 --- ------- shy~
728051
424805 255127
o 679932
68573 o
1271350 10000
330657300
18453 428977
728051 4415482
68573 o
Florida Agency For Health Care Administration I 028011900 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 24407
ICFMR-DD Calculation Sheet NM 37976 Rates Effective 100112011 through 033112012
TACACHALE 3 OvvnershipState[l]
3 Line 1 x
4 Current Period Cost
5 Incentive Basis
of line 3 or 4
15 Prospective Rate Line II x Inflation (104648267)
39429
0000
190255 229684
0000 0000
0000
-~---~--~middot~~-_C~~~middotmiddotmiddotmiddotmiddot-l~~~~middot-
16 Interim Rate
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component -~~-----------
2 I Plus Property Interim Rate Component
-~-~
39429
0000
39429
0000
0000
319916
0000
319916
0000
359345
0000
0000
376048
0000
0000
376048
3714
0000
-~------- ----t---- -------------- - -----middot--middot-----~----I
11503 6962
25 Medicaid Utilization 10000 9983
000 000
000
nted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
------------------- ---
---l
Florida Agency For Health Care Administrationf- _0_2_8_0_1_5_10_0_-_20_1_1_1_1o_-1
Office ofMedicaid Cost Reimbursement Planning and Analysis --_R_I_2_3_8_2_0_I_N_M_3_5_8_A_9
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 4 1621 NE Waldo Road Gainesville FL 32609
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Interim
Total Interim
Interim Component
Settlement Based on Costs
X Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Provider Number 028015100 Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
23518 23820 100112011
35393 35849 100112011
x Prospective
X Total Prospective Prospective Adjusted for New Cost
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit Prospective Portion
WRydellSamuel ~ Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
PnntPfl Im OQ()RIOll ltIt ORltIIR TTina vprirm 4 1 hv 17111 Rlt(~h TDFZGVT
I
Florida Agency For Health Care AdministrationlL--___O_2_8_01_S_1_0_0__---I
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
Provider Name TACACHALE 4 Cost Report Entered by Squire Yashica Provider Numbel 28015100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 59
II Column B---middot-~~~~tl-1ColumnA Residential I[Non-Ambulatory Medical Institutional __ +L______Lj_____ __ _____0_____ - _ _ ~_~__
IA Allocation of Expenses (excluding B ampcJ 1 Resident Days
2 Operating Expenses Component A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
I 900212520
431992431992
332844332844 3433434334 0000000000
21522
472741 425478
o 31
929733
490554 225792
o ------------_
716346 73893
o
i B Direct Care Expense I Staffmg 050 100 2 Total Staffmg Required 626000 900200 1526200 3 Staffing Percent 410169047 589830953 10000 4 Allocation of Direct Care 148918599 214147801 363066400
23788915 Direct Care Expense Per Diem 1189446
C Additional Services Expense 1 Medicaid Inpatient Days 2150112520 8981
223725 5857012 Additional Services 361976 3 Additional Services Exp amp Per Diem 28911 249109
=-~=~~ =-======1=======-=+===middot=middot=========F======-=middotmiddot D Medicaid Per Diem Cost
9297334319921 Operating Component 431992 2960844 49327112 Resident Care Component 1811407
73893343343 Property Cost Component 34334 o4 ROElUse Allow Component 00000
5 Total Cost Per Diem 2277733 3427170
TACACHALE 4 OwnershipState[l]
Florida Agency For Health Care Administration I 028015100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23820
ICFMR-DD Calculation Sheet NM 35849 Rates Effective 100 1120 II through 033112012
~----------~----------- __----_ bull_-_____bull-----__--_shyi ResidentialInstitutional Non-Ambulatory Medical
Base Semester
0000000
15 Prospective Rate Line II x Inflation (104648267)
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
12520 ~----~---- shy
10000
0000
0000 0000
0000
0000
355054
3433 0000
000000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationl--0_2_8_01_6_0_0_0_-_2_0_11_I_I0_1 Office of Medicaid Cost Reimbursement Planning and Analysis I--_R_I_2_3_4_3_8__N_1_I_3_4_2_1_9--J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND l1ARIANNA 3 3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
028016000 091082011 063012010 Unaudited [3]
New Effective Rate Date
23145 23438 10012011
33788 34219 100112011
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ~___ _~~~__bull __~__________bull _~ _~_~~__________~_bullbull_Lbullbull~_____ ~~__
IBasis-__ ~----~-~--- -~~------~~-------- ----~-- ----------- --__--
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion Field Audit - Interim Portion
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Horne Office
For Infonnation only - No Change in rate
Florida Agency For Health Care Administration ___0_2_80_1_6_0_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name SUNLAND MARIANNA 3 Cost Report Entered by Squire Yashica Provider Numbel 28016000 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 shy 063012010 Date 982011 Days In Reporting Period 365
Number of Beds 44
ColumnA Residential Institutional
12849
~~-~-----T---~~-------- ~-
----C-ol-umn--B---- i I Column C Total Ii Non-Ambulatory Medical
2718 15567
237433
iA Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
~ Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
389532
551093 63945
100 271800
297292863 56006229
2060568
389532 1789055
63945 00000
--------
2242532
389532
551093 63945 00000
2718 56434
207631
389532 2819291
63945
336480 o
419225 17928
_____ 420l3~_ 857886 99543
o
914250 10000
188387400
14777 306873
606385 3048633
99543 o
Florida Agency For Health Care Administration 028016000 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23438
ICFMR-DD Calculation Sheet NM 34219 Rates Effective 100112011 through 033112012
SUNLAND MARIANNA 3 OwnershipState[1 J
Base Semester
j------- +--------+--- ---- ---------- -+---- --~_i-- -~------~
1000025 Medicaid Utilization 9385
000 000
000
inted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationf--0_2_8_0_24_1_0_0_-_2_0_11_1_10-1 Office ofMedicaid Cost Reimbursement Planning and Analysis ~_R_I_3_3_5_2_6_I_N_M_4_7_8_7_6----l
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 5 1621 NB Waldo Road Gainesville FL 32609
Provider Number Date
FYE
Audit Status
028024100
091082011 06302010 Unaudited [3]
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Current Rate
33110
47277
New Rate
33526
47876
Effective Date
100112011
1010112011
IRateType-~--~ Interim
Total Interim
Interim Component
Settlement Based on Costs
x Prospective
X Total Prospective
Prospective Adjusted for New Cost
Budget
X Unaudited Costs
Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit - Prospective Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
D t~rl A )OI)Qf)Oll t (Qmiddot1middot1 Q TTjnn cmiddot lt11 h 17111 Rltgtth rnmiddotJ7rVT
-----
Florida Agency For Health Care Administration-I ___0_28_0_2_4_1_00__--- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFIMR-DD Profile Sheet Rate P eriod( s) 042011 to 1012011
Provider Name TACACHALE 5 Provider Numbel 28024100 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 40
ColumnA ColumnB Non-Ambulatory Medical
Column C Total --___----IjI Residential Institutional
4440 2634 7074
170516 426135
o 31563
888061 888061 628214
163155 252460
o 587525 587525 415615 122108 122108 86379 00000 00000 o
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Stafflllg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense I Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
050 222000
457354759 59893807
1348960
262414
100 263400
542645241 71063193
2697919
2517 71674
284760
888061 3570204
122108
4580372
485400 10000
130957000
6428 174304
628214 1899489
86379 o
2614082- ~-- ~~-~~
Florida Agency For Health Care Administration I 028024100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 33526
ICFMR-DD Calculation Sheet NM 47876 Rates Effective 1 lI20 II through 033l120 12
TACACHALE 5 Ownership State [ 1]
I Fiscal Year Begin ----- __ _----l____
I Current Cost Report i 070112009
I Prior Cost Report LI
-------_-- ---- -~-~----- ~---~~~--=-~--
-- --------- --------j----------------1Fiscal Year End Audit Status Base Semester I
06302010 Unaudited [3] -------l I
__~~ ~~__~_~1 ____ ~~_~ ___________ J
Period Base
3 Line I x - _ -----__ -- - --~--
4 Current Period Cost
5 Incentive Basis
15 Prospective Rate Line I I x Inflation (104648267)
16 Interim Rate ~---------~-----------------
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component ---____-___ --__-shy ---- shy
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
---------- shy
88806 88806 357020
0000 0000 0000
88806 219890 308696 88806 357020
0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
0000 0000 0000 0000
0000 0000 I 0000 0000
------- --------
445826
0000
0000
33526 47876 2517
------1-----middot_--_middot_---------- shy
4440 2634 8809 955625 Medicaid Utilization
000
000
inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administrationl--0_2_8_02_6_7_0_0_-_2_0_11_I_I0---l Office ofMedicaid Cost Reimbursement Planning and Analysis --_RI_3_2_9_8_2_I_N_TM_4_6_5__4_S-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 7 Provider Number 028026700 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 063012010
Audit Status Unaudited [3]
Provider Type ICFMR~DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 32563 32982 100112011
8 Non-Ambulatory amp 9 Medical 45952 46545 100112011
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
x Unaudited Costs
Field Audited Costs Field Audit Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
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
Printpj rn flQf(llV)fl11 M fll(middotlmiddot1 l( nina vprltrm 4 1 hv 17111 Rth TnmiddotF7CiVT
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Florida Agency For Health Care Administrationll---__O_28_0_0_3_8_0_0__ Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name SUNLAND MARIAc~NA 1 Cost Report Entered by Squire Yashica Provider Numbel 28003800 Rate Semester October 2011 Audit Status Unaudited (3] Cost R~port 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 115
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componen1
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
328046 328046
1109059 31369
605699 605699 43234 43234
00000
100 281000
130406534 69945318
2489157
2810 81313
289370
328046 328046 2139654 3384226
43234 43234 00000
~-- shy2510933 3755506
1299691 2440119
174172 0
2154800 10000
536363600
40286 1165779
1321565 8969534
174172 0
Florida Agency For Health Care Administration I 028003800 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 26256
ICFMR-DD Calculation Sheet NM 39281 Rates Effective 10101120 II through 033112012
SUNLAND MARIANNA 1 OwnershipState[l]
~Fj~al y e~-B-gi~-- -fu~~l-Y~~~-E~-d- --A~dit Statu --IBase Semester 1 Current Cost Repoifr--- 070172009 06302010 UriauditedN--------------~---i
Prior Cost Report I ~________________ L_ _____ _ _ __ _ __ ___________~
---------shy ~----------------------~------- ------j---~~~+__~~~__t_~~_______I----t_~~~__t~--____j
Inflation Factor 000000000
3 Line 1 x i--=-------=~-=- --=----------------------------------------+----f-----+-----------t------------- ----+---------------r------------l
4 Current Period Cost 32805 213965 32805 338423
0000 0000 00005 Incentive Basis (line 3 -line 4) --~------------~--+----+---------
0000
32805 213965 2467706 Allowed Current Period Costs ~~==~~~o~==-~~~~--r-~~~-~~~~~~+_
32805 338423 371227
7 Incentive Line 5 x 0000 0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
ase 15 Prospective Rate Line II x Inflation (104648267)
~~1--6----In--te~r~im~R__at_e----E~~___ _ ___________~~___+I-______O_O_O_O+-_____--+--____~____+------ -0--0_0_0---------------------- ____-------_------1
I-_N_A__~_______~______~_____~_________--+_----=OO~O--=--O+- 0000 0000 0000 ----i--~---------------_I
18 Total amp Residential Care Rate ==~-=~~~~-~--~-
19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component ~------------------------------ -------------shy
--------shy
25 Medicaid Utilization 10000
000 000
000
26256 39281
-- --------- ---- --f----------- ----------- -------------------t------------~--------
2810 -----~- -----+---------------~-=__=-______---------- -f-------------------------- ----shy
inted on 090812011 at 0851 18 Using version 41 by 17111 Batch IDFZGV J
--l
Florida Agency For Health Care Administration 028004600 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis --_R_I_2_5_9_6_2_I_N_M_3_9_0_9_1
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 1 1621 NE Waldo Road Gainesville FL 32609
Provider Number 028004600 Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Provider Type ICFMR-DD
Level of Care 7 Institutional
8 Non-Ambulatory amp 9 Medical
Current New Rate Rate
25632 25962
38592 39091
E
10
101
ffective Date
0112011
0112011
Interim
Total Interim Interim Component
x Prospective
X Total Prospective Prospective Adjusted for New Cost
Settlement Based on Costs -~-------------------
Budget Desk Audited Costs
X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit Prospective Portion
Field Audit - Interim Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (3) Home Office
For Information only - No Change in rate
Florida Agency For Health Care AdministrationL-1___0_2_8_00_4_6_0_0__-- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 042011 to 102011
Provider Name TACACHALE 1 Cost Report Entered by Squire Yashica Provider Numbel 28004600 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 071012009 - 063012010 Date 982011 Days In Reporting Period 365
Number of Beds 112
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem j ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additiona] Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
ColumnA Column C Total Residential Institutional
302] 7 38380
1078781 539053
8163
o __~9~2J_
1657761
878394 1256078
431934
o 2134472
29630 556142
1137]9 00000 o
100 3021700 3429850 881000627 10000
729914482 828506200 2415576
38096 916394
30197 1119140
303472
431934 431934 1657761 2020603 3275] 89 11538674
29630 29630 113719 00000 0
__ ___2~8-21-6~-- ==c== cc_=c=37=3=6=7=53~ c=_=c=_=_13312_~~5~_==
Florida Agency For Health Care Administration I 028004600 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RJ 25962
ICFMR-DD Calculation Sheet NM 39091 Rates Effective 1 I120 II through 033112012
TACACHALE 1 OwnershipState[l]
000000000
327519
9677
000
000
Jrinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
I
028006200 - 2011110 Florida Agency For Health Care Administration RI25693 1 NM39517 shyOffice of Medicaid Cost Reimbursement Planning and Analysis
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 2
1621 N E Waldo Road Gainesville FL 32609
Provider Type ICFMR-DD
Level of Care 7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
25368
028006200 0910812011 06302010 Unaudited [3]
New Effective Rate Date
25693 100112011
39014 39517 100112011
Interim x Prospective
Total Interim Interim Component
X Total Prospective Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
X Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Di stribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit Prospective Portion
w Rydell Samuel r Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
Florida Agency For Health Care AdministrationL-r___0_2_8_00_6_2_0_0___ Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 10201]
Provider Name TACACHALE 2 Cost Report Entered by Squire Yashica Provider Numbel 28006200 Rate Semester October 20 II Audit Status Unaudited [3] Cost Report 07012009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 90
I
Column C Total
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem i ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
18449
461030 38424 00000
050 922450
356605779 239302912
1297105
18436 439401
16643
422004
461030 38424 00000
100 1664300 643394221
431754388 2594210
16543 433774
262210
873770 565260
o 41
1480898
804464 813384
o-______shy
1617848 134836
o
2586750 10000
1057300
34979 873175
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
422004 1996474
38424 00000
422004 3317451
38424
1480898 9201596
134836 o
------------~ --------~
5 Total Cost Per Diem 2456902 _7Zmiddot_879 ~_0817~31L__
Florida Agency For Health Care Administration I 028006200 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25693
ICFMR-DD Calculation Sheet NM 39517 Rates Effective 1001120 II through 033112012
TACACHALE 2 OwnershipState[l]
i ~~~~~t~ie~~~of~~~~~II~~~~~~~1~ndt~nau~it~~~n~-f~~ s~m~~q c_~___ ~_____________ ~_________~~_~-~_~~~~_~~~~__~~~_~_~__~_~--~_~_~___ _____ _______ ~_____ _
1 Prior Period Base
Inflation Factor 000000000 r-=-=C-==-----==---=-~Lc_________________________________J___________---shy___________________J___
4 Current Period Cost
5 Incentive Basis line 3 - line 4) 0000 bull ~----- -shy ------------t----------r-~-----------
6 Allowed~urrentJgtefl()d Costs~___~___________~~__________r__shy _--4=220=-0+_------shy___-=---__ shy __ +shy ____________ 1 -------=-=----If---=-------=-~r_-------=----I
r~~~___~==~~_~~_~~~~=~~_________f---~O~O-~O~O+_---~-~-~----~O~O~OO--f--~~~-~-----~---~~---+----~~-~ 0000 0000
15 Prospective Rate Line I I x Inflation (104648267) -----+----~-+-
-16 Interim Rate
17 NA
-158-_~-~~IL1l~~_c-~l~l~ ~~~ Rate 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
18449 16643 ~~- -----~-------~---- -----~----~---------~
9993 9940
000
000
rinted on 090820 I I at 085118 Using version 41 by 17111 Batch TDFZGVJ
000
Florida Agency For Health Care Administrationr--0_2_8_00_9_7_0_0_-_2_0_11_I_l0_--I Office of Medicaid Cost Reimbursement Planning and Analysis --_R_I_4_2_6_4_3_I_N_M__6_9_2_8_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND MARIANNA 2 Provider Number 028009700 ---------------shy3700 Williams Drive Date 09082011
Marianna FL 32446 FYE 06302010 Audit Status Unaudited [3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date
7 Institutional 42106 42643 100112011
8 Non-Ambulatory amp 9 Medical 68404 69283 100112011
~~-- ----~--- ~
iRate Type I Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs _~_bull_ __~_ ~_bull J
Budget Desk Audited Costs
X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit Interim Portion ~~-~--~ ~------~bull - ~---- - ---~- - -------- - ~------__ __---__
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Florida Agency For Health Care AdministrationL-I___O_2_8_00_9_7_0_0__---l
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
RatePeriod(s) 042011 to 102011
Provider Name SUNLAND MARIANNA 2 Provider Numbel 28009700 Audit Status Unaudited [3] Date 982011
~-~~~~~~-~----- ~- ~~---- ~~ --~- shy
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 121
~~--~-column-B-~-~COIU=~TotalColumnA Residential II Non-Ambulatory Medical Institutional
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
~~-~~+---3-1-4-2-2l1 ~- 057-shy - - -- shy 32479
636490
515567 82350 00000
050 1571100
936963263 799847029
2545500
30327 905763
298666
636490 3359733
82350 00000
4078574
636490
515567 82350 00000
100 105700 63036737
53811871 5691000
1057 31589
298855
636490 5905423
82350
6624263
1075906 904102
o ~~_~~l4
2067257
951057 48171
__~675~2_ 1674511
267466 o
1676800 10000
853658900
31384 937352
2067257 11148452
267466 o
13483175
Florida Agency For Health Care Administration I 028009700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 42643
ICFMR-DD Calculation Sheet NM 69283 Rates Effective 1010 l20 11 through 033112012
SUNLAND MARIANNA 2 OvvnershipState[l]
Inflation Factor 000000000
---~-shy
6
31422 9652
63649 590542 654191
0000 0000
63649 i 590542 654191
0000 0000 0000
0000 0000 0000
1057-shy ----- -------~~- -
10000
000 000
000
~inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
--
Florida Agency For Health Care Administrationl-0_28Ol_19OO_-2Ol1lO=-j
Office ofMedicaid Cost Reimbursement Planning and Analysis I-_R_I_2_4_4_0-7_I-N--M~3--7-976--1 2727 Mahan Drive-Mail Stop 21
Tallahassee Florida 32308
TACACHALE 3 Provider Number 028011900 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 06302010
Audit Status Unaudited [3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date
7 Institutional 24099 24407 10012011
8 Non-Ambulatory amp 9 Medical 37493 37976 100112011
r=--c~--~-- - --- ---- ---------- -------- ~----~-- - ---- ------shy
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
i-BaSIS I Budget
X Unaudited Costs
Field Audited Costs Field Audit - Interiin Portion
Distribution Contract Management DPODS - DCF (3) Home Office
Desk Audited Costs
Desk Audit - Interim Portion
Desk Audit - Prospective Portion
w Rydell SueJ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
_______
Florida Agency For Health Care Administrationll-__O_28_0_1_1_9_00__---l
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 3 Provider NumbeJ 28011900 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
5 ROEUse Per Diem
B Direct Care Expense 1 Staffing
2 Total Staffmg Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
j C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 49
ColumnA ColumnB Residential Non-Ambulatory Medical Institutional
11503 6962
Column C Total
18465
430542 276993
o 05~
394287
368227 37137 00000
050 575150
452393125 149587089
1300418
11503 269061
233905 __-------
394287 1902551
37137 00000
2333974
394287
368227 37137 00000
100 696200
547606875 181070211
2600836
6950 159916
230095
394287 3199159
37137
3630582 --- ------- shy~
728051
424805 255127
o 679932
68573 o
1271350 10000
330657300
18453 428977
728051 4415482
68573 o
Florida Agency For Health Care Administration I 028011900 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 24407
ICFMR-DD Calculation Sheet NM 37976 Rates Effective 100112011 through 033112012
TACACHALE 3 OvvnershipState[l]
3 Line 1 x
4 Current Period Cost
5 Incentive Basis
of line 3 or 4
15 Prospective Rate Line II x Inflation (104648267)
39429
0000
190255 229684
0000 0000
0000
-~---~--~middot~~-_C~~~middotmiddotmiddotmiddotmiddot-l~~~~middot-
16 Interim Rate
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component -~~-----------
2 I Plus Property Interim Rate Component
-~-~
39429
0000
39429
0000
0000
319916
0000
319916
0000
359345
0000
0000
376048
0000
0000
376048
3714
0000
-~------- ----t---- -------------- - -----middot--middot-----~----I
11503 6962
25 Medicaid Utilization 10000 9983
000 000
000
nted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
------------------- ---
---l
Florida Agency For Health Care Administrationf- _0_2_8_0_1_5_10_0_-_20_1_1_1_1o_-1
Office ofMedicaid Cost Reimbursement Planning and Analysis --_R_I_2_3_8_2_0_I_N_M_3_5_8_A_9
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 4 1621 NE Waldo Road Gainesville FL 32609
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Interim
Total Interim
Interim Component
Settlement Based on Costs
X Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Provider Number 028015100 Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
23518 23820 100112011
35393 35849 100112011
x Prospective
X Total Prospective Prospective Adjusted for New Cost
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit Prospective Portion
WRydellSamuel ~ Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
PnntPfl Im OQ()RIOll ltIt ORltIIR TTina vprirm 4 1 hv 17111 Rlt(~h TDFZGVT
I
Florida Agency For Health Care AdministrationlL--___O_2_8_01_S_1_0_0__---I
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
Provider Name TACACHALE 4 Cost Report Entered by Squire Yashica Provider Numbel 28015100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 59
II Column B---middot-~~~~tl-1ColumnA Residential I[Non-Ambulatory Medical Institutional __ +L______Lj_____ __ _____0_____ - _ _ ~_~__
IA Allocation of Expenses (excluding B ampcJ 1 Resident Days
2 Operating Expenses Component A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
I 900212520
431992431992
332844332844 3433434334 0000000000
21522
472741 425478
o 31
929733
490554 225792
o ------------_
716346 73893
o
i B Direct Care Expense I Staffmg 050 100 2 Total Staffmg Required 626000 900200 1526200 3 Staffing Percent 410169047 589830953 10000 4 Allocation of Direct Care 148918599 214147801 363066400
23788915 Direct Care Expense Per Diem 1189446
C Additional Services Expense 1 Medicaid Inpatient Days 2150112520 8981
223725 5857012 Additional Services 361976 3 Additional Services Exp amp Per Diem 28911 249109
=-~=~~ =-======1=======-=+===middot=middot=========F======-=middotmiddot D Medicaid Per Diem Cost
9297334319921 Operating Component 431992 2960844 49327112 Resident Care Component 1811407
73893343343 Property Cost Component 34334 o4 ROElUse Allow Component 00000
5 Total Cost Per Diem 2277733 3427170
TACACHALE 4 OwnershipState[l]
Florida Agency For Health Care Administration I 028015100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23820
ICFMR-DD Calculation Sheet NM 35849 Rates Effective 100 1120 II through 033112012
~----------~----------- __----_ bull_-_____bull-----__--_shyi ResidentialInstitutional Non-Ambulatory Medical
Base Semester
0000000
15 Prospective Rate Line II x Inflation (104648267)
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
12520 ~----~---- shy
10000
0000
0000 0000
0000
0000
355054
3433 0000
000000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationl--0_2_8_01_6_0_0_0_-_2_0_11_I_I0_1 Office of Medicaid Cost Reimbursement Planning and Analysis I--_R_I_2_3_4_3_8__N_1_I_3_4_2_1_9--J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND l1ARIANNA 3 3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
028016000 091082011 063012010 Unaudited [3]
New Effective Rate Date
23145 23438 10012011
33788 34219 100112011
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ~___ _~~~__bull __~__________bull _~ _~_~~__________~_bullbull_Lbullbull~_____ ~~__
IBasis-__ ~----~-~--- -~~------~~-------- ----~-- ----------- --__--
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion Field Audit - Interim Portion
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Horne Office
For Infonnation only - No Change in rate
Florida Agency For Health Care Administration ___0_2_80_1_6_0_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name SUNLAND MARIANNA 3 Cost Report Entered by Squire Yashica Provider Numbel 28016000 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 shy 063012010 Date 982011 Days In Reporting Period 365
Number of Beds 44
ColumnA Residential Institutional
12849
~~-~-----T---~~-------- ~-
----C-ol-umn--B---- i I Column C Total Ii Non-Ambulatory Medical
2718 15567
237433
iA Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
~ Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
389532
551093 63945
100 271800
297292863 56006229
2060568
389532 1789055
63945 00000
--------
2242532
389532
551093 63945 00000
2718 56434
207631
389532 2819291
63945
336480 o
419225 17928
_____ 420l3~_ 857886 99543
o
914250 10000
188387400
14777 306873
606385 3048633
99543 o
Florida Agency For Health Care Administration 028016000 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23438
ICFMR-DD Calculation Sheet NM 34219 Rates Effective 100112011 through 033112012
SUNLAND MARIANNA 3 OwnershipState[1 J
Base Semester
j------- +--------+--- ---- ---------- -+---- --~_i-- -~------~
1000025 Medicaid Utilization 9385
000 000
000
inted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationf--0_2_8_0_24_1_0_0_-_2_0_11_1_10-1 Office ofMedicaid Cost Reimbursement Planning and Analysis ~_R_I_3_3_5_2_6_I_N_M_4_7_8_7_6----l
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 5 1621 NB Waldo Road Gainesville FL 32609
Provider Number Date
FYE
Audit Status
028024100
091082011 06302010 Unaudited [3]
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Current Rate
33110
47277
New Rate
33526
47876
Effective Date
100112011
1010112011
IRateType-~--~ Interim
Total Interim
Interim Component
Settlement Based on Costs
x Prospective
X Total Prospective
Prospective Adjusted for New Cost
Budget
X Unaudited Costs
Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit - Prospective Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
D t~rl A )OI)Qf)Oll t (Qmiddot1middot1 Q TTjnn cmiddot lt11 h 17111 Rltgtth rnmiddotJ7rVT
-----
Florida Agency For Health Care Administration-I ___0_28_0_2_4_1_00__--- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFIMR-DD Profile Sheet Rate P eriod( s) 042011 to 1012011
Provider Name TACACHALE 5 Provider Numbel 28024100 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 40
ColumnA ColumnB Non-Ambulatory Medical
Column C Total --___----IjI Residential Institutional
4440 2634 7074
170516 426135
o 31563
888061 888061 628214
163155 252460
o 587525 587525 415615 122108 122108 86379 00000 00000 o
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Stafflllg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense I Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
050 222000
457354759 59893807
1348960
262414
100 263400
542645241 71063193
2697919
2517 71674
284760
888061 3570204
122108
4580372
485400 10000
130957000
6428 174304
628214 1899489
86379 o
2614082- ~-- ~~-~~
Florida Agency For Health Care Administration I 028024100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 33526
ICFMR-DD Calculation Sheet NM 47876 Rates Effective 1 lI20 II through 033l120 12
TACACHALE 5 Ownership State [ 1]
I Fiscal Year Begin ----- __ _----l____
I Current Cost Report i 070112009
I Prior Cost Report LI
-------_-- ---- -~-~----- ~---~~~--=-~--
-- --------- --------j----------------1Fiscal Year End Audit Status Base Semester I
06302010 Unaudited [3] -------l I
__~~ ~~__~_~1 ____ ~~_~ ___________ J
Period Base
3 Line I x - _ -----__ -- - --~--
4 Current Period Cost
5 Incentive Basis
15 Prospective Rate Line I I x Inflation (104648267)
16 Interim Rate ~---------~-----------------
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component ---____-___ --__-shy ---- shy
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
---------- shy
88806 88806 357020
0000 0000 0000
88806 219890 308696 88806 357020
0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
0000 0000 0000 0000
0000 0000 I 0000 0000
------- --------
445826
0000
0000
33526 47876 2517
------1-----middot_--_middot_---------- shy
4440 2634 8809 955625 Medicaid Utilization
000
000
inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administrationl--0_2_8_02_6_7_0_0_-_2_0_11_I_I0---l Office ofMedicaid Cost Reimbursement Planning and Analysis --_RI_3_2_9_8_2_I_N_TM_4_6_5__4_S-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 7 Provider Number 028026700 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 063012010
Audit Status Unaudited [3]
Provider Type ICFMR~DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 32563 32982 100112011
8 Non-Ambulatory amp 9 Medical 45952 46545 100112011
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
x Unaudited Costs
Field Audited Costs Field Audit Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
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
Printpj rn flQf(llV)fl11 M fll(middotlmiddot1 l( nina vprltrm 4 1 hv 17111 Rth TnmiddotF7CiVT
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Florida Agency For Health Care Administration I 028003800 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 26256
ICFMR-DD Calculation Sheet NM 39281 Rates Effective 10101120 II through 033112012
SUNLAND MARIANNA 1 OwnershipState[l]
~Fj~al y e~-B-gi~-- -fu~~l-Y~~~-E~-d- --A~dit Statu --IBase Semester 1 Current Cost Repoifr--- 070172009 06302010 UriauditedN--------------~---i
Prior Cost Report I ~________________ L_ _____ _ _ __ _ __ ___________~
---------shy ~----------------------~------- ------j---~~~+__~~~__t_~~_______I----t_~~~__t~--____j
Inflation Factor 000000000
3 Line 1 x i--=-------=~-=- --=----------------------------------------+----f-----+-----------t------------- ----+---------------r------------l
4 Current Period Cost 32805 213965 32805 338423
0000 0000 00005 Incentive Basis (line 3 -line 4) --~------------~--+----+---------
0000
32805 213965 2467706 Allowed Current Period Costs ~~==~~~o~==-~~~~--r-~~~-~~~~~~+_
32805 338423 371227
7 Incentive Line 5 x 0000 0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
ase 15 Prospective Rate Line II x Inflation (104648267)
~~1--6----In--te~r~im~R__at_e----E~~___ _ ___________~~___+I-______O_O_O_O+-_____--+--____~____+------ -0--0_0_0---------------------- ____-------_------1
I-_N_A__~_______~______~_____~_________--+_----=OO~O--=--O+- 0000 0000 0000 ----i--~---------------_I
18 Total amp Residential Care Rate ==~-=~~~~-~--~-
19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component ~------------------------------ -------------shy
--------shy
25 Medicaid Utilization 10000
000 000
000
26256 39281
-- --------- ---- --f----------- ----------- -------------------t------------~--------
2810 -----~- -----+---------------~-=__=-______---------- -f-------------------------- ----shy
inted on 090812011 at 0851 18 Using version 41 by 17111 Batch IDFZGV J
--l
Florida Agency For Health Care Administration 028004600 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis --_R_I_2_5_9_6_2_I_N_M_3_9_0_9_1
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 1 1621 NE Waldo Road Gainesville FL 32609
Provider Number 028004600 Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Provider Type ICFMR-DD
Level of Care 7 Institutional
8 Non-Ambulatory amp 9 Medical
Current New Rate Rate
25632 25962
38592 39091
E
10
101
ffective Date
0112011
0112011
Interim
Total Interim Interim Component
x Prospective
X Total Prospective Prospective Adjusted for New Cost
Settlement Based on Costs -~-------------------
Budget Desk Audited Costs
X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit Prospective Portion
Field Audit - Interim Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (3) Home Office
For Information only - No Change in rate
Florida Agency For Health Care AdministrationL-1___0_2_8_00_4_6_0_0__-- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 042011 to 102011
Provider Name TACACHALE 1 Cost Report Entered by Squire Yashica Provider Numbel 28004600 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 071012009 - 063012010 Date 982011 Days In Reporting Period 365
Number of Beds 112
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem j ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additiona] Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
ColumnA Column C Total Residential Institutional
302] 7 38380
1078781 539053
8163
o __~9~2J_
1657761
878394 1256078
431934
o 2134472
29630 556142
1137]9 00000 o
100 3021700 3429850 881000627 10000
729914482 828506200 2415576
38096 916394
30197 1119140
303472
431934 431934 1657761 2020603 3275] 89 11538674
29630 29630 113719 00000 0
__ ___2~8-21-6~-- ==c== cc_=c=37=3=6=7=53~ c=_=c=_=_13312_~~5~_==
Florida Agency For Health Care Administration I 028004600 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RJ 25962
ICFMR-DD Calculation Sheet NM 39091 Rates Effective 1 I120 II through 033112012
TACACHALE 1 OwnershipState[l]
000000000
327519
9677
000
000
Jrinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
I
028006200 - 2011110 Florida Agency For Health Care Administration RI25693 1 NM39517 shyOffice of Medicaid Cost Reimbursement Planning and Analysis
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 2
1621 N E Waldo Road Gainesville FL 32609
Provider Type ICFMR-DD
Level of Care 7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
25368
028006200 0910812011 06302010 Unaudited [3]
New Effective Rate Date
25693 100112011
39014 39517 100112011
Interim x Prospective
Total Interim Interim Component
X Total Prospective Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
X Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Di stribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit Prospective Portion
w Rydell Samuel r Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
Florida Agency For Health Care AdministrationL-r___0_2_8_00_6_2_0_0___ Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 10201]
Provider Name TACACHALE 2 Cost Report Entered by Squire Yashica Provider Numbel 28006200 Rate Semester October 20 II Audit Status Unaudited [3] Cost Report 07012009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 90
I
Column C Total
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem i ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
18449
461030 38424 00000
050 922450
356605779 239302912
1297105
18436 439401
16643
422004
461030 38424 00000
100 1664300 643394221
431754388 2594210
16543 433774
262210
873770 565260
o 41
1480898
804464 813384
o-______shy
1617848 134836
o
2586750 10000
1057300
34979 873175
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
422004 1996474
38424 00000
422004 3317451
38424
1480898 9201596
134836 o
------------~ --------~
5 Total Cost Per Diem 2456902 _7Zmiddot_879 ~_0817~31L__
Florida Agency For Health Care Administration I 028006200 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25693
ICFMR-DD Calculation Sheet NM 39517 Rates Effective 1001120 II through 033112012
TACACHALE 2 OwnershipState[l]
i ~~~~~t~ie~~~of~~~~~II~~~~~~~1~ndt~nau~it~~~n~-f~~ s~m~~q c_~___ ~_____________ ~_________~~_~-~_~~~~_~~~~__~~~_~_~__~_~--~_~_~___ _____ _______ ~_____ _
1 Prior Period Base
Inflation Factor 000000000 r-=-=C-==-----==---=-~Lc_________________________________J___________---shy___________________J___
4 Current Period Cost
5 Incentive Basis line 3 - line 4) 0000 bull ~----- -shy ------------t----------r-~-----------
6 Allowed~urrentJgtefl()d Costs~___~___________~~__________r__shy _--4=220=-0+_------shy___-=---__ shy __ +shy ____________ 1 -------=-=----If---=-------=-~r_-------=----I
r~~~___~==~~_~~_~~~~=~~_________f---~O~O-~O~O+_---~-~-~----~O~O~OO--f--~~~-~-----~---~~---+----~~-~ 0000 0000
15 Prospective Rate Line I I x Inflation (104648267) -----+----~-+-
-16 Interim Rate
17 NA
-158-_~-~~IL1l~~_c-~l~l~ ~~~ Rate 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
18449 16643 ~~- -----~-------~---- -----~----~---------~
9993 9940
000
000
rinted on 090820 I I at 085118 Using version 41 by 17111 Batch TDFZGVJ
000
Florida Agency For Health Care Administrationr--0_2_8_00_9_7_0_0_-_2_0_11_I_l0_--I Office of Medicaid Cost Reimbursement Planning and Analysis --_R_I_4_2_6_4_3_I_N_M__6_9_2_8_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND MARIANNA 2 Provider Number 028009700 ---------------shy3700 Williams Drive Date 09082011
Marianna FL 32446 FYE 06302010 Audit Status Unaudited [3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date
7 Institutional 42106 42643 100112011
8 Non-Ambulatory amp 9 Medical 68404 69283 100112011
~~-- ----~--- ~
iRate Type I Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs _~_bull_ __~_ ~_bull J
Budget Desk Audited Costs
X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit Interim Portion ~~-~--~ ~------~bull - ~---- - ---~- - -------- - ~------__ __---__
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Florida Agency For Health Care AdministrationL-I___O_2_8_00_9_7_0_0__---l
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
RatePeriod(s) 042011 to 102011
Provider Name SUNLAND MARIANNA 2 Provider Numbel 28009700 Audit Status Unaudited [3] Date 982011
~-~~~~~~-~----- ~- ~~---- ~~ --~- shy
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 121
~~--~-column-B-~-~COIU=~TotalColumnA Residential II Non-Ambulatory Medical Institutional
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
~~-~~+---3-1-4-2-2l1 ~- 057-shy - - -- shy 32479
636490
515567 82350 00000
050 1571100
936963263 799847029
2545500
30327 905763
298666
636490 3359733
82350 00000
4078574
636490
515567 82350 00000
100 105700 63036737
53811871 5691000
1057 31589
298855
636490 5905423
82350
6624263
1075906 904102
o ~~_~~l4
2067257
951057 48171
__~675~2_ 1674511
267466 o
1676800 10000
853658900
31384 937352
2067257 11148452
267466 o
13483175
Florida Agency For Health Care Administration I 028009700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 42643
ICFMR-DD Calculation Sheet NM 69283 Rates Effective 1010 l20 11 through 033112012
SUNLAND MARIANNA 2 OvvnershipState[l]
Inflation Factor 000000000
---~-shy
6
31422 9652
63649 590542 654191
0000 0000
63649 i 590542 654191
0000 0000 0000
0000 0000 0000
1057-shy ----- -------~~- -
10000
000 000
000
~inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
--
Florida Agency For Health Care Administrationl-0_28Ol_19OO_-2Ol1lO=-j
Office ofMedicaid Cost Reimbursement Planning and Analysis I-_R_I_2_4_4_0-7_I-N--M~3--7-976--1 2727 Mahan Drive-Mail Stop 21
Tallahassee Florida 32308
TACACHALE 3 Provider Number 028011900 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 06302010
Audit Status Unaudited [3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date
7 Institutional 24099 24407 10012011
8 Non-Ambulatory amp 9 Medical 37493 37976 100112011
r=--c~--~-- - --- ---- ---------- -------- ~----~-- - ---- ------shy
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
i-BaSIS I Budget
X Unaudited Costs
Field Audited Costs Field Audit - Interiin Portion
Distribution Contract Management DPODS - DCF (3) Home Office
Desk Audited Costs
Desk Audit - Interim Portion
Desk Audit - Prospective Portion
w Rydell SueJ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
_______
Florida Agency For Health Care Administrationll-__O_28_0_1_1_9_00__---l
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 3 Provider NumbeJ 28011900 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
5 ROEUse Per Diem
B Direct Care Expense 1 Staffing
2 Total Staffmg Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
j C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 49
ColumnA ColumnB Residential Non-Ambulatory Medical Institutional
11503 6962
Column C Total
18465
430542 276993
o 05~
394287
368227 37137 00000
050 575150
452393125 149587089
1300418
11503 269061
233905 __-------
394287 1902551
37137 00000
2333974
394287
368227 37137 00000
100 696200
547606875 181070211
2600836
6950 159916
230095
394287 3199159
37137
3630582 --- ------- shy~
728051
424805 255127
o 679932
68573 o
1271350 10000
330657300
18453 428977
728051 4415482
68573 o
Florida Agency For Health Care Administration I 028011900 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 24407
ICFMR-DD Calculation Sheet NM 37976 Rates Effective 100112011 through 033112012
TACACHALE 3 OvvnershipState[l]
3 Line 1 x
4 Current Period Cost
5 Incentive Basis
of line 3 or 4
15 Prospective Rate Line II x Inflation (104648267)
39429
0000
190255 229684
0000 0000
0000
-~---~--~middot~~-_C~~~middotmiddotmiddotmiddotmiddot-l~~~~middot-
16 Interim Rate
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component -~~-----------
2 I Plus Property Interim Rate Component
-~-~
39429
0000
39429
0000
0000
319916
0000
319916
0000
359345
0000
0000
376048
0000
0000
376048
3714
0000
-~------- ----t---- -------------- - -----middot--middot-----~----I
11503 6962
25 Medicaid Utilization 10000 9983
000 000
000
nted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
------------------- ---
---l
Florida Agency For Health Care Administrationf- _0_2_8_0_1_5_10_0_-_20_1_1_1_1o_-1
Office ofMedicaid Cost Reimbursement Planning and Analysis --_R_I_2_3_8_2_0_I_N_M_3_5_8_A_9
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 4 1621 NE Waldo Road Gainesville FL 32609
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Interim
Total Interim
Interim Component
Settlement Based on Costs
X Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Provider Number 028015100 Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
23518 23820 100112011
35393 35849 100112011
x Prospective
X Total Prospective Prospective Adjusted for New Cost
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit Prospective Portion
WRydellSamuel ~ Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
PnntPfl Im OQ()RIOll ltIt ORltIIR TTina vprirm 4 1 hv 17111 Rlt(~h TDFZGVT
I
Florida Agency For Health Care AdministrationlL--___O_2_8_01_S_1_0_0__---I
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
Provider Name TACACHALE 4 Cost Report Entered by Squire Yashica Provider Numbel 28015100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 59
II Column B---middot-~~~~tl-1ColumnA Residential I[Non-Ambulatory Medical Institutional __ +L______Lj_____ __ _____0_____ - _ _ ~_~__
IA Allocation of Expenses (excluding B ampcJ 1 Resident Days
2 Operating Expenses Component A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
I 900212520
431992431992
332844332844 3433434334 0000000000
21522
472741 425478
o 31
929733
490554 225792
o ------------_
716346 73893
o
i B Direct Care Expense I Staffmg 050 100 2 Total Staffmg Required 626000 900200 1526200 3 Staffing Percent 410169047 589830953 10000 4 Allocation of Direct Care 148918599 214147801 363066400
23788915 Direct Care Expense Per Diem 1189446
C Additional Services Expense 1 Medicaid Inpatient Days 2150112520 8981
223725 5857012 Additional Services 361976 3 Additional Services Exp amp Per Diem 28911 249109
=-~=~~ =-======1=======-=+===middot=middot=========F======-=middotmiddot D Medicaid Per Diem Cost
9297334319921 Operating Component 431992 2960844 49327112 Resident Care Component 1811407
73893343343 Property Cost Component 34334 o4 ROElUse Allow Component 00000
5 Total Cost Per Diem 2277733 3427170
TACACHALE 4 OwnershipState[l]
Florida Agency For Health Care Administration I 028015100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23820
ICFMR-DD Calculation Sheet NM 35849 Rates Effective 100 1120 II through 033112012
~----------~----------- __----_ bull_-_____bull-----__--_shyi ResidentialInstitutional Non-Ambulatory Medical
Base Semester
0000000
15 Prospective Rate Line II x Inflation (104648267)
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
12520 ~----~---- shy
10000
0000
0000 0000
0000
0000
355054
3433 0000
000000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationl--0_2_8_01_6_0_0_0_-_2_0_11_I_I0_1 Office of Medicaid Cost Reimbursement Planning and Analysis I--_R_I_2_3_4_3_8__N_1_I_3_4_2_1_9--J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND l1ARIANNA 3 3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
028016000 091082011 063012010 Unaudited [3]
New Effective Rate Date
23145 23438 10012011
33788 34219 100112011
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ~___ _~~~__bull __~__________bull _~ _~_~~__________~_bullbull_Lbullbull~_____ ~~__
IBasis-__ ~----~-~--- -~~------~~-------- ----~-- ----------- --__--
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion Field Audit - Interim Portion
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Horne Office
For Infonnation only - No Change in rate
Florida Agency For Health Care Administration ___0_2_80_1_6_0_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name SUNLAND MARIANNA 3 Cost Report Entered by Squire Yashica Provider Numbel 28016000 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 shy 063012010 Date 982011 Days In Reporting Period 365
Number of Beds 44
ColumnA Residential Institutional
12849
~~-~-----T---~~-------- ~-
----C-ol-umn--B---- i I Column C Total Ii Non-Ambulatory Medical
2718 15567
237433
iA Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
~ Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
389532
551093 63945
100 271800
297292863 56006229
2060568
389532 1789055
63945 00000
--------
2242532
389532
551093 63945 00000
2718 56434
207631
389532 2819291
63945
336480 o
419225 17928
_____ 420l3~_ 857886 99543
o
914250 10000
188387400
14777 306873
606385 3048633
99543 o
Florida Agency For Health Care Administration 028016000 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23438
ICFMR-DD Calculation Sheet NM 34219 Rates Effective 100112011 through 033112012
SUNLAND MARIANNA 3 OwnershipState[1 J
Base Semester
j------- +--------+--- ---- ---------- -+---- --~_i-- -~------~
1000025 Medicaid Utilization 9385
000 000
000
inted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationf--0_2_8_0_24_1_0_0_-_2_0_11_1_10-1 Office ofMedicaid Cost Reimbursement Planning and Analysis ~_R_I_3_3_5_2_6_I_N_M_4_7_8_7_6----l
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 5 1621 NB Waldo Road Gainesville FL 32609
Provider Number Date
FYE
Audit Status
028024100
091082011 06302010 Unaudited [3]
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Current Rate
33110
47277
New Rate
33526
47876
Effective Date
100112011
1010112011
IRateType-~--~ Interim
Total Interim
Interim Component
Settlement Based on Costs
x Prospective
X Total Prospective
Prospective Adjusted for New Cost
Budget
X Unaudited Costs
Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit - Prospective Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
D t~rl A )OI)Qf)Oll t (Qmiddot1middot1 Q TTjnn cmiddot lt11 h 17111 Rltgtth rnmiddotJ7rVT
-----
Florida Agency For Health Care Administration-I ___0_28_0_2_4_1_00__--- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFIMR-DD Profile Sheet Rate P eriod( s) 042011 to 1012011
Provider Name TACACHALE 5 Provider Numbel 28024100 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 40
ColumnA ColumnB Non-Ambulatory Medical
Column C Total --___----IjI Residential Institutional
4440 2634 7074
170516 426135
o 31563
888061 888061 628214
163155 252460
o 587525 587525 415615 122108 122108 86379 00000 00000 o
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Stafflllg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense I Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
050 222000
457354759 59893807
1348960
262414
100 263400
542645241 71063193
2697919
2517 71674
284760
888061 3570204
122108
4580372
485400 10000
130957000
6428 174304
628214 1899489
86379 o
2614082- ~-- ~~-~~
Florida Agency For Health Care Administration I 028024100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 33526
ICFMR-DD Calculation Sheet NM 47876 Rates Effective 1 lI20 II through 033l120 12
TACACHALE 5 Ownership State [ 1]
I Fiscal Year Begin ----- __ _----l____
I Current Cost Report i 070112009
I Prior Cost Report LI
-------_-- ---- -~-~----- ~---~~~--=-~--
-- --------- --------j----------------1Fiscal Year End Audit Status Base Semester I
06302010 Unaudited [3] -------l I
__~~ ~~__~_~1 ____ ~~_~ ___________ J
Period Base
3 Line I x - _ -----__ -- - --~--
4 Current Period Cost
5 Incentive Basis
15 Prospective Rate Line I I x Inflation (104648267)
16 Interim Rate ~---------~-----------------
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component ---____-___ --__-shy ---- shy
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
---------- shy
88806 88806 357020
0000 0000 0000
88806 219890 308696 88806 357020
0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
0000 0000 0000 0000
0000 0000 I 0000 0000
------- --------
445826
0000
0000
33526 47876 2517
------1-----middot_--_middot_---------- shy
4440 2634 8809 955625 Medicaid Utilization
000
000
inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administrationl--0_2_8_02_6_7_0_0_-_2_0_11_I_I0---l Office ofMedicaid Cost Reimbursement Planning and Analysis --_RI_3_2_9_8_2_I_N_TM_4_6_5__4_S-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 7 Provider Number 028026700 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 063012010
Audit Status Unaudited [3]
Provider Type ICFMR~DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 32563 32982 100112011
8 Non-Ambulatory amp 9 Medical 45952 46545 100112011
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
x Unaudited Costs
Field Audited Costs Field Audit Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
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
Printpj rn flQf(llV)fl11 M fll(middotlmiddot1 l( nina vprltrm 4 1 hv 17111 Rth TnmiddotF7CiVT
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
--l
Florida Agency For Health Care Administration 028004600 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis --_R_I_2_5_9_6_2_I_N_M_3_9_0_9_1
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 1 1621 NE Waldo Road Gainesville FL 32609
Provider Number 028004600 Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Provider Type ICFMR-DD
Level of Care 7 Institutional
8 Non-Ambulatory amp 9 Medical
Current New Rate Rate
25632 25962
38592 39091
E
10
101
ffective Date
0112011
0112011
Interim
Total Interim Interim Component
x Prospective
X Total Prospective Prospective Adjusted for New Cost
Settlement Based on Costs -~-------------------
Budget Desk Audited Costs
X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit Prospective Portion
Field Audit - Interim Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (3) Home Office
For Information only - No Change in rate
Florida Agency For Health Care AdministrationL-1___0_2_8_00_4_6_0_0__-- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 042011 to 102011
Provider Name TACACHALE 1 Cost Report Entered by Squire Yashica Provider Numbel 28004600 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 071012009 - 063012010 Date 982011 Days In Reporting Period 365
Number of Beds 112
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem j ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additiona] Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
ColumnA Column C Total Residential Institutional
302] 7 38380
1078781 539053
8163
o __~9~2J_
1657761
878394 1256078
431934
o 2134472
29630 556142
1137]9 00000 o
100 3021700 3429850 881000627 10000
729914482 828506200 2415576
38096 916394
30197 1119140
303472
431934 431934 1657761 2020603 3275] 89 11538674
29630 29630 113719 00000 0
__ ___2~8-21-6~-- ==c== cc_=c=37=3=6=7=53~ c=_=c=_=_13312_~~5~_==
Florida Agency For Health Care Administration I 028004600 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RJ 25962
ICFMR-DD Calculation Sheet NM 39091 Rates Effective 1 I120 II through 033112012
TACACHALE 1 OwnershipState[l]
000000000
327519
9677
000
000
Jrinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
I
028006200 - 2011110 Florida Agency For Health Care Administration RI25693 1 NM39517 shyOffice of Medicaid Cost Reimbursement Planning and Analysis
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 2
1621 N E Waldo Road Gainesville FL 32609
Provider Type ICFMR-DD
Level of Care 7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
25368
028006200 0910812011 06302010 Unaudited [3]
New Effective Rate Date
25693 100112011
39014 39517 100112011
Interim x Prospective
Total Interim Interim Component
X Total Prospective Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
X Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Di stribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit Prospective Portion
w Rydell Samuel r Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
Florida Agency For Health Care AdministrationL-r___0_2_8_00_6_2_0_0___ Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 10201]
Provider Name TACACHALE 2 Cost Report Entered by Squire Yashica Provider Numbel 28006200 Rate Semester October 20 II Audit Status Unaudited [3] Cost Report 07012009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 90
I
Column C Total
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem i ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
18449
461030 38424 00000
050 922450
356605779 239302912
1297105
18436 439401
16643
422004
461030 38424 00000
100 1664300 643394221
431754388 2594210
16543 433774
262210
873770 565260
o 41
1480898
804464 813384
o-______shy
1617848 134836
o
2586750 10000
1057300
34979 873175
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
422004 1996474
38424 00000
422004 3317451
38424
1480898 9201596
134836 o
------------~ --------~
5 Total Cost Per Diem 2456902 _7Zmiddot_879 ~_0817~31L__
Florida Agency For Health Care Administration I 028006200 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25693
ICFMR-DD Calculation Sheet NM 39517 Rates Effective 1001120 II through 033112012
TACACHALE 2 OwnershipState[l]
i ~~~~~t~ie~~~of~~~~~II~~~~~~~1~ndt~nau~it~~~n~-f~~ s~m~~q c_~___ ~_____________ ~_________~~_~-~_~~~~_~~~~__~~~_~_~__~_~--~_~_~___ _____ _______ ~_____ _
1 Prior Period Base
Inflation Factor 000000000 r-=-=C-==-----==---=-~Lc_________________________________J___________---shy___________________J___
4 Current Period Cost
5 Incentive Basis line 3 - line 4) 0000 bull ~----- -shy ------------t----------r-~-----------
6 Allowed~urrentJgtefl()d Costs~___~___________~~__________r__shy _--4=220=-0+_------shy___-=---__ shy __ +shy ____________ 1 -------=-=----If---=-------=-~r_-------=----I
r~~~___~==~~_~~_~~~~=~~_________f---~O~O-~O~O+_---~-~-~----~O~O~OO--f--~~~-~-----~---~~---+----~~-~ 0000 0000
15 Prospective Rate Line I I x Inflation (104648267) -----+----~-+-
-16 Interim Rate
17 NA
-158-_~-~~IL1l~~_c-~l~l~ ~~~ Rate 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
18449 16643 ~~- -----~-------~---- -----~----~---------~
9993 9940
000
000
rinted on 090820 I I at 085118 Using version 41 by 17111 Batch TDFZGVJ
000
Florida Agency For Health Care Administrationr--0_2_8_00_9_7_0_0_-_2_0_11_I_l0_--I Office of Medicaid Cost Reimbursement Planning and Analysis --_R_I_4_2_6_4_3_I_N_M__6_9_2_8_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND MARIANNA 2 Provider Number 028009700 ---------------shy3700 Williams Drive Date 09082011
Marianna FL 32446 FYE 06302010 Audit Status Unaudited [3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date
7 Institutional 42106 42643 100112011
8 Non-Ambulatory amp 9 Medical 68404 69283 100112011
~~-- ----~--- ~
iRate Type I Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs _~_bull_ __~_ ~_bull J
Budget Desk Audited Costs
X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit Interim Portion ~~-~--~ ~------~bull - ~---- - ---~- - -------- - ~------__ __---__
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Florida Agency For Health Care AdministrationL-I___O_2_8_00_9_7_0_0__---l
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
RatePeriod(s) 042011 to 102011
Provider Name SUNLAND MARIANNA 2 Provider Numbel 28009700 Audit Status Unaudited [3] Date 982011
~-~~~~~~-~----- ~- ~~---- ~~ --~- shy
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 121
~~--~-column-B-~-~COIU=~TotalColumnA Residential II Non-Ambulatory Medical Institutional
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
~~-~~+---3-1-4-2-2l1 ~- 057-shy - - -- shy 32479
636490
515567 82350 00000
050 1571100
936963263 799847029
2545500
30327 905763
298666
636490 3359733
82350 00000
4078574
636490
515567 82350 00000
100 105700 63036737
53811871 5691000
1057 31589
298855
636490 5905423
82350
6624263
1075906 904102
o ~~_~~l4
2067257
951057 48171
__~675~2_ 1674511
267466 o
1676800 10000
853658900
31384 937352
2067257 11148452
267466 o
13483175
Florida Agency For Health Care Administration I 028009700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 42643
ICFMR-DD Calculation Sheet NM 69283 Rates Effective 1010 l20 11 through 033112012
SUNLAND MARIANNA 2 OvvnershipState[l]
Inflation Factor 000000000
---~-shy
6
31422 9652
63649 590542 654191
0000 0000
63649 i 590542 654191
0000 0000 0000
0000 0000 0000
1057-shy ----- -------~~- -
10000
000 000
000
~inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
--
Florida Agency For Health Care Administrationl-0_28Ol_19OO_-2Ol1lO=-j
Office ofMedicaid Cost Reimbursement Planning and Analysis I-_R_I_2_4_4_0-7_I-N--M~3--7-976--1 2727 Mahan Drive-Mail Stop 21
Tallahassee Florida 32308
TACACHALE 3 Provider Number 028011900 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 06302010
Audit Status Unaudited [3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date
7 Institutional 24099 24407 10012011
8 Non-Ambulatory amp 9 Medical 37493 37976 100112011
r=--c~--~-- - --- ---- ---------- -------- ~----~-- - ---- ------shy
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
i-BaSIS I Budget
X Unaudited Costs
Field Audited Costs Field Audit - Interiin Portion
Distribution Contract Management DPODS - DCF (3) Home Office
Desk Audited Costs
Desk Audit - Interim Portion
Desk Audit - Prospective Portion
w Rydell SueJ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
_______
Florida Agency For Health Care Administrationll-__O_28_0_1_1_9_00__---l
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 3 Provider NumbeJ 28011900 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
5 ROEUse Per Diem
B Direct Care Expense 1 Staffing
2 Total Staffmg Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
j C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 49
ColumnA ColumnB Residential Non-Ambulatory Medical Institutional
11503 6962
Column C Total
18465
430542 276993
o 05~
394287
368227 37137 00000
050 575150
452393125 149587089
1300418
11503 269061
233905 __-------
394287 1902551
37137 00000
2333974
394287
368227 37137 00000
100 696200
547606875 181070211
2600836
6950 159916
230095
394287 3199159
37137
3630582 --- ------- shy~
728051
424805 255127
o 679932
68573 o
1271350 10000
330657300
18453 428977
728051 4415482
68573 o
Florida Agency For Health Care Administration I 028011900 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 24407
ICFMR-DD Calculation Sheet NM 37976 Rates Effective 100112011 through 033112012
TACACHALE 3 OvvnershipState[l]
3 Line 1 x
4 Current Period Cost
5 Incentive Basis
of line 3 or 4
15 Prospective Rate Line II x Inflation (104648267)
39429
0000
190255 229684
0000 0000
0000
-~---~--~middot~~-_C~~~middotmiddotmiddotmiddotmiddot-l~~~~middot-
16 Interim Rate
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component -~~-----------
2 I Plus Property Interim Rate Component
-~-~
39429
0000
39429
0000
0000
319916
0000
319916
0000
359345
0000
0000
376048
0000
0000
376048
3714
0000
-~------- ----t---- -------------- - -----middot--middot-----~----I
11503 6962
25 Medicaid Utilization 10000 9983
000 000
000
nted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
------------------- ---
---l
Florida Agency For Health Care Administrationf- _0_2_8_0_1_5_10_0_-_20_1_1_1_1o_-1
Office ofMedicaid Cost Reimbursement Planning and Analysis --_R_I_2_3_8_2_0_I_N_M_3_5_8_A_9
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 4 1621 NE Waldo Road Gainesville FL 32609
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Interim
Total Interim
Interim Component
Settlement Based on Costs
X Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Provider Number 028015100 Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
23518 23820 100112011
35393 35849 100112011
x Prospective
X Total Prospective Prospective Adjusted for New Cost
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit Prospective Portion
WRydellSamuel ~ Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
PnntPfl Im OQ()RIOll ltIt ORltIIR TTina vprirm 4 1 hv 17111 Rlt(~h TDFZGVT
I
Florida Agency For Health Care AdministrationlL--___O_2_8_01_S_1_0_0__---I
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
Provider Name TACACHALE 4 Cost Report Entered by Squire Yashica Provider Numbel 28015100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 59
II Column B---middot-~~~~tl-1ColumnA Residential I[Non-Ambulatory Medical Institutional __ +L______Lj_____ __ _____0_____ - _ _ ~_~__
IA Allocation of Expenses (excluding B ampcJ 1 Resident Days
2 Operating Expenses Component A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
I 900212520
431992431992
332844332844 3433434334 0000000000
21522
472741 425478
o 31
929733
490554 225792
o ------------_
716346 73893
o
i B Direct Care Expense I Staffmg 050 100 2 Total Staffmg Required 626000 900200 1526200 3 Staffing Percent 410169047 589830953 10000 4 Allocation of Direct Care 148918599 214147801 363066400
23788915 Direct Care Expense Per Diem 1189446
C Additional Services Expense 1 Medicaid Inpatient Days 2150112520 8981
223725 5857012 Additional Services 361976 3 Additional Services Exp amp Per Diem 28911 249109
=-~=~~ =-======1=======-=+===middot=middot=========F======-=middotmiddot D Medicaid Per Diem Cost
9297334319921 Operating Component 431992 2960844 49327112 Resident Care Component 1811407
73893343343 Property Cost Component 34334 o4 ROElUse Allow Component 00000
5 Total Cost Per Diem 2277733 3427170
TACACHALE 4 OwnershipState[l]
Florida Agency For Health Care Administration I 028015100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23820
ICFMR-DD Calculation Sheet NM 35849 Rates Effective 100 1120 II through 033112012
~----------~----------- __----_ bull_-_____bull-----__--_shyi ResidentialInstitutional Non-Ambulatory Medical
Base Semester
0000000
15 Prospective Rate Line II x Inflation (104648267)
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
12520 ~----~---- shy
10000
0000
0000 0000
0000
0000
355054
3433 0000
000000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationl--0_2_8_01_6_0_0_0_-_2_0_11_I_I0_1 Office of Medicaid Cost Reimbursement Planning and Analysis I--_R_I_2_3_4_3_8__N_1_I_3_4_2_1_9--J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND l1ARIANNA 3 3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
028016000 091082011 063012010 Unaudited [3]
New Effective Rate Date
23145 23438 10012011
33788 34219 100112011
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ~___ _~~~__bull __~__________bull _~ _~_~~__________~_bullbull_Lbullbull~_____ ~~__
IBasis-__ ~----~-~--- -~~------~~-------- ----~-- ----------- --__--
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion Field Audit - Interim Portion
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Horne Office
For Infonnation only - No Change in rate
Florida Agency For Health Care Administration ___0_2_80_1_6_0_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name SUNLAND MARIANNA 3 Cost Report Entered by Squire Yashica Provider Numbel 28016000 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 shy 063012010 Date 982011 Days In Reporting Period 365
Number of Beds 44
ColumnA Residential Institutional
12849
~~-~-----T---~~-------- ~-
----C-ol-umn--B---- i I Column C Total Ii Non-Ambulatory Medical
2718 15567
237433
iA Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
~ Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
389532
551093 63945
100 271800
297292863 56006229
2060568
389532 1789055
63945 00000
--------
2242532
389532
551093 63945 00000
2718 56434
207631
389532 2819291
63945
336480 o
419225 17928
_____ 420l3~_ 857886 99543
o
914250 10000
188387400
14777 306873
606385 3048633
99543 o
Florida Agency For Health Care Administration 028016000 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23438
ICFMR-DD Calculation Sheet NM 34219 Rates Effective 100112011 through 033112012
SUNLAND MARIANNA 3 OwnershipState[1 J
Base Semester
j------- +--------+--- ---- ---------- -+---- --~_i-- -~------~
1000025 Medicaid Utilization 9385
000 000
000
inted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationf--0_2_8_0_24_1_0_0_-_2_0_11_1_10-1 Office ofMedicaid Cost Reimbursement Planning and Analysis ~_R_I_3_3_5_2_6_I_N_M_4_7_8_7_6----l
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 5 1621 NB Waldo Road Gainesville FL 32609
Provider Number Date
FYE
Audit Status
028024100
091082011 06302010 Unaudited [3]
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Current Rate
33110
47277
New Rate
33526
47876
Effective Date
100112011
1010112011
IRateType-~--~ Interim
Total Interim
Interim Component
Settlement Based on Costs
x Prospective
X Total Prospective
Prospective Adjusted for New Cost
Budget
X Unaudited Costs
Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit - Prospective Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
D t~rl A )OI)Qf)Oll t (Qmiddot1middot1 Q TTjnn cmiddot lt11 h 17111 Rltgtth rnmiddotJ7rVT
-----
Florida Agency For Health Care Administration-I ___0_28_0_2_4_1_00__--- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFIMR-DD Profile Sheet Rate P eriod( s) 042011 to 1012011
Provider Name TACACHALE 5 Provider Numbel 28024100 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 40
ColumnA ColumnB Non-Ambulatory Medical
Column C Total --___----IjI Residential Institutional
4440 2634 7074
170516 426135
o 31563
888061 888061 628214
163155 252460
o 587525 587525 415615 122108 122108 86379 00000 00000 o
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Stafflllg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense I Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
050 222000
457354759 59893807
1348960
262414
100 263400
542645241 71063193
2697919
2517 71674
284760
888061 3570204
122108
4580372
485400 10000
130957000
6428 174304
628214 1899489
86379 o
2614082- ~-- ~~-~~
Florida Agency For Health Care Administration I 028024100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 33526
ICFMR-DD Calculation Sheet NM 47876 Rates Effective 1 lI20 II through 033l120 12
TACACHALE 5 Ownership State [ 1]
I Fiscal Year Begin ----- __ _----l____
I Current Cost Report i 070112009
I Prior Cost Report LI
-------_-- ---- -~-~----- ~---~~~--=-~--
-- --------- --------j----------------1Fiscal Year End Audit Status Base Semester I
06302010 Unaudited [3] -------l I
__~~ ~~__~_~1 ____ ~~_~ ___________ J
Period Base
3 Line I x - _ -----__ -- - --~--
4 Current Period Cost
5 Incentive Basis
15 Prospective Rate Line I I x Inflation (104648267)
16 Interim Rate ~---------~-----------------
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component ---____-___ --__-shy ---- shy
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
---------- shy
88806 88806 357020
0000 0000 0000
88806 219890 308696 88806 357020
0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
0000 0000 0000 0000
0000 0000 I 0000 0000
------- --------
445826
0000
0000
33526 47876 2517
------1-----middot_--_middot_---------- shy
4440 2634 8809 955625 Medicaid Utilization
000
000
inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administrationl--0_2_8_02_6_7_0_0_-_2_0_11_I_I0---l Office ofMedicaid Cost Reimbursement Planning and Analysis --_RI_3_2_9_8_2_I_N_TM_4_6_5__4_S-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 7 Provider Number 028026700 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 063012010
Audit Status Unaudited [3]
Provider Type ICFMR~DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 32563 32982 100112011
8 Non-Ambulatory amp 9 Medical 45952 46545 100112011
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
x Unaudited Costs
Field Audited Costs Field Audit Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
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
Printpj rn flQf(llV)fl11 M fll(middotlmiddot1 l( nina vprltrm 4 1 hv 17111 Rth TnmiddotF7CiVT
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Florida Agency For Health Care AdministrationL-1___0_2_8_00_4_6_0_0__-- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 042011 to 102011
Provider Name TACACHALE 1 Cost Report Entered by Squire Yashica Provider Numbel 28004600 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 071012009 - 063012010 Date 982011 Days In Reporting Period 365
Number of Beds 112
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem j ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additiona] Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
ColumnA Column C Total Residential Institutional
302] 7 38380
1078781 539053
8163
o __~9~2J_
1657761
878394 1256078
431934
o 2134472
29630 556142
1137]9 00000 o
100 3021700 3429850 881000627 10000
729914482 828506200 2415576
38096 916394
30197 1119140
303472
431934 431934 1657761 2020603 3275] 89 11538674
29630 29630 113719 00000 0
__ ___2~8-21-6~-- ==c== cc_=c=37=3=6=7=53~ c=_=c=_=_13312_~~5~_==
Florida Agency For Health Care Administration I 028004600 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RJ 25962
ICFMR-DD Calculation Sheet NM 39091 Rates Effective 1 I120 II through 033112012
TACACHALE 1 OwnershipState[l]
000000000
327519
9677
000
000
Jrinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
I
028006200 - 2011110 Florida Agency For Health Care Administration RI25693 1 NM39517 shyOffice of Medicaid Cost Reimbursement Planning and Analysis
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 2
1621 N E Waldo Road Gainesville FL 32609
Provider Type ICFMR-DD
Level of Care 7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
25368
028006200 0910812011 06302010 Unaudited [3]
New Effective Rate Date
25693 100112011
39014 39517 100112011
Interim x Prospective
Total Interim Interim Component
X Total Prospective Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
X Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Di stribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit Prospective Portion
w Rydell Samuel r Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
Florida Agency For Health Care AdministrationL-r___0_2_8_00_6_2_0_0___ Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 10201]
Provider Name TACACHALE 2 Cost Report Entered by Squire Yashica Provider Numbel 28006200 Rate Semester October 20 II Audit Status Unaudited [3] Cost Report 07012009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 90
I
Column C Total
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem i ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
18449
461030 38424 00000
050 922450
356605779 239302912
1297105
18436 439401
16643
422004
461030 38424 00000
100 1664300 643394221
431754388 2594210
16543 433774
262210
873770 565260
o 41
1480898
804464 813384
o-______shy
1617848 134836
o
2586750 10000
1057300
34979 873175
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
422004 1996474
38424 00000
422004 3317451
38424
1480898 9201596
134836 o
------------~ --------~
5 Total Cost Per Diem 2456902 _7Zmiddot_879 ~_0817~31L__
Florida Agency For Health Care Administration I 028006200 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25693
ICFMR-DD Calculation Sheet NM 39517 Rates Effective 1001120 II through 033112012
TACACHALE 2 OwnershipState[l]
i ~~~~~t~ie~~~of~~~~~II~~~~~~~1~ndt~nau~it~~~n~-f~~ s~m~~q c_~___ ~_____________ ~_________~~_~-~_~~~~_~~~~__~~~_~_~__~_~--~_~_~___ _____ _______ ~_____ _
1 Prior Period Base
Inflation Factor 000000000 r-=-=C-==-----==---=-~Lc_________________________________J___________---shy___________________J___
4 Current Period Cost
5 Incentive Basis line 3 - line 4) 0000 bull ~----- -shy ------------t----------r-~-----------
6 Allowed~urrentJgtefl()d Costs~___~___________~~__________r__shy _--4=220=-0+_------shy___-=---__ shy __ +shy ____________ 1 -------=-=----If---=-------=-~r_-------=----I
r~~~___~==~~_~~_~~~~=~~_________f---~O~O-~O~O+_---~-~-~----~O~O~OO--f--~~~-~-----~---~~---+----~~-~ 0000 0000
15 Prospective Rate Line I I x Inflation (104648267) -----+----~-+-
-16 Interim Rate
17 NA
-158-_~-~~IL1l~~_c-~l~l~ ~~~ Rate 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
18449 16643 ~~- -----~-------~---- -----~----~---------~
9993 9940
000
000
rinted on 090820 I I at 085118 Using version 41 by 17111 Batch TDFZGVJ
000
Florida Agency For Health Care Administrationr--0_2_8_00_9_7_0_0_-_2_0_11_I_l0_--I Office of Medicaid Cost Reimbursement Planning and Analysis --_R_I_4_2_6_4_3_I_N_M__6_9_2_8_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND MARIANNA 2 Provider Number 028009700 ---------------shy3700 Williams Drive Date 09082011
Marianna FL 32446 FYE 06302010 Audit Status Unaudited [3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date
7 Institutional 42106 42643 100112011
8 Non-Ambulatory amp 9 Medical 68404 69283 100112011
~~-- ----~--- ~
iRate Type I Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs _~_bull_ __~_ ~_bull J
Budget Desk Audited Costs
X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit Interim Portion ~~-~--~ ~------~bull - ~---- - ---~- - -------- - ~------__ __---__
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Florida Agency For Health Care AdministrationL-I___O_2_8_00_9_7_0_0__---l
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
RatePeriod(s) 042011 to 102011
Provider Name SUNLAND MARIANNA 2 Provider Numbel 28009700 Audit Status Unaudited [3] Date 982011
~-~~~~~~-~----- ~- ~~---- ~~ --~- shy
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 121
~~--~-column-B-~-~COIU=~TotalColumnA Residential II Non-Ambulatory Medical Institutional
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
~~-~~+---3-1-4-2-2l1 ~- 057-shy - - -- shy 32479
636490
515567 82350 00000
050 1571100
936963263 799847029
2545500
30327 905763
298666
636490 3359733
82350 00000
4078574
636490
515567 82350 00000
100 105700 63036737
53811871 5691000
1057 31589
298855
636490 5905423
82350
6624263
1075906 904102
o ~~_~~l4
2067257
951057 48171
__~675~2_ 1674511
267466 o
1676800 10000
853658900
31384 937352
2067257 11148452
267466 o
13483175
Florida Agency For Health Care Administration I 028009700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 42643
ICFMR-DD Calculation Sheet NM 69283 Rates Effective 1010 l20 11 through 033112012
SUNLAND MARIANNA 2 OvvnershipState[l]
Inflation Factor 000000000
---~-shy
6
31422 9652
63649 590542 654191
0000 0000
63649 i 590542 654191
0000 0000 0000
0000 0000 0000
1057-shy ----- -------~~- -
10000
000 000
000
~inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
--
Florida Agency For Health Care Administrationl-0_28Ol_19OO_-2Ol1lO=-j
Office ofMedicaid Cost Reimbursement Planning and Analysis I-_R_I_2_4_4_0-7_I-N--M~3--7-976--1 2727 Mahan Drive-Mail Stop 21
Tallahassee Florida 32308
TACACHALE 3 Provider Number 028011900 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 06302010
Audit Status Unaudited [3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date
7 Institutional 24099 24407 10012011
8 Non-Ambulatory amp 9 Medical 37493 37976 100112011
r=--c~--~-- - --- ---- ---------- -------- ~----~-- - ---- ------shy
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
i-BaSIS I Budget
X Unaudited Costs
Field Audited Costs Field Audit - Interiin Portion
Distribution Contract Management DPODS - DCF (3) Home Office
Desk Audited Costs
Desk Audit - Interim Portion
Desk Audit - Prospective Portion
w Rydell SueJ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
_______
Florida Agency For Health Care Administrationll-__O_28_0_1_1_9_00__---l
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 3 Provider NumbeJ 28011900 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
5 ROEUse Per Diem
B Direct Care Expense 1 Staffing
2 Total Staffmg Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
j C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 49
ColumnA ColumnB Residential Non-Ambulatory Medical Institutional
11503 6962
Column C Total
18465
430542 276993
o 05~
394287
368227 37137 00000
050 575150
452393125 149587089
1300418
11503 269061
233905 __-------
394287 1902551
37137 00000
2333974
394287
368227 37137 00000
100 696200
547606875 181070211
2600836
6950 159916
230095
394287 3199159
37137
3630582 --- ------- shy~
728051
424805 255127
o 679932
68573 o
1271350 10000
330657300
18453 428977
728051 4415482
68573 o
Florida Agency For Health Care Administration I 028011900 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 24407
ICFMR-DD Calculation Sheet NM 37976 Rates Effective 100112011 through 033112012
TACACHALE 3 OvvnershipState[l]
3 Line 1 x
4 Current Period Cost
5 Incentive Basis
of line 3 or 4
15 Prospective Rate Line II x Inflation (104648267)
39429
0000
190255 229684
0000 0000
0000
-~---~--~middot~~-_C~~~middotmiddotmiddotmiddotmiddot-l~~~~middot-
16 Interim Rate
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component -~~-----------
2 I Plus Property Interim Rate Component
-~-~
39429
0000
39429
0000
0000
319916
0000
319916
0000
359345
0000
0000
376048
0000
0000
376048
3714
0000
-~------- ----t---- -------------- - -----middot--middot-----~----I
11503 6962
25 Medicaid Utilization 10000 9983
000 000
000
nted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
------------------- ---
---l
Florida Agency For Health Care Administrationf- _0_2_8_0_1_5_10_0_-_20_1_1_1_1o_-1
Office ofMedicaid Cost Reimbursement Planning and Analysis --_R_I_2_3_8_2_0_I_N_M_3_5_8_A_9
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 4 1621 NE Waldo Road Gainesville FL 32609
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Interim
Total Interim
Interim Component
Settlement Based on Costs
X Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Provider Number 028015100 Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
23518 23820 100112011
35393 35849 100112011
x Prospective
X Total Prospective Prospective Adjusted for New Cost
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit Prospective Portion
WRydellSamuel ~ Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
PnntPfl Im OQ()RIOll ltIt ORltIIR TTina vprirm 4 1 hv 17111 Rlt(~h TDFZGVT
I
Florida Agency For Health Care AdministrationlL--___O_2_8_01_S_1_0_0__---I
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
Provider Name TACACHALE 4 Cost Report Entered by Squire Yashica Provider Numbel 28015100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 59
II Column B---middot-~~~~tl-1ColumnA Residential I[Non-Ambulatory Medical Institutional __ +L______Lj_____ __ _____0_____ - _ _ ~_~__
IA Allocation of Expenses (excluding B ampcJ 1 Resident Days
2 Operating Expenses Component A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
I 900212520
431992431992
332844332844 3433434334 0000000000
21522
472741 425478
o 31
929733
490554 225792
o ------------_
716346 73893
o
i B Direct Care Expense I Staffmg 050 100 2 Total Staffmg Required 626000 900200 1526200 3 Staffing Percent 410169047 589830953 10000 4 Allocation of Direct Care 148918599 214147801 363066400
23788915 Direct Care Expense Per Diem 1189446
C Additional Services Expense 1 Medicaid Inpatient Days 2150112520 8981
223725 5857012 Additional Services 361976 3 Additional Services Exp amp Per Diem 28911 249109
=-~=~~ =-======1=======-=+===middot=middot=========F======-=middotmiddot D Medicaid Per Diem Cost
9297334319921 Operating Component 431992 2960844 49327112 Resident Care Component 1811407
73893343343 Property Cost Component 34334 o4 ROElUse Allow Component 00000
5 Total Cost Per Diem 2277733 3427170
TACACHALE 4 OwnershipState[l]
Florida Agency For Health Care Administration I 028015100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23820
ICFMR-DD Calculation Sheet NM 35849 Rates Effective 100 1120 II through 033112012
~----------~----------- __----_ bull_-_____bull-----__--_shyi ResidentialInstitutional Non-Ambulatory Medical
Base Semester
0000000
15 Prospective Rate Line II x Inflation (104648267)
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
12520 ~----~---- shy
10000
0000
0000 0000
0000
0000
355054
3433 0000
000000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationl--0_2_8_01_6_0_0_0_-_2_0_11_I_I0_1 Office of Medicaid Cost Reimbursement Planning and Analysis I--_R_I_2_3_4_3_8__N_1_I_3_4_2_1_9--J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND l1ARIANNA 3 3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
028016000 091082011 063012010 Unaudited [3]
New Effective Rate Date
23145 23438 10012011
33788 34219 100112011
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ~___ _~~~__bull __~__________bull _~ _~_~~__________~_bullbull_Lbullbull~_____ ~~__
IBasis-__ ~----~-~--- -~~------~~-------- ----~-- ----------- --__--
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion Field Audit - Interim Portion
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Horne Office
For Infonnation only - No Change in rate
Florida Agency For Health Care Administration ___0_2_80_1_6_0_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name SUNLAND MARIANNA 3 Cost Report Entered by Squire Yashica Provider Numbel 28016000 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 shy 063012010 Date 982011 Days In Reporting Period 365
Number of Beds 44
ColumnA Residential Institutional
12849
~~-~-----T---~~-------- ~-
----C-ol-umn--B---- i I Column C Total Ii Non-Ambulatory Medical
2718 15567
237433
iA Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
~ Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
389532
551093 63945
100 271800
297292863 56006229
2060568
389532 1789055
63945 00000
--------
2242532
389532
551093 63945 00000
2718 56434
207631
389532 2819291
63945
336480 o
419225 17928
_____ 420l3~_ 857886 99543
o
914250 10000
188387400
14777 306873
606385 3048633
99543 o
Florida Agency For Health Care Administration 028016000 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23438
ICFMR-DD Calculation Sheet NM 34219 Rates Effective 100112011 through 033112012
SUNLAND MARIANNA 3 OwnershipState[1 J
Base Semester
j------- +--------+--- ---- ---------- -+---- --~_i-- -~------~
1000025 Medicaid Utilization 9385
000 000
000
inted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationf--0_2_8_0_24_1_0_0_-_2_0_11_1_10-1 Office ofMedicaid Cost Reimbursement Planning and Analysis ~_R_I_3_3_5_2_6_I_N_M_4_7_8_7_6----l
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 5 1621 NB Waldo Road Gainesville FL 32609
Provider Number Date
FYE
Audit Status
028024100
091082011 06302010 Unaudited [3]
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Current Rate
33110
47277
New Rate
33526
47876
Effective Date
100112011
1010112011
IRateType-~--~ Interim
Total Interim
Interim Component
Settlement Based on Costs
x Prospective
X Total Prospective
Prospective Adjusted for New Cost
Budget
X Unaudited Costs
Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit - Prospective Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
D t~rl A )OI)Qf)Oll t (Qmiddot1middot1 Q TTjnn cmiddot lt11 h 17111 Rltgtth rnmiddotJ7rVT
-----
Florida Agency For Health Care Administration-I ___0_28_0_2_4_1_00__--- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFIMR-DD Profile Sheet Rate P eriod( s) 042011 to 1012011
Provider Name TACACHALE 5 Provider Numbel 28024100 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 40
ColumnA ColumnB Non-Ambulatory Medical
Column C Total --___----IjI Residential Institutional
4440 2634 7074
170516 426135
o 31563
888061 888061 628214
163155 252460
o 587525 587525 415615 122108 122108 86379 00000 00000 o
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Stafflllg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense I Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
050 222000
457354759 59893807
1348960
262414
100 263400
542645241 71063193
2697919
2517 71674
284760
888061 3570204
122108
4580372
485400 10000
130957000
6428 174304
628214 1899489
86379 o
2614082- ~-- ~~-~~
Florida Agency For Health Care Administration I 028024100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 33526
ICFMR-DD Calculation Sheet NM 47876 Rates Effective 1 lI20 II through 033l120 12
TACACHALE 5 Ownership State [ 1]
I Fiscal Year Begin ----- __ _----l____
I Current Cost Report i 070112009
I Prior Cost Report LI
-------_-- ---- -~-~----- ~---~~~--=-~--
-- --------- --------j----------------1Fiscal Year End Audit Status Base Semester I
06302010 Unaudited [3] -------l I
__~~ ~~__~_~1 ____ ~~_~ ___________ J
Period Base
3 Line I x - _ -----__ -- - --~--
4 Current Period Cost
5 Incentive Basis
15 Prospective Rate Line I I x Inflation (104648267)
16 Interim Rate ~---------~-----------------
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component ---____-___ --__-shy ---- shy
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
---------- shy
88806 88806 357020
0000 0000 0000
88806 219890 308696 88806 357020
0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
0000 0000 0000 0000
0000 0000 I 0000 0000
------- --------
445826
0000
0000
33526 47876 2517
------1-----middot_--_middot_---------- shy
4440 2634 8809 955625 Medicaid Utilization
000
000
inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administrationl--0_2_8_02_6_7_0_0_-_2_0_11_I_I0---l Office ofMedicaid Cost Reimbursement Planning and Analysis --_RI_3_2_9_8_2_I_N_TM_4_6_5__4_S-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 7 Provider Number 028026700 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 063012010
Audit Status Unaudited [3]
Provider Type ICFMR~DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 32563 32982 100112011
8 Non-Ambulatory amp 9 Medical 45952 46545 100112011
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
x Unaudited Costs
Field Audited Costs Field Audit Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
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
Printpj rn flQf(llV)fl11 M fll(middotlmiddot1 l( nina vprltrm 4 1 hv 17111 Rth TnmiddotF7CiVT
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Florida Agency For Health Care Administration I 028004600 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RJ 25962
ICFMR-DD Calculation Sheet NM 39091 Rates Effective 1 I120 II through 033112012
TACACHALE 1 OwnershipState[l]
000000000
327519
9677
000
000
Jrinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
I
028006200 - 2011110 Florida Agency For Health Care Administration RI25693 1 NM39517 shyOffice of Medicaid Cost Reimbursement Planning and Analysis
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 2
1621 N E Waldo Road Gainesville FL 32609
Provider Type ICFMR-DD
Level of Care 7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
25368
028006200 0910812011 06302010 Unaudited [3]
New Effective Rate Date
25693 100112011
39014 39517 100112011
Interim x Prospective
Total Interim Interim Component
X Total Prospective Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
X Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Di stribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit Prospective Portion
w Rydell Samuel r Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
Florida Agency For Health Care AdministrationL-r___0_2_8_00_6_2_0_0___ Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 10201]
Provider Name TACACHALE 2 Cost Report Entered by Squire Yashica Provider Numbel 28006200 Rate Semester October 20 II Audit Status Unaudited [3] Cost Report 07012009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 90
I
Column C Total
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem i ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
18449
461030 38424 00000
050 922450
356605779 239302912
1297105
18436 439401
16643
422004
461030 38424 00000
100 1664300 643394221
431754388 2594210
16543 433774
262210
873770 565260
o 41
1480898
804464 813384
o-______shy
1617848 134836
o
2586750 10000
1057300
34979 873175
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
422004 1996474
38424 00000
422004 3317451
38424
1480898 9201596
134836 o
------------~ --------~
5 Total Cost Per Diem 2456902 _7Zmiddot_879 ~_0817~31L__
Florida Agency For Health Care Administration I 028006200 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25693
ICFMR-DD Calculation Sheet NM 39517 Rates Effective 1001120 II through 033112012
TACACHALE 2 OwnershipState[l]
i ~~~~~t~ie~~~of~~~~~II~~~~~~~1~ndt~nau~it~~~n~-f~~ s~m~~q c_~___ ~_____________ ~_________~~_~-~_~~~~_~~~~__~~~_~_~__~_~--~_~_~___ _____ _______ ~_____ _
1 Prior Period Base
Inflation Factor 000000000 r-=-=C-==-----==---=-~Lc_________________________________J___________---shy___________________J___
4 Current Period Cost
5 Incentive Basis line 3 - line 4) 0000 bull ~----- -shy ------------t----------r-~-----------
6 Allowed~urrentJgtefl()d Costs~___~___________~~__________r__shy _--4=220=-0+_------shy___-=---__ shy __ +shy ____________ 1 -------=-=----If---=-------=-~r_-------=----I
r~~~___~==~~_~~_~~~~=~~_________f---~O~O-~O~O+_---~-~-~----~O~O~OO--f--~~~-~-----~---~~---+----~~-~ 0000 0000
15 Prospective Rate Line I I x Inflation (104648267) -----+----~-+-
-16 Interim Rate
17 NA
-158-_~-~~IL1l~~_c-~l~l~ ~~~ Rate 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
18449 16643 ~~- -----~-------~---- -----~----~---------~
9993 9940
000
000
rinted on 090820 I I at 085118 Using version 41 by 17111 Batch TDFZGVJ
000
Florida Agency For Health Care Administrationr--0_2_8_00_9_7_0_0_-_2_0_11_I_l0_--I Office of Medicaid Cost Reimbursement Planning and Analysis --_R_I_4_2_6_4_3_I_N_M__6_9_2_8_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND MARIANNA 2 Provider Number 028009700 ---------------shy3700 Williams Drive Date 09082011
Marianna FL 32446 FYE 06302010 Audit Status Unaudited [3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date
7 Institutional 42106 42643 100112011
8 Non-Ambulatory amp 9 Medical 68404 69283 100112011
~~-- ----~--- ~
iRate Type I Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs _~_bull_ __~_ ~_bull J
Budget Desk Audited Costs
X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit Interim Portion ~~-~--~ ~------~bull - ~---- - ---~- - -------- - ~------__ __---__
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Florida Agency For Health Care AdministrationL-I___O_2_8_00_9_7_0_0__---l
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
RatePeriod(s) 042011 to 102011
Provider Name SUNLAND MARIANNA 2 Provider Numbel 28009700 Audit Status Unaudited [3] Date 982011
~-~~~~~~-~----- ~- ~~---- ~~ --~- shy
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 121
~~--~-column-B-~-~COIU=~TotalColumnA Residential II Non-Ambulatory Medical Institutional
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
~~-~~+---3-1-4-2-2l1 ~- 057-shy - - -- shy 32479
636490
515567 82350 00000
050 1571100
936963263 799847029
2545500
30327 905763
298666
636490 3359733
82350 00000
4078574
636490
515567 82350 00000
100 105700 63036737
53811871 5691000
1057 31589
298855
636490 5905423
82350
6624263
1075906 904102
o ~~_~~l4
2067257
951057 48171
__~675~2_ 1674511
267466 o
1676800 10000
853658900
31384 937352
2067257 11148452
267466 o
13483175
Florida Agency For Health Care Administration I 028009700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 42643
ICFMR-DD Calculation Sheet NM 69283 Rates Effective 1010 l20 11 through 033112012
SUNLAND MARIANNA 2 OvvnershipState[l]
Inflation Factor 000000000
---~-shy
6
31422 9652
63649 590542 654191
0000 0000
63649 i 590542 654191
0000 0000 0000
0000 0000 0000
1057-shy ----- -------~~- -
10000
000 000
000
~inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
--
Florida Agency For Health Care Administrationl-0_28Ol_19OO_-2Ol1lO=-j
Office ofMedicaid Cost Reimbursement Planning and Analysis I-_R_I_2_4_4_0-7_I-N--M~3--7-976--1 2727 Mahan Drive-Mail Stop 21
Tallahassee Florida 32308
TACACHALE 3 Provider Number 028011900 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 06302010
Audit Status Unaudited [3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date
7 Institutional 24099 24407 10012011
8 Non-Ambulatory amp 9 Medical 37493 37976 100112011
r=--c~--~-- - --- ---- ---------- -------- ~----~-- - ---- ------shy
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
i-BaSIS I Budget
X Unaudited Costs
Field Audited Costs Field Audit - Interiin Portion
Distribution Contract Management DPODS - DCF (3) Home Office
Desk Audited Costs
Desk Audit - Interim Portion
Desk Audit - Prospective Portion
w Rydell SueJ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
_______
Florida Agency For Health Care Administrationll-__O_28_0_1_1_9_00__---l
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 3 Provider NumbeJ 28011900 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
5 ROEUse Per Diem
B Direct Care Expense 1 Staffing
2 Total Staffmg Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
j C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 49
ColumnA ColumnB Residential Non-Ambulatory Medical Institutional
11503 6962
Column C Total
18465
430542 276993
o 05~
394287
368227 37137 00000
050 575150
452393125 149587089
1300418
11503 269061
233905 __-------
394287 1902551
37137 00000
2333974
394287
368227 37137 00000
100 696200
547606875 181070211
2600836
6950 159916
230095
394287 3199159
37137
3630582 --- ------- shy~
728051
424805 255127
o 679932
68573 o
1271350 10000
330657300
18453 428977
728051 4415482
68573 o
Florida Agency For Health Care Administration I 028011900 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 24407
ICFMR-DD Calculation Sheet NM 37976 Rates Effective 100112011 through 033112012
TACACHALE 3 OvvnershipState[l]
3 Line 1 x
4 Current Period Cost
5 Incentive Basis
of line 3 or 4
15 Prospective Rate Line II x Inflation (104648267)
39429
0000
190255 229684
0000 0000
0000
-~---~--~middot~~-_C~~~middotmiddotmiddotmiddotmiddot-l~~~~middot-
16 Interim Rate
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component -~~-----------
2 I Plus Property Interim Rate Component
-~-~
39429
0000
39429
0000
0000
319916
0000
319916
0000
359345
0000
0000
376048
0000
0000
376048
3714
0000
-~------- ----t---- -------------- - -----middot--middot-----~----I
11503 6962
25 Medicaid Utilization 10000 9983
000 000
000
nted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
------------------- ---
---l
Florida Agency For Health Care Administrationf- _0_2_8_0_1_5_10_0_-_20_1_1_1_1o_-1
Office ofMedicaid Cost Reimbursement Planning and Analysis --_R_I_2_3_8_2_0_I_N_M_3_5_8_A_9
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 4 1621 NE Waldo Road Gainesville FL 32609
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Interim
Total Interim
Interim Component
Settlement Based on Costs
X Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Provider Number 028015100 Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
23518 23820 100112011
35393 35849 100112011
x Prospective
X Total Prospective Prospective Adjusted for New Cost
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit Prospective Portion
WRydellSamuel ~ Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
PnntPfl Im OQ()RIOll ltIt ORltIIR TTina vprirm 4 1 hv 17111 Rlt(~h TDFZGVT
I
Florida Agency For Health Care AdministrationlL--___O_2_8_01_S_1_0_0__---I
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
Provider Name TACACHALE 4 Cost Report Entered by Squire Yashica Provider Numbel 28015100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 59
II Column B---middot-~~~~tl-1ColumnA Residential I[Non-Ambulatory Medical Institutional __ +L______Lj_____ __ _____0_____ - _ _ ~_~__
IA Allocation of Expenses (excluding B ampcJ 1 Resident Days
2 Operating Expenses Component A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
I 900212520
431992431992
332844332844 3433434334 0000000000
21522
472741 425478
o 31
929733
490554 225792
o ------------_
716346 73893
o
i B Direct Care Expense I Staffmg 050 100 2 Total Staffmg Required 626000 900200 1526200 3 Staffing Percent 410169047 589830953 10000 4 Allocation of Direct Care 148918599 214147801 363066400
23788915 Direct Care Expense Per Diem 1189446
C Additional Services Expense 1 Medicaid Inpatient Days 2150112520 8981
223725 5857012 Additional Services 361976 3 Additional Services Exp amp Per Diem 28911 249109
=-~=~~ =-======1=======-=+===middot=middot=========F======-=middotmiddot D Medicaid Per Diem Cost
9297334319921 Operating Component 431992 2960844 49327112 Resident Care Component 1811407
73893343343 Property Cost Component 34334 o4 ROElUse Allow Component 00000
5 Total Cost Per Diem 2277733 3427170
TACACHALE 4 OwnershipState[l]
Florida Agency For Health Care Administration I 028015100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23820
ICFMR-DD Calculation Sheet NM 35849 Rates Effective 100 1120 II through 033112012
~----------~----------- __----_ bull_-_____bull-----__--_shyi ResidentialInstitutional Non-Ambulatory Medical
Base Semester
0000000
15 Prospective Rate Line II x Inflation (104648267)
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
12520 ~----~---- shy
10000
0000
0000 0000
0000
0000
355054
3433 0000
000000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationl--0_2_8_01_6_0_0_0_-_2_0_11_I_I0_1 Office of Medicaid Cost Reimbursement Planning and Analysis I--_R_I_2_3_4_3_8__N_1_I_3_4_2_1_9--J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND l1ARIANNA 3 3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
028016000 091082011 063012010 Unaudited [3]
New Effective Rate Date
23145 23438 10012011
33788 34219 100112011
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ~___ _~~~__bull __~__________bull _~ _~_~~__________~_bullbull_Lbullbull~_____ ~~__
IBasis-__ ~----~-~--- -~~------~~-------- ----~-- ----------- --__--
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion Field Audit - Interim Portion
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Horne Office
For Infonnation only - No Change in rate
Florida Agency For Health Care Administration ___0_2_80_1_6_0_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name SUNLAND MARIANNA 3 Cost Report Entered by Squire Yashica Provider Numbel 28016000 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 shy 063012010 Date 982011 Days In Reporting Period 365
Number of Beds 44
ColumnA Residential Institutional
12849
~~-~-----T---~~-------- ~-
----C-ol-umn--B---- i I Column C Total Ii Non-Ambulatory Medical
2718 15567
237433
iA Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
~ Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
389532
551093 63945
100 271800
297292863 56006229
2060568
389532 1789055
63945 00000
--------
2242532
389532
551093 63945 00000
2718 56434
207631
389532 2819291
63945
336480 o
419225 17928
_____ 420l3~_ 857886 99543
o
914250 10000
188387400
14777 306873
606385 3048633
99543 o
Florida Agency For Health Care Administration 028016000 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23438
ICFMR-DD Calculation Sheet NM 34219 Rates Effective 100112011 through 033112012
SUNLAND MARIANNA 3 OwnershipState[1 J
Base Semester
j------- +--------+--- ---- ---------- -+---- --~_i-- -~------~
1000025 Medicaid Utilization 9385
000 000
000
inted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationf--0_2_8_0_24_1_0_0_-_2_0_11_1_10-1 Office ofMedicaid Cost Reimbursement Planning and Analysis ~_R_I_3_3_5_2_6_I_N_M_4_7_8_7_6----l
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 5 1621 NB Waldo Road Gainesville FL 32609
Provider Number Date
FYE
Audit Status
028024100
091082011 06302010 Unaudited [3]
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Current Rate
33110
47277
New Rate
33526
47876
Effective Date
100112011
1010112011
IRateType-~--~ Interim
Total Interim
Interim Component
Settlement Based on Costs
x Prospective
X Total Prospective
Prospective Adjusted for New Cost
Budget
X Unaudited Costs
Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit - Prospective Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
D t~rl A )OI)Qf)Oll t (Qmiddot1middot1 Q TTjnn cmiddot lt11 h 17111 Rltgtth rnmiddotJ7rVT
-----
Florida Agency For Health Care Administration-I ___0_28_0_2_4_1_00__--- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFIMR-DD Profile Sheet Rate P eriod( s) 042011 to 1012011
Provider Name TACACHALE 5 Provider Numbel 28024100 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 40
ColumnA ColumnB Non-Ambulatory Medical
Column C Total --___----IjI Residential Institutional
4440 2634 7074
170516 426135
o 31563
888061 888061 628214
163155 252460
o 587525 587525 415615 122108 122108 86379 00000 00000 o
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Stafflllg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense I Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
050 222000
457354759 59893807
1348960
262414
100 263400
542645241 71063193
2697919
2517 71674
284760
888061 3570204
122108
4580372
485400 10000
130957000
6428 174304
628214 1899489
86379 o
2614082- ~-- ~~-~~
Florida Agency For Health Care Administration I 028024100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 33526
ICFMR-DD Calculation Sheet NM 47876 Rates Effective 1 lI20 II through 033l120 12
TACACHALE 5 Ownership State [ 1]
I Fiscal Year Begin ----- __ _----l____
I Current Cost Report i 070112009
I Prior Cost Report LI
-------_-- ---- -~-~----- ~---~~~--=-~--
-- --------- --------j----------------1Fiscal Year End Audit Status Base Semester I
06302010 Unaudited [3] -------l I
__~~ ~~__~_~1 ____ ~~_~ ___________ J
Period Base
3 Line I x - _ -----__ -- - --~--
4 Current Period Cost
5 Incentive Basis
15 Prospective Rate Line I I x Inflation (104648267)
16 Interim Rate ~---------~-----------------
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component ---____-___ --__-shy ---- shy
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
---------- shy
88806 88806 357020
0000 0000 0000
88806 219890 308696 88806 357020
0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
0000 0000 0000 0000
0000 0000 I 0000 0000
------- --------
445826
0000
0000
33526 47876 2517
------1-----middot_--_middot_---------- shy
4440 2634 8809 955625 Medicaid Utilization
000
000
inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administrationl--0_2_8_02_6_7_0_0_-_2_0_11_I_I0---l Office ofMedicaid Cost Reimbursement Planning and Analysis --_RI_3_2_9_8_2_I_N_TM_4_6_5__4_S-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 7 Provider Number 028026700 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 063012010
Audit Status Unaudited [3]
Provider Type ICFMR~DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 32563 32982 100112011
8 Non-Ambulatory amp 9 Medical 45952 46545 100112011
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
x Unaudited Costs
Field Audited Costs Field Audit Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
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
Printpj rn flQf(llV)fl11 M fll(middotlmiddot1 l( nina vprltrm 4 1 hv 17111 Rth TnmiddotF7CiVT
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
I
028006200 - 2011110 Florida Agency For Health Care Administration RI25693 1 NM39517 shyOffice of Medicaid Cost Reimbursement Planning and Analysis
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 2
1621 N E Waldo Road Gainesville FL 32609
Provider Type ICFMR-DD
Level of Care 7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
25368
028006200 0910812011 06302010 Unaudited [3]
New Effective Rate Date
25693 100112011
39014 39517 100112011
Interim x Prospective
Total Interim Interim Component
X Total Prospective Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
X Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Di stribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit Prospective Portion
w Rydell Samuel r Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
Florida Agency For Health Care AdministrationL-r___0_2_8_00_6_2_0_0___ Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 10201]
Provider Name TACACHALE 2 Cost Report Entered by Squire Yashica Provider Numbel 28006200 Rate Semester October 20 II Audit Status Unaudited [3] Cost Report 07012009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 90
I
Column C Total
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem i ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
18449
461030 38424 00000
050 922450
356605779 239302912
1297105
18436 439401
16643
422004
461030 38424 00000
100 1664300 643394221
431754388 2594210
16543 433774
262210
873770 565260
o 41
1480898
804464 813384
o-______shy
1617848 134836
o
2586750 10000
1057300
34979 873175
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
422004 1996474
38424 00000
422004 3317451
38424
1480898 9201596
134836 o
------------~ --------~
5 Total Cost Per Diem 2456902 _7Zmiddot_879 ~_0817~31L__
Florida Agency For Health Care Administration I 028006200 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25693
ICFMR-DD Calculation Sheet NM 39517 Rates Effective 1001120 II through 033112012
TACACHALE 2 OwnershipState[l]
i ~~~~~t~ie~~~of~~~~~II~~~~~~~1~ndt~nau~it~~~n~-f~~ s~m~~q c_~___ ~_____________ ~_________~~_~-~_~~~~_~~~~__~~~_~_~__~_~--~_~_~___ _____ _______ ~_____ _
1 Prior Period Base
Inflation Factor 000000000 r-=-=C-==-----==---=-~Lc_________________________________J___________---shy___________________J___
4 Current Period Cost
5 Incentive Basis line 3 - line 4) 0000 bull ~----- -shy ------------t----------r-~-----------
6 Allowed~urrentJgtefl()d Costs~___~___________~~__________r__shy _--4=220=-0+_------shy___-=---__ shy __ +shy ____________ 1 -------=-=----If---=-------=-~r_-------=----I
r~~~___~==~~_~~_~~~~=~~_________f---~O~O-~O~O+_---~-~-~----~O~O~OO--f--~~~-~-----~---~~---+----~~-~ 0000 0000
15 Prospective Rate Line I I x Inflation (104648267) -----+----~-+-
-16 Interim Rate
17 NA
-158-_~-~~IL1l~~_c-~l~l~ ~~~ Rate 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
18449 16643 ~~- -----~-------~---- -----~----~---------~
9993 9940
000
000
rinted on 090820 I I at 085118 Using version 41 by 17111 Batch TDFZGVJ
000
Florida Agency For Health Care Administrationr--0_2_8_00_9_7_0_0_-_2_0_11_I_l0_--I Office of Medicaid Cost Reimbursement Planning and Analysis --_R_I_4_2_6_4_3_I_N_M__6_9_2_8_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND MARIANNA 2 Provider Number 028009700 ---------------shy3700 Williams Drive Date 09082011
Marianna FL 32446 FYE 06302010 Audit Status Unaudited [3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date
7 Institutional 42106 42643 100112011
8 Non-Ambulatory amp 9 Medical 68404 69283 100112011
~~-- ----~--- ~
iRate Type I Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs _~_bull_ __~_ ~_bull J
Budget Desk Audited Costs
X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit Interim Portion ~~-~--~ ~------~bull - ~---- - ---~- - -------- - ~------__ __---__
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Florida Agency For Health Care AdministrationL-I___O_2_8_00_9_7_0_0__---l
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
RatePeriod(s) 042011 to 102011
Provider Name SUNLAND MARIANNA 2 Provider Numbel 28009700 Audit Status Unaudited [3] Date 982011
~-~~~~~~-~----- ~- ~~---- ~~ --~- shy
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 121
~~--~-column-B-~-~COIU=~TotalColumnA Residential II Non-Ambulatory Medical Institutional
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
~~-~~+---3-1-4-2-2l1 ~- 057-shy - - -- shy 32479
636490
515567 82350 00000
050 1571100
936963263 799847029
2545500
30327 905763
298666
636490 3359733
82350 00000
4078574
636490
515567 82350 00000
100 105700 63036737
53811871 5691000
1057 31589
298855
636490 5905423
82350
6624263
1075906 904102
o ~~_~~l4
2067257
951057 48171
__~675~2_ 1674511
267466 o
1676800 10000
853658900
31384 937352
2067257 11148452
267466 o
13483175
Florida Agency For Health Care Administration I 028009700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 42643
ICFMR-DD Calculation Sheet NM 69283 Rates Effective 1010 l20 11 through 033112012
SUNLAND MARIANNA 2 OvvnershipState[l]
Inflation Factor 000000000
---~-shy
6
31422 9652
63649 590542 654191
0000 0000
63649 i 590542 654191
0000 0000 0000
0000 0000 0000
1057-shy ----- -------~~- -
10000
000 000
000
~inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
--
Florida Agency For Health Care Administrationl-0_28Ol_19OO_-2Ol1lO=-j
Office ofMedicaid Cost Reimbursement Planning and Analysis I-_R_I_2_4_4_0-7_I-N--M~3--7-976--1 2727 Mahan Drive-Mail Stop 21
Tallahassee Florida 32308
TACACHALE 3 Provider Number 028011900 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 06302010
Audit Status Unaudited [3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date
7 Institutional 24099 24407 10012011
8 Non-Ambulatory amp 9 Medical 37493 37976 100112011
r=--c~--~-- - --- ---- ---------- -------- ~----~-- - ---- ------shy
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
i-BaSIS I Budget
X Unaudited Costs
Field Audited Costs Field Audit - Interiin Portion
Distribution Contract Management DPODS - DCF (3) Home Office
Desk Audited Costs
Desk Audit - Interim Portion
Desk Audit - Prospective Portion
w Rydell SueJ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
_______
Florida Agency For Health Care Administrationll-__O_28_0_1_1_9_00__---l
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 3 Provider NumbeJ 28011900 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
5 ROEUse Per Diem
B Direct Care Expense 1 Staffing
2 Total Staffmg Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
j C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 49
ColumnA ColumnB Residential Non-Ambulatory Medical Institutional
11503 6962
Column C Total
18465
430542 276993
o 05~
394287
368227 37137 00000
050 575150
452393125 149587089
1300418
11503 269061
233905 __-------
394287 1902551
37137 00000
2333974
394287
368227 37137 00000
100 696200
547606875 181070211
2600836
6950 159916
230095
394287 3199159
37137
3630582 --- ------- shy~
728051
424805 255127
o 679932
68573 o
1271350 10000
330657300
18453 428977
728051 4415482
68573 o
Florida Agency For Health Care Administration I 028011900 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 24407
ICFMR-DD Calculation Sheet NM 37976 Rates Effective 100112011 through 033112012
TACACHALE 3 OvvnershipState[l]
3 Line 1 x
4 Current Period Cost
5 Incentive Basis
of line 3 or 4
15 Prospective Rate Line II x Inflation (104648267)
39429
0000
190255 229684
0000 0000
0000
-~---~--~middot~~-_C~~~middotmiddotmiddotmiddotmiddot-l~~~~middot-
16 Interim Rate
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component -~~-----------
2 I Plus Property Interim Rate Component
-~-~
39429
0000
39429
0000
0000
319916
0000
319916
0000
359345
0000
0000
376048
0000
0000
376048
3714
0000
-~------- ----t---- -------------- - -----middot--middot-----~----I
11503 6962
25 Medicaid Utilization 10000 9983
000 000
000
nted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
------------------- ---
---l
Florida Agency For Health Care Administrationf- _0_2_8_0_1_5_10_0_-_20_1_1_1_1o_-1
Office ofMedicaid Cost Reimbursement Planning and Analysis --_R_I_2_3_8_2_0_I_N_M_3_5_8_A_9
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 4 1621 NE Waldo Road Gainesville FL 32609
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Interim
Total Interim
Interim Component
Settlement Based on Costs
X Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Provider Number 028015100 Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
23518 23820 100112011
35393 35849 100112011
x Prospective
X Total Prospective Prospective Adjusted for New Cost
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit Prospective Portion
WRydellSamuel ~ Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
PnntPfl Im OQ()RIOll ltIt ORltIIR TTina vprirm 4 1 hv 17111 Rlt(~h TDFZGVT
I
Florida Agency For Health Care AdministrationlL--___O_2_8_01_S_1_0_0__---I
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
Provider Name TACACHALE 4 Cost Report Entered by Squire Yashica Provider Numbel 28015100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 59
II Column B---middot-~~~~tl-1ColumnA Residential I[Non-Ambulatory Medical Institutional __ +L______Lj_____ __ _____0_____ - _ _ ~_~__
IA Allocation of Expenses (excluding B ampcJ 1 Resident Days
2 Operating Expenses Component A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
I 900212520
431992431992
332844332844 3433434334 0000000000
21522
472741 425478
o 31
929733
490554 225792
o ------------_
716346 73893
o
i B Direct Care Expense I Staffmg 050 100 2 Total Staffmg Required 626000 900200 1526200 3 Staffing Percent 410169047 589830953 10000 4 Allocation of Direct Care 148918599 214147801 363066400
23788915 Direct Care Expense Per Diem 1189446
C Additional Services Expense 1 Medicaid Inpatient Days 2150112520 8981
223725 5857012 Additional Services 361976 3 Additional Services Exp amp Per Diem 28911 249109
=-~=~~ =-======1=======-=+===middot=middot=========F======-=middotmiddot D Medicaid Per Diem Cost
9297334319921 Operating Component 431992 2960844 49327112 Resident Care Component 1811407
73893343343 Property Cost Component 34334 o4 ROElUse Allow Component 00000
5 Total Cost Per Diem 2277733 3427170
TACACHALE 4 OwnershipState[l]
Florida Agency For Health Care Administration I 028015100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23820
ICFMR-DD Calculation Sheet NM 35849 Rates Effective 100 1120 II through 033112012
~----------~----------- __----_ bull_-_____bull-----__--_shyi ResidentialInstitutional Non-Ambulatory Medical
Base Semester
0000000
15 Prospective Rate Line II x Inflation (104648267)
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
12520 ~----~---- shy
10000
0000
0000 0000
0000
0000
355054
3433 0000
000000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationl--0_2_8_01_6_0_0_0_-_2_0_11_I_I0_1 Office of Medicaid Cost Reimbursement Planning and Analysis I--_R_I_2_3_4_3_8__N_1_I_3_4_2_1_9--J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND l1ARIANNA 3 3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
028016000 091082011 063012010 Unaudited [3]
New Effective Rate Date
23145 23438 10012011
33788 34219 100112011
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ~___ _~~~__bull __~__________bull _~ _~_~~__________~_bullbull_Lbullbull~_____ ~~__
IBasis-__ ~----~-~--- -~~------~~-------- ----~-- ----------- --__--
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion Field Audit - Interim Portion
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Horne Office
For Infonnation only - No Change in rate
Florida Agency For Health Care Administration ___0_2_80_1_6_0_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name SUNLAND MARIANNA 3 Cost Report Entered by Squire Yashica Provider Numbel 28016000 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 shy 063012010 Date 982011 Days In Reporting Period 365
Number of Beds 44
ColumnA Residential Institutional
12849
~~-~-----T---~~-------- ~-
----C-ol-umn--B---- i I Column C Total Ii Non-Ambulatory Medical
2718 15567
237433
iA Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
~ Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
389532
551093 63945
100 271800
297292863 56006229
2060568
389532 1789055
63945 00000
--------
2242532
389532
551093 63945 00000
2718 56434
207631
389532 2819291
63945
336480 o
419225 17928
_____ 420l3~_ 857886 99543
o
914250 10000
188387400
14777 306873
606385 3048633
99543 o
Florida Agency For Health Care Administration 028016000 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23438
ICFMR-DD Calculation Sheet NM 34219 Rates Effective 100112011 through 033112012
SUNLAND MARIANNA 3 OwnershipState[1 J
Base Semester
j------- +--------+--- ---- ---------- -+---- --~_i-- -~------~
1000025 Medicaid Utilization 9385
000 000
000
inted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationf--0_2_8_0_24_1_0_0_-_2_0_11_1_10-1 Office ofMedicaid Cost Reimbursement Planning and Analysis ~_R_I_3_3_5_2_6_I_N_M_4_7_8_7_6----l
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 5 1621 NB Waldo Road Gainesville FL 32609
Provider Number Date
FYE
Audit Status
028024100
091082011 06302010 Unaudited [3]
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Current Rate
33110
47277
New Rate
33526
47876
Effective Date
100112011
1010112011
IRateType-~--~ Interim
Total Interim
Interim Component
Settlement Based on Costs
x Prospective
X Total Prospective
Prospective Adjusted for New Cost
Budget
X Unaudited Costs
Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit - Prospective Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
D t~rl A )OI)Qf)Oll t (Qmiddot1middot1 Q TTjnn cmiddot lt11 h 17111 Rltgtth rnmiddotJ7rVT
-----
Florida Agency For Health Care Administration-I ___0_28_0_2_4_1_00__--- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFIMR-DD Profile Sheet Rate P eriod( s) 042011 to 1012011
Provider Name TACACHALE 5 Provider Numbel 28024100 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 40
ColumnA ColumnB Non-Ambulatory Medical
Column C Total --___----IjI Residential Institutional
4440 2634 7074
170516 426135
o 31563
888061 888061 628214
163155 252460
o 587525 587525 415615 122108 122108 86379 00000 00000 o
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Stafflllg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense I Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
050 222000
457354759 59893807
1348960
262414
100 263400
542645241 71063193
2697919
2517 71674
284760
888061 3570204
122108
4580372
485400 10000
130957000
6428 174304
628214 1899489
86379 o
2614082- ~-- ~~-~~
Florida Agency For Health Care Administration I 028024100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 33526
ICFMR-DD Calculation Sheet NM 47876 Rates Effective 1 lI20 II through 033l120 12
TACACHALE 5 Ownership State [ 1]
I Fiscal Year Begin ----- __ _----l____
I Current Cost Report i 070112009
I Prior Cost Report LI
-------_-- ---- -~-~----- ~---~~~--=-~--
-- --------- --------j----------------1Fiscal Year End Audit Status Base Semester I
06302010 Unaudited [3] -------l I
__~~ ~~__~_~1 ____ ~~_~ ___________ J
Period Base
3 Line I x - _ -----__ -- - --~--
4 Current Period Cost
5 Incentive Basis
15 Prospective Rate Line I I x Inflation (104648267)
16 Interim Rate ~---------~-----------------
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component ---____-___ --__-shy ---- shy
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
---------- shy
88806 88806 357020
0000 0000 0000
88806 219890 308696 88806 357020
0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
0000 0000 0000 0000
0000 0000 I 0000 0000
------- --------
445826
0000
0000
33526 47876 2517
------1-----middot_--_middot_---------- shy
4440 2634 8809 955625 Medicaid Utilization
000
000
inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administrationl--0_2_8_02_6_7_0_0_-_2_0_11_I_I0---l Office ofMedicaid Cost Reimbursement Planning and Analysis --_RI_3_2_9_8_2_I_N_TM_4_6_5__4_S-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 7 Provider Number 028026700 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 063012010
Audit Status Unaudited [3]
Provider Type ICFMR~DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 32563 32982 100112011
8 Non-Ambulatory amp 9 Medical 45952 46545 100112011
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
x Unaudited Costs
Field Audited Costs Field Audit Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
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
Printpj rn flQf(llV)fl11 M fll(middotlmiddot1 l( nina vprltrm 4 1 hv 17111 Rth TnmiddotF7CiVT
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Florida Agency For Health Care AdministrationL-r___0_2_8_00_6_2_0_0___ Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 10201]
Provider Name TACACHALE 2 Cost Report Entered by Squire Yashica Provider Numbel 28006200 Rate Semester October 20 II Audit Status Unaudited [3] Cost Report 07012009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 90
I
Column C Total
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem i ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
18449
461030 38424 00000
050 922450
356605779 239302912
1297105
18436 439401
16643
422004
461030 38424 00000
100 1664300 643394221
431754388 2594210
16543 433774
262210
873770 565260
o 41
1480898
804464 813384
o-______shy
1617848 134836
o
2586750 10000
1057300
34979 873175
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
422004 1996474
38424 00000
422004 3317451
38424
1480898 9201596
134836 o
------------~ --------~
5 Total Cost Per Diem 2456902 _7Zmiddot_879 ~_0817~31L__
Florida Agency For Health Care Administration I 028006200 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25693
ICFMR-DD Calculation Sheet NM 39517 Rates Effective 1001120 II through 033112012
TACACHALE 2 OwnershipState[l]
i ~~~~~t~ie~~~of~~~~~II~~~~~~~1~ndt~nau~it~~~n~-f~~ s~m~~q c_~___ ~_____________ ~_________~~_~-~_~~~~_~~~~__~~~_~_~__~_~--~_~_~___ _____ _______ ~_____ _
1 Prior Period Base
Inflation Factor 000000000 r-=-=C-==-----==---=-~Lc_________________________________J___________---shy___________________J___
4 Current Period Cost
5 Incentive Basis line 3 - line 4) 0000 bull ~----- -shy ------------t----------r-~-----------
6 Allowed~urrentJgtefl()d Costs~___~___________~~__________r__shy _--4=220=-0+_------shy___-=---__ shy __ +shy ____________ 1 -------=-=----If---=-------=-~r_-------=----I
r~~~___~==~~_~~_~~~~=~~_________f---~O~O-~O~O+_---~-~-~----~O~O~OO--f--~~~-~-----~---~~---+----~~-~ 0000 0000
15 Prospective Rate Line I I x Inflation (104648267) -----+----~-+-
-16 Interim Rate
17 NA
-158-_~-~~IL1l~~_c-~l~l~ ~~~ Rate 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
18449 16643 ~~- -----~-------~---- -----~----~---------~
9993 9940
000
000
rinted on 090820 I I at 085118 Using version 41 by 17111 Batch TDFZGVJ
000
Florida Agency For Health Care Administrationr--0_2_8_00_9_7_0_0_-_2_0_11_I_l0_--I Office of Medicaid Cost Reimbursement Planning and Analysis --_R_I_4_2_6_4_3_I_N_M__6_9_2_8_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND MARIANNA 2 Provider Number 028009700 ---------------shy3700 Williams Drive Date 09082011
Marianna FL 32446 FYE 06302010 Audit Status Unaudited [3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date
7 Institutional 42106 42643 100112011
8 Non-Ambulatory amp 9 Medical 68404 69283 100112011
~~-- ----~--- ~
iRate Type I Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs _~_bull_ __~_ ~_bull J
Budget Desk Audited Costs
X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit Interim Portion ~~-~--~ ~------~bull - ~---- - ---~- - -------- - ~------__ __---__
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Florida Agency For Health Care AdministrationL-I___O_2_8_00_9_7_0_0__---l
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
RatePeriod(s) 042011 to 102011
Provider Name SUNLAND MARIANNA 2 Provider Numbel 28009700 Audit Status Unaudited [3] Date 982011
~-~~~~~~-~----- ~- ~~---- ~~ --~- shy
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 121
~~--~-column-B-~-~COIU=~TotalColumnA Residential II Non-Ambulatory Medical Institutional
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
~~-~~+---3-1-4-2-2l1 ~- 057-shy - - -- shy 32479
636490
515567 82350 00000
050 1571100
936963263 799847029
2545500
30327 905763
298666
636490 3359733
82350 00000
4078574
636490
515567 82350 00000
100 105700 63036737
53811871 5691000
1057 31589
298855
636490 5905423
82350
6624263
1075906 904102
o ~~_~~l4
2067257
951057 48171
__~675~2_ 1674511
267466 o
1676800 10000
853658900
31384 937352
2067257 11148452
267466 o
13483175
Florida Agency For Health Care Administration I 028009700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 42643
ICFMR-DD Calculation Sheet NM 69283 Rates Effective 1010 l20 11 through 033112012
SUNLAND MARIANNA 2 OvvnershipState[l]
Inflation Factor 000000000
---~-shy
6
31422 9652
63649 590542 654191
0000 0000
63649 i 590542 654191
0000 0000 0000
0000 0000 0000
1057-shy ----- -------~~- -
10000
000 000
000
~inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
--
Florida Agency For Health Care Administrationl-0_28Ol_19OO_-2Ol1lO=-j
Office ofMedicaid Cost Reimbursement Planning and Analysis I-_R_I_2_4_4_0-7_I-N--M~3--7-976--1 2727 Mahan Drive-Mail Stop 21
Tallahassee Florida 32308
TACACHALE 3 Provider Number 028011900 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 06302010
Audit Status Unaudited [3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date
7 Institutional 24099 24407 10012011
8 Non-Ambulatory amp 9 Medical 37493 37976 100112011
r=--c~--~-- - --- ---- ---------- -------- ~----~-- - ---- ------shy
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
i-BaSIS I Budget
X Unaudited Costs
Field Audited Costs Field Audit - Interiin Portion
Distribution Contract Management DPODS - DCF (3) Home Office
Desk Audited Costs
Desk Audit - Interim Portion
Desk Audit - Prospective Portion
w Rydell SueJ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
_______
Florida Agency For Health Care Administrationll-__O_28_0_1_1_9_00__---l
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 3 Provider NumbeJ 28011900 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
5 ROEUse Per Diem
B Direct Care Expense 1 Staffing
2 Total Staffmg Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
j C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 49
ColumnA ColumnB Residential Non-Ambulatory Medical Institutional
11503 6962
Column C Total
18465
430542 276993
o 05~
394287
368227 37137 00000
050 575150
452393125 149587089
1300418
11503 269061
233905 __-------
394287 1902551
37137 00000
2333974
394287
368227 37137 00000
100 696200
547606875 181070211
2600836
6950 159916
230095
394287 3199159
37137
3630582 --- ------- shy~
728051
424805 255127
o 679932
68573 o
1271350 10000
330657300
18453 428977
728051 4415482
68573 o
Florida Agency For Health Care Administration I 028011900 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 24407
ICFMR-DD Calculation Sheet NM 37976 Rates Effective 100112011 through 033112012
TACACHALE 3 OvvnershipState[l]
3 Line 1 x
4 Current Period Cost
5 Incentive Basis
of line 3 or 4
15 Prospective Rate Line II x Inflation (104648267)
39429
0000
190255 229684
0000 0000
0000
-~---~--~middot~~-_C~~~middotmiddotmiddotmiddotmiddot-l~~~~middot-
16 Interim Rate
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component -~~-----------
2 I Plus Property Interim Rate Component
-~-~
39429
0000
39429
0000
0000
319916
0000
319916
0000
359345
0000
0000
376048
0000
0000
376048
3714
0000
-~------- ----t---- -------------- - -----middot--middot-----~----I
11503 6962
25 Medicaid Utilization 10000 9983
000 000
000
nted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
------------------- ---
---l
Florida Agency For Health Care Administrationf- _0_2_8_0_1_5_10_0_-_20_1_1_1_1o_-1
Office ofMedicaid Cost Reimbursement Planning and Analysis --_R_I_2_3_8_2_0_I_N_M_3_5_8_A_9
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 4 1621 NE Waldo Road Gainesville FL 32609
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Interim
Total Interim
Interim Component
Settlement Based on Costs
X Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Provider Number 028015100 Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
23518 23820 100112011
35393 35849 100112011
x Prospective
X Total Prospective Prospective Adjusted for New Cost
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit Prospective Portion
WRydellSamuel ~ Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
PnntPfl Im OQ()RIOll ltIt ORltIIR TTina vprirm 4 1 hv 17111 Rlt(~h TDFZGVT
I
Florida Agency For Health Care AdministrationlL--___O_2_8_01_S_1_0_0__---I
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
Provider Name TACACHALE 4 Cost Report Entered by Squire Yashica Provider Numbel 28015100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 59
II Column B---middot-~~~~tl-1ColumnA Residential I[Non-Ambulatory Medical Institutional __ +L______Lj_____ __ _____0_____ - _ _ ~_~__
IA Allocation of Expenses (excluding B ampcJ 1 Resident Days
2 Operating Expenses Component A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
I 900212520
431992431992
332844332844 3433434334 0000000000
21522
472741 425478
o 31
929733
490554 225792
o ------------_
716346 73893
o
i B Direct Care Expense I Staffmg 050 100 2 Total Staffmg Required 626000 900200 1526200 3 Staffing Percent 410169047 589830953 10000 4 Allocation of Direct Care 148918599 214147801 363066400
23788915 Direct Care Expense Per Diem 1189446
C Additional Services Expense 1 Medicaid Inpatient Days 2150112520 8981
223725 5857012 Additional Services 361976 3 Additional Services Exp amp Per Diem 28911 249109
=-~=~~ =-======1=======-=+===middot=middot=========F======-=middotmiddot D Medicaid Per Diem Cost
9297334319921 Operating Component 431992 2960844 49327112 Resident Care Component 1811407
73893343343 Property Cost Component 34334 o4 ROElUse Allow Component 00000
5 Total Cost Per Diem 2277733 3427170
TACACHALE 4 OwnershipState[l]
Florida Agency For Health Care Administration I 028015100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23820
ICFMR-DD Calculation Sheet NM 35849 Rates Effective 100 1120 II through 033112012
~----------~----------- __----_ bull_-_____bull-----__--_shyi ResidentialInstitutional Non-Ambulatory Medical
Base Semester
0000000
15 Prospective Rate Line II x Inflation (104648267)
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
12520 ~----~---- shy
10000
0000
0000 0000
0000
0000
355054
3433 0000
000000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationl--0_2_8_01_6_0_0_0_-_2_0_11_I_I0_1 Office of Medicaid Cost Reimbursement Planning and Analysis I--_R_I_2_3_4_3_8__N_1_I_3_4_2_1_9--J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND l1ARIANNA 3 3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
028016000 091082011 063012010 Unaudited [3]
New Effective Rate Date
23145 23438 10012011
33788 34219 100112011
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ~___ _~~~__bull __~__________bull _~ _~_~~__________~_bullbull_Lbullbull~_____ ~~__
IBasis-__ ~----~-~--- -~~------~~-------- ----~-- ----------- --__--
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion Field Audit - Interim Portion
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Horne Office
For Infonnation only - No Change in rate
Florida Agency For Health Care Administration ___0_2_80_1_6_0_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name SUNLAND MARIANNA 3 Cost Report Entered by Squire Yashica Provider Numbel 28016000 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 shy 063012010 Date 982011 Days In Reporting Period 365
Number of Beds 44
ColumnA Residential Institutional
12849
~~-~-----T---~~-------- ~-
----C-ol-umn--B---- i I Column C Total Ii Non-Ambulatory Medical
2718 15567
237433
iA Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
~ Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
389532
551093 63945
100 271800
297292863 56006229
2060568
389532 1789055
63945 00000
--------
2242532
389532
551093 63945 00000
2718 56434
207631
389532 2819291
63945
336480 o
419225 17928
_____ 420l3~_ 857886 99543
o
914250 10000
188387400
14777 306873
606385 3048633
99543 o
Florida Agency For Health Care Administration 028016000 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23438
ICFMR-DD Calculation Sheet NM 34219 Rates Effective 100112011 through 033112012
SUNLAND MARIANNA 3 OwnershipState[1 J
Base Semester
j------- +--------+--- ---- ---------- -+---- --~_i-- -~------~
1000025 Medicaid Utilization 9385
000 000
000
inted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationf--0_2_8_0_24_1_0_0_-_2_0_11_1_10-1 Office ofMedicaid Cost Reimbursement Planning and Analysis ~_R_I_3_3_5_2_6_I_N_M_4_7_8_7_6----l
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 5 1621 NB Waldo Road Gainesville FL 32609
Provider Number Date
FYE
Audit Status
028024100
091082011 06302010 Unaudited [3]
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Current Rate
33110
47277
New Rate
33526
47876
Effective Date
100112011
1010112011
IRateType-~--~ Interim
Total Interim
Interim Component
Settlement Based on Costs
x Prospective
X Total Prospective
Prospective Adjusted for New Cost
Budget
X Unaudited Costs
Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit - Prospective Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
D t~rl A )OI)Qf)Oll t (Qmiddot1middot1 Q TTjnn cmiddot lt11 h 17111 Rltgtth rnmiddotJ7rVT
-----
Florida Agency For Health Care Administration-I ___0_28_0_2_4_1_00__--- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFIMR-DD Profile Sheet Rate P eriod( s) 042011 to 1012011
Provider Name TACACHALE 5 Provider Numbel 28024100 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 40
ColumnA ColumnB Non-Ambulatory Medical
Column C Total --___----IjI Residential Institutional
4440 2634 7074
170516 426135
o 31563
888061 888061 628214
163155 252460
o 587525 587525 415615 122108 122108 86379 00000 00000 o
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Stafflllg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense I Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
050 222000
457354759 59893807
1348960
262414
100 263400
542645241 71063193
2697919
2517 71674
284760
888061 3570204
122108
4580372
485400 10000
130957000
6428 174304
628214 1899489
86379 o
2614082- ~-- ~~-~~
Florida Agency For Health Care Administration I 028024100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 33526
ICFMR-DD Calculation Sheet NM 47876 Rates Effective 1 lI20 II through 033l120 12
TACACHALE 5 Ownership State [ 1]
I Fiscal Year Begin ----- __ _----l____
I Current Cost Report i 070112009
I Prior Cost Report LI
-------_-- ---- -~-~----- ~---~~~--=-~--
-- --------- --------j----------------1Fiscal Year End Audit Status Base Semester I
06302010 Unaudited [3] -------l I
__~~ ~~__~_~1 ____ ~~_~ ___________ J
Period Base
3 Line I x - _ -----__ -- - --~--
4 Current Period Cost
5 Incentive Basis
15 Prospective Rate Line I I x Inflation (104648267)
16 Interim Rate ~---------~-----------------
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component ---____-___ --__-shy ---- shy
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
---------- shy
88806 88806 357020
0000 0000 0000
88806 219890 308696 88806 357020
0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
0000 0000 0000 0000
0000 0000 I 0000 0000
------- --------
445826
0000
0000
33526 47876 2517
------1-----middot_--_middot_---------- shy
4440 2634 8809 955625 Medicaid Utilization
000
000
inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administrationl--0_2_8_02_6_7_0_0_-_2_0_11_I_I0---l Office ofMedicaid Cost Reimbursement Planning and Analysis --_RI_3_2_9_8_2_I_N_TM_4_6_5__4_S-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 7 Provider Number 028026700 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 063012010
Audit Status Unaudited [3]
Provider Type ICFMR~DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 32563 32982 100112011
8 Non-Ambulatory amp 9 Medical 45952 46545 100112011
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
x Unaudited Costs
Field Audited Costs Field Audit Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
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
Printpj rn flQf(llV)fl11 M fll(middotlmiddot1 l( nina vprltrm 4 1 hv 17111 Rth TnmiddotF7CiVT
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Florida Agency For Health Care Administration I 028006200 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25693
ICFMR-DD Calculation Sheet NM 39517 Rates Effective 1001120 II through 033112012
TACACHALE 2 OwnershipState[l]
i ~~~~~t~ie~~~of~~~~~II~~~~~~~1~ndt~nau~it~~~n~-f~~ s~m~~q c_~___ ~_____________ ~_________~~_~-~_~~~~_~~~~__~~~_~_~__~_~--~_~_~___ _____ _______ ~_____ _
1 Prior Period Base
Inflation Factor 000000000 r-=-=C-==-----==---=-~Lc_________________________________J___________---shy___________________J___
4 Current Period Cost
5 Incentive Basis line 3 - line 4) 0000 bull ~----- -shy ------------t----------r-~-----------
6 Allowed~urrentJgtefl()d Costs~___~___________~~__________r__shy _--4=220=-0+_------shy___-=---__ shy __ +shy ____________ 1 -------=-=----If---=-------=-~r_-------=----I
r~~~___~==~~_~~_~~~~=~~_________f---~O~O-~O~O+_---~-~-~----~O~O~OO--f--~~~-~-----~---~~---+----~~-~ 0000 0000
15 Prospective Rate Line I I x Inflation (104648267) -----+----~-+-
-16 Interim Rate
17 NA
-158-_~-~~IL1l~~_c-~l~l~ ~~~ Rate 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
18449 16643 ~~- -----~-------~---- -----~----~---------~
9993 9940
000
000
rinted on 090820 I I at 085118 Using version 41 by 17111 Batch TDFZGVJ
000
Florida Agency For Health Care Administrationr--0_2_8_00_9_7_0_0_-_2_0_11_I_l0_--I Office of Medicaid Cost Reimbursement Planning and Analysis --_R_I_4_2_6_4_3_I_N_M__6_9_2_8_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND MARIANNA 2 Provider Number 028009700 ---------------shy3700 Williams Drive Date 09082011
Marianna FL 32446 FYE 06302010 Audit Status Unaudited [3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date
7 Institutional 42106 42643 100112011
8 Non-Ambulatory amp 9 Medical 68404 69283 100112011
~~-- ----~--- ~
iRate Type I Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs _~_bull_ __~_ ~_bull J
Budget Desk Audited Costs
X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit Interim Portion ~~-~--~ ~------~bull - ~---- - ---~- - -------- - ~------__ __---__
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Florida Agency For Health Care AdministrationL-I___O_2_8_00_9_7_0_0__---l
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
RatePeriod(s) 042011 to 102011
Provider Name SUNLAND MARIANNA 2 Provider Numbel 28009700 Audit Status Unaudited [3] Date 982011
~-~~~~~~-~----- ~- ~~---- ~~ --~- shy
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 121
~~--~-column-B-~-~COIU=~TotalColumnA Residential II Non-Ambulatory Medical Institutional
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
~~-~~+---3-1-4-2-2l1 ~- 057-shy - - -- shy 32479
636490
515567 82350 00000
050 1571100
936963263 799847029
2545500
30327 905763
298666
636490 3359733
82350 00000
4078574
636490
515567 82350 00000
100 105700 63036737
53811871 5691000
1057 31589
298855
636490 5905423
82350
6624263
1075906 904102
o ~~_~~l4
2067257
951057 48171
__~675~2_ 1674511
267466 o
1676800 10000
853658900
31384 937352
2067257 11148452
267466 o
13483175
Florida Agency For Health Care Administration I 028009700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 42643
ICFMR-DD Calculation Sheet NM 69283 Rates Effective 1010 l20 11 through 033112012
SUNLAND MARIANNA 2 OvvnershipState[l]
Inflation Factor 000000000
---~-shy
6
31422 9652
63649 590542 654191
0000 0000
63649 i 590542 654191
0000 0000 0000
0000 0000 0000
1057-shy ----- -------~~- -
10000
000 000
000
~inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
--
Florida Agency For Health Care Administrationl-0_28Ol_19OO_-2Ol1lO=-j
Office ofMedicaid Cost Reimbursement Planning and Analysis I-_R_I_2_4_4_0-7_I-N--M~3--7-976--1 2727 Mahan Drive-Mail Stop 21
Tallahassee Florida 32308
TACACHALE 3 Provider Number 028011900 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 06302010
Audit Status Unaudited [3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date
7 Institutional 24099 24407 10012011
8 Non-Ambulatory amp 9 Medical 37493 37976 100112011
r=--c~--~-- - --- ---- ---------- -------- ~----~-- - ---- ------shy
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
i-BaSIS I Budget
X Unaudited Costs
Field Audited Costs Field Audit - Interiin Portion
Distribution Contract Management DPODS - DCF (3) Home Office
Desk Audited Costs
Desk Audit - Interim Portion
Desk Audit - Prospective Portion
w Rydell SueJ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
_______
Florida Agency For Health Care Administrationll-__O_28_0_1_1_9_00__---l
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 3 Provider NumbeJ 28011900 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
5 ROEUse Per Diem
B Direct Care Expense 1 Staffing
2 Total Staffmg Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
j C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 49
ColumnA ColumnB Residential Non-Ambulatory Medical Institutional
11503 6962
Column C Total
18465
430542 276993
o 05~
394287
368227 37137 00000
050 575150
452393125 149587089
1300418
11503 269061
233905 __-------
394287 1902551
37137 00000
2333974
394287
368227 37137 00000
100 696200
547606875 181070211
2600836
6950 159916
230095
394287 3199159
37137
3630582 --- ------- shy~
728051
424805 255127
o 679932
68573 o
1271350 10000
330657300
18453 428977
728051 4415482
68573 o
Florida Agency For Health Care Administration I 028011900 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 24407
ICFMR-DD Calculation Sheet NM 37976 Rates Effective 100112011 through 033112012
TACACHALE 3 OvvnershipState[l]
3 Line 1 x
4 Current Period Cost
5 Incentive Basis
of line 3 or 4
15 Prospective Rate Line II x Inflation (104648267)
39429
0000
190255 229684
0000 0000
0000
-~---~--~middot~~-_C~~~middotmiddotmiddotmiddotmiddot-l~~~~middot-
16 Interim Rate
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component -~~-----------
2 I Plus Property Interim Rate Component
-~-~
39429
0000
39429
0000
0000
319916
0000
319916
0000
359345
0000
0000
376048
0000
0000
376048
3714
0000
-~------- ----t---- -------------- - -----middot--middot-----~----I
11503 6962
25 Medicaid Utilization 10000 9983
000 000
000
nted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
------------------- ---
---l
Florida Agency For Health Care Administrationf- _0_2_8_0_1_5_10_0_-_20_1_1_1_1o_-1
Office ofMedicaid Cost Reimbursement Planning and Analysis --_R_I_2_3_8_2_0_I_N_M_3_5_8_A_9
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 4 1621 NE Waldo Road Gainesville FL 32609
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Interim
Total Interim
Interim Component
Settlement Based on Costs
X Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Provider Number 028015100 Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
23518 23820 100112011
35393 35849 100112011
x Prospective
X Total Prospective Prospective Adjusted for New Cost
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit Prospective Portion
WRydellSamuel ~ Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
PnntPfl Im OQ()RIOll ltIt ORltIIR TTina vprirm 4 1 hv 17111 Rlt(~h TDFZGVT
I
Florida Agency For Health Care AdministrationlL--___O_2_8_01_S_1_0_0__---I
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
Provider Name TACACHALE 4 Cost Report Entered by Squire Yashica Provider Numbel 28015100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 59
II Column B---middot-~~~~tl-1ColumnA Residential I[Non-Ambulatory Medical Institutional __ +L______Lj_____ __ _____0_____ - _ _ ~_~__
IA Allocation of Expenses (excluding B ampcJ 1 Resident Days
2 Operating Expenses Component A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
I 900212520
431992431992
332844332844 3433434334 0000000000
21522
472741 425478
o 31
929733
490554 225792
o ------------_
716346 73893
o
i B Direct Care Expense I Staffmg 050 100 2 Total Staffmg Required 626000 900200 1526200 3 Staffing Percent 410169047 589830953 10000 4 Allocation of Direct Care 148918599 214147801 363066400
23788915 Direct Care Expense Per Diem 1189446
C Additional Services Expense 1 Medicaid Inpatient Days 2150112520 8981
223725 5857012 Additional Services 361976 3 Additional Services Exp amp Per Diem 28911 249109
=-~=~~ =-======1=======-=+===middot=middot=========F======-=middotmiddot D Medicaid Per Diem Cost
9297334319921 Operating Component 431992 2960844 49327112 Resident Care Component 1811407
73893343343 Property Cost Component 34334 o4 ROElUse Allow Component 00000
5 Total Cost Per Diem 2277733 3427170
TACACHALE 4 OwnershipState[l]
Florida Agency For Health Care Administration I 028015100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23820
ICFMR-DD Calculation Sheet NM 35849 Rates Effective 100 1120 II through 033112012
~----------~----------- __----_ bull_-_____bull-----__--_shyi ResidentialInstitutional Non-Ambulatory Medical
Base Semester
0000000
15 Prospective Rate Line II x Inflation (104648267)
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
12520 ~----~---- shy
10000
0000
0000 0000
0000
0000
355054
3433 0000
000000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationl--0_2_8_01_6_0_0_0_-_2_0_11_I_I0_1 Office of Medicaid Cost Reimbursement Planning and Analysis I--_R_I_2_3_4_3_8__N_1_I_3_4_2_1_9--J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND l1ARIANNA 3 3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
028016000 091082011 063012010 Unaudited [3]
New Effective Rate Date
23145 23438 10012011
33788 34219 100112011
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ~___ _~~~__bull __~__________bull _~ _~_~~__________~_bullbull_Lbullbull~_____ ~~__
IBasis-__ ~----~-~--- -~~------~~-------- ----~-- ----------- --__--
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion Field Audit - Interim Portion
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Horne Office
For Infonnation only - No Change in rate
Florida Agency For Health Care Administration ___0_2_80_1_6_0_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name SUNLAND MARIANNA 3 Cost Report Entered by Squire Yashica Provider Numbel 28016000 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 shy 063012010 Date 982011 Days In Reporting Period 365
Number of Beds 44
ColumnA Residential Institutional
12849
~~-~-----T---~~-------- ~-
----C-ol-umn--B---- i I Column C Total Ii Non-Ambulatory Medical
2718 15567
237433
iA Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
~ Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
389532
551093 63945
100 271800
297292863 56006229
2060568
389532 1789055
63945 00000
--------
2242532
389532
551093 63945 00000
2718 56434
207631
389532 2819291
63945
336480 o
419225 17928
_____ 420l3~_ 857886 99543
o
914250 10000
188387400
14777 306873
606385 3048633
99543 o
Florida Agency For Health Care Administration 028016000 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23438
ICFMR-DD Calculation Sheet NM 34219 Rates Effective 100112011 through 033112012
SUNLAND MARIANNA 3 OwnershipState[1 J
Base Semester
j------- +--------+--- ---- ---------- -+---- --~_i-- -~------~
1000025 Medicaid Utilization 9385
000 000
000
inted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationf--0_2_8_0_24_1_0_0_-_2_0_11_1_10-1 Office ofMedicaid Cost Reimbursement Planning and Analysis ~_R_I_3_3_5_2_6_I_N_M_4_7_8_7_6----l
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 5 1621 NB Waldo Road Gainesville FL 32609
Provider Number Date
FYE
Audit Status
028024100
091082011 06302010 Unaudited [3]
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Current Rate
33110
47277
New Rate
33526
47876
Effective Date
100112011
1010112011
IRateType-~--~ Interim
Total Interim
Interim Component
Settlement Based on Costs
x Prospective
X Total Prospective
Prospective Adjusted for New Cost
Budget
X Unaudited Costs
Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit - Prospective Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
D t~rl A )OI)Qf)Oll t (Qmiddot1middot1 Q TTjnn cmiddot lt11 h 17111 Rltgtth rnmiddotJ7rVT
-----
Florida Agency For Health Care Administration-I ___0_28_0_2_4_1_00__--- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFIMR-DD Profile Sheet Rate P eriod( s) 042011 to 1012011
Provider Name TACACHALE 5 Provider Numbel 28024100 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 40
ColumnA ColumnB Non-Ambulatory Medical
Column C Total --___----IjI Residential Institutional
4440 2634 7074
170516 426135
o 31563
888061 888061 628214
163155 252460
o 587525 587525 415615 122108 122108 86379 00000 00000 o
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Stafflllg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense I Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
050 222000
457354759 59893807
1348960
262414
100 263400
542645241 71063193
2697919
2517 71674
284760
888061 3570204
122108
4580372
485400 10000
130957000
6428 174304
628214 1899489
86379 o
2614082- ~-- ~~-~~
Florida Agency For Health Care Administration I 028024100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 33526
ICFMR-DD Calculation Sheet NM 47876 Rates Effective 1 lI20 II through 033l120 12
TACACHALE 5 Ownership State [ 1]
I Fiscal Year Begin ----- __ _----l____
I Current Cost Report i 070112009
I Prior Cost Report LI
-------_-- ---- -~-~----- ~---~~~--=-~--
-- --------- --------j----------------1Fiscal Year End Audit Status Base Semester I
06302010 Unaudited [3] -------l I
__~~ ~~__~_~1 ____ ~~_~ ___________ J
Period Base
3 Line I x - _ -----__ -- - --~--
4 Current Period Cost
5 Incentive Basis
15 Prospective Rate Line I I x Inflation (104648267)
16 Interim Rate ~---------~-----------------
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component ---____-___ --__-shy ---- shy
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
---------- shy
88806 88806 357020
0000 0000 0000
88806 219890 308696 88806 357020
0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
0000 0000 0000 0000
0000 0000 I 0000 0000
------- --------
445826
0000
0000
33526 47876 2517
------1-----middot_--_middot_---------- shy
4440 2634 8809 955625 Medicaid Utilization
000
000
inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administrationl--0_2_8_02_6_7_0_0_-_2_0_11_I_I0---l Office ofMedicaid Cost Reimbursement Planning and Analysis --_RI_3_2_9_8_2_I_N_TM_4_6_5__4_S-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 7 Provider Number 028026700 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 063012010
Audit Status Unaudited [3]
Provider Type ICFMR~DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 32563 32982 100112011
8 Non-Ambulatory amp 9 Medical 45952 46545 100112011
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
x Unaudited Costs
Field Audited Costs Field Audit Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
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
Printpj rn flQf(llV)fl11 M fll(middotlmiddot1 l( nina vprltrm 4 1 hv 17111 Rth TnmiddotF7CiVT
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Florida Agency For Health Care Administrationr--0_2_8_00_9_7_0_0_-_2_0_11_I_l0_--I Office of Medicaid Cost Reimbursement Planning and Analysis --_R_I_4_2_6_4_3_I_N_M__6_9_2_8_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND MARIANNA 2 Provider Number 028009700 ---------------shy3700 Williams Drive Date 09082011
Marianna FL 32446 FYE 06302010 Audit Status Unaudited [3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date
7 Institutional 42106 42643 100112011
8 Non-Ambulatory amp 9 Medical 68404 69283 100112011
~~-- ----~--- ~
iRate Type I Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs _~_bull_ __~_ ~_bull J
Budget Desk Audited Costs
X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit Interim Portion ~~-~--~ ~------~bull - ~---- - ---~- - -------- - ~------__ __---__
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Florida Agency For Health Care AdministrationL-I___O_2_8_00_9_7_0_0__---l
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
RatePeriod(s) 042011 to 102011
Provider Name SUNLAND MARIANNA 2 Provider Numbel 28009700 Audit Status Unaudited [3] Date 982011
~-~~~~~~-~----- ~- ~~---- ~~ --~- shy
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 121
~~--~-column-B-~-~COIU=~TotalColumnA Residential II Non-Ambulatory Medical Institutional
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
~~-~~+---3-1-4-2-2l1 ~- 057-shy - - -- shy 32479
636490
515567 82350 00000
050 1571100
936963263 799847029
2545500
30327 905763
298666
636490 3359733
82350 00000
4078574
636490
515567 82350 00000
100 105700 63036737
53811871 5691000
1057 31589
298855
636490 5905423
82350
6624263
1075906 904102
o ~~_~~l4
2067257
951057 48171
__~675~2_ 1674511
267466 o
1676800 10000
853658900
31384 937352
2067257 11148452
267466 o
13483175
Florida Agency For Health Care Administration I 028009700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 42643
ICFMR-DD Calculation Sheet NM 69283 Rates Effective 1010 l20 11 through 033112012
SUNLAND MARIANNA 2 OvvnershipState[l]
Inflation Factor 000000000
---~-shy
6
31422 9652
63649 590542 654191
0000 0000
63649 i 590542 654191
0000 0000 0000
0000 0000 0000
1057-shy ----- -------~~- -
10000
000 000
000
~inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
--
Florida Agency For Health Care Administrationl-0_28Ol_19OO_-2Ol1lO=-j
Office ofMedicaid Cost Reimbursement Planning and Analysis I-_R_I_2_4_4_0-7_I-N--M~3--7-976--1 2727 Mahan Drive-Mail Stop 21
Tallahassee Florida 32308
TACACHALE 3 Provider Number 028011900 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 06302010
Audit Status Unaudited [3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date
7 Institutional 24099 24407 10012011
8 Non-Ambulatory amp 9 Medical 37493 37976 100112011
r=--c~--~-- - --- ---- ---------- -------- ~----~-- - ---- ------shy
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
i-BaSIS I Budget
X Unaudited Costs
Field Audited Costs Field Audit - Interiin Portion
Distribution Contract Management DPODS - DCF (3) Home Office
Desk Audited Costs
Desk Audit - Interim Portion
Desk Audit - Prospective Portion
w Rydell SueJ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
_______
Florida Agency For Health Care Administrationll-__O_28_0_1_1_9_00__---l
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 3 Provider NumbeJ 28011900 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
5 ROEUse Per Diem
B Direct Care Expense 1 Staffing
2 Total Staffmg Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
j C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 49
ColumnA ColumnB Residential Non-Ambulatory Medical Institutional
11503 6962
Column C Total
18465
430542 276993
o 05~
394287
368227 37137 00000
050 575150
452393125 149587089
1300418
11503 269061
233905 __-------
394287 1902551
37137 00000
2333974
394287
368227 37137 00000
100 696200
547606875 181070211
2600836
6950 159916
230095
394287 3199159
37137
3630582 --- ------- shy~
728051
424805 255127
o 679932
68573 o
1271350 10000
330657300
18453 428977
728051 4415482
68573 o
Florida Agency For Health Care Administration I 028011900 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 24407
ICFMR-DD Calculation Sheet NM 37976 Rates Effective 100112011 through 033112012
TACACHALE 3 OvvnershipState[l]
3 Line 1 x
4 Current Period Cost
5 Incentive Basis
of line 3 or 4
15 Prospective Rate Line II x Inflation (104648267)
39429
0000
190255 229684
0000 0000
0000
-~---~--~middot~~-_C~~~middotmiddotmiddotmiddotmiddot-l~~~~middot-
16 Interim Rate
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component -~~-----------
2 I Plus Property Interim Rate Component
-~-~
39429
0000
39429
0000
0000
319916
0000
319916
0000
359345
0000
0000
376048
0000
0000
376048
3714
0000
-~------- ----t---- -------------- - -----middot--middot-----~----I
11503 6962
25 Medicaid Utilization 10000 9983
000 000
000
nted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
------------------- ---
---l
Florida Agency For Health Care Administrationf- _0_2_8_0_1_5_10_0_-_20_1_1_1_1o_-1
Office ofMedicaid Cost Reimbursement Planning and Analysis --_R_I_2_3_8_2_0_I_N_M_3_5_8_A_9
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 4 1621 NE Waldo Road Gainesville FL 32609
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Interim
Total Interim
Interim Component
Settlement Based on Costs
X Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Provider Number 028015100 Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
23518 23820 100112011
35393 35849 100112011
x Prospective
X Total Prospective Prospective Adjusted for New Cost
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit Prospective Portion
WRydellSamuel ~ Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
PnntPfl Im OQ()RIOll ltIt ORltIIR TTina vprirm 4 1 hv 17111 Rlt(~h TDFZGVT
I
Florida Agency For Health Care AdministrationlL--___O_2_8_01_S_1_0_0__---I
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
Provider Name TACACHALE 4 Cost Report Entered by Squire Yashica Provider Numbel 28015100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 59
II Column B---middot-~~~~tl-1ColumnA Residential I[Non-Ambulatory Medical Institutional __ +L______Lj_____ __ _____0_____ - _ _ ~_~__
IA Allocation of Expenses (excluding B ampcJ 1 Resident Days
2 Operating Expenses Component A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
I 900212520
431992431992
332844332844 3433434334 0000000000
21522
472741 425478
o 31
929733
490554 225792
o ------------_
716346 73893
o
i B Direct Care Expense I Staffmg 050 100 2 Total Staffmg Required 626000 900200 1526200 3 Staffing Percent 410169047 589830953 10000 4 Allocation of Direct Care 148918599 214147801 363066400
23788915 Direct Care Expense Per Diem 1189446
C Additional Services Expense 1 Medicaid Inpatient Days 2150112520 8981
223725 5857012 Additional Services 361976 3 Additional Services Exp amp Per Diem 28911 249109
=-~=~~ =-======1=======-=+===middot=middot=========F======-=middotmiddot D Medicaid Per Diem Cost
9297334319921 Operating Component 431992 2960844 49327112 Resident Care Component 1811407
73893343343 Property Cost Component 34334 o4 ROElUse Allow Component 00000
5 Total Cost Per Diem 2277733 3427170
TACACHALE 4 OwnershipState[l]
Florida Agency For Health Care Administration I 028015100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23820
ICFMR-DD Calculation Sheet NM 35849 Rates Effective 100 1120 II through 033112012
~----------~----------- __----_ bull_-_____bull-----__--_shyi ResidentialInstitutional Non-Ambulatory Medical
Base Semester
0000000
15 Prospective Rate Line II x Inflation (104648267)
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
12520 ~----~---- shy
10000
0000
0000 0000
0000
0000
355054
3433 0000
000000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationl--0_2_8_01_6_0_0_0_-_2_0_11_I_I0_1 Office of Medicaid Cost Reimbursement Planning and Analysis I--_R_I_2_3_4_3_8__N_1_I_3_4_2_1_9--J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND l1ARIANNA 3 3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
028016000 091082011 063012010 Unaudited [3]
New Effective Rate Date
23145 23438 10012011
33788 34219 100112011
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ~___ _~~~__bull __~__________bull _~ _~_~~__________~_bullbull_Lbullbull~_____ ~~__
IBasis-__ ~----~-~--- -~~------~~-------- ----~-- ----------- --__--
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion Field Audit - Interim Portion
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Horne Office
For Infonnation only - No Change in rate
Florida Agency For Health Care Administration ___0_2_80_1_6_0_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name SUNLAND MARIANNA 3 Cost Report Entered by Squire Yashica Provider Numbel 28016000 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 shy 063012010 Date 982011 Days In Reporting Period 365
Number of Beds 44
ColumnA Residential Institutional
12849
~~-~-----T---~~-------- ~-
----C-ol-umn--B---- i I Column C Total Ii Non-Ambulatory Medical
2718 15567
237433
iA Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
~ Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
389532
551093 63945
100 271800
297292863 56006229
2060568
389532 1789055
63945 00000
--------
2242532
389532
551093 63945 00000
2718 56434
207631
389532 2819291
63945
336480 o
419225 17928
_____ 420l3~_ 857886 99543
o
914250 10000
188387400
14777 306873
606385 3048633
99543 o
Florida Agency For Health Care Administration 028016000 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23438
ICFMR-DD Calculation Sheet NM 34219 Rates Effective 100112011 through 033112012
SUNLAND MARIANNA 3 OwnershipState[1 J
Base Semester
j------- +--------+--- ---- ---------- -+---- --~_i-- -~------~
1000025 Medicaid Utilization 9385
000 000
000
inted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationf--0_2_8_0_24_1_0_0_-_2_0_11_1_10-1 Office ofMedicaid Cost Reimbursement Planning and Analysis ~_R_I_3_3_5_2_6_I_N_M_4_7_8_7_6----l
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 5 1621 NB Waldo Road Gainesville FL 32609
Provider Number Date
FYE
Audit Status
028024100
091082011 06302010 Unaudited [3]
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Current Rate
33110
47277
New Rate
33526
47876
Effective Date
100112011
1010112011
IRateType-~--~ Interim
Total Interim
Interim Component
Settlement Based on Costs
x Prospective
X Total Prospective
Prospective Adjusted for New Cost
Budget
X Unaudited Costs
Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit - Prospective Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
D t~rl A )OI)Qf)Oll t (Qmiddot1middot1 Q TTjnn cmiddot lt11 h 17111 Rltgtth rnmiddotJ7rVT
-----
Florida Agency For Health Care Administration-I ___0_28_0_2_4_1_00__--- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFIMR-DD Profile Sheet Rate P eriod( s) 042011 to 1012011
Provider Name TACACHALE 5 Provider Numbel 28024100 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 40
ColumnA ColumnB Non-Ambulatory Medical
Column C Total --___----IjI Residential Institutional
4440 2634 7074
170516 426135
o 31563
888061 888061 628214
163155 252460
o 587525 587525 415615 122108 122108 86379 00000 00000 o
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Stafflllg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense I Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
050 222000
457354759 59893807
1348960
262414
100 263400
542645241 71063193
2697919
2517 71674
284760
888061 3570204
122108
4580372
485400 10000
130957000
6428 174304
628214 1899489
86379 o
2614082- ~-- ~~-~~
Florida Agency For Health Care Administration I 028024100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 33526
ICFMR-DD Calculation Sheet NM 47876 Rates Effective 1 lI20 II through 033l120 12
TACACHALE 5 Ownership State [ 1]
I Fiscal Year Begin ----- __ _----l____
I Current Cost Report i 070112009
I Prior Cost Report LI
-------_-- ---- -~-~----- ~---~~~--=-~--
-- --------- --------j----------------1Fiscal Year End Audit Status Base Semester I
06302010 Unaudited [3] -------l I
__~~ ~~__~_~1 ____ ~~_~ ___________ J
Period Base
3 Line I x - _ -----__ -- - --~--
4 Current Period Cost
5 Incentive Basis
15 Prospective Rate Line I I x Inflation (104648267)
16 Interim Rate ~---------~-----------------
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component ---____-___ --__-shy ---- shy
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
---------- shy
88806 88806 357020
0000 0000 0000
88806 219890 308696 88806 357020
0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
0000 0000 0000 0000
0000 0000 I 0000 0000
------- --------
445826
0000
0000
33526 47876 2517
------1-----middot_--_middot_---------- shy
4440 2634 8809 955625 Medicaid Utilization
000
000
inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administrationl--0_2_8_02_6_7_0_0_-_2_0_11_I_I0---l Office ofMedicaid Cost Reimbursement Planning and Analysis --_RI_3_2_9_8_2_I_N_TM_4_6_5__4_S-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 7 Provider Number 028026700 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 063012010
Audit Status Unaudited [3]
Provider Type ICFMR~DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 32563 32982 100112011
8 Non-Ambulatory amp 9 Medical 45952 46545 100112011
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
x Unaudited Costs
Field Audited Costs Field Audit Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
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
Printpj rn flQf(llV)fl11 M fll(middotlmiddot1 l( nina vprltrm 4 1 hv 17111 Rth TnmiddotF7CiVT
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Florida Agency For Health Care AdministrationL-I___O_2_8_00_9_7_0_0__---l
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
RatePeriod(s) 042011 to 102011
Provider Name SUNLAND MARIANNA 2 Provider Numbel 28009700 Audit Status Unaudited [3] Date 982011
~-~~~~~~-~----- ~- ~~---- ~~ --~- shy
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 121
~~--~-column-B-~-~COIU=~TotalColumnA Residential II Non-Ambulatory Medical Institutional
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
~~-~~+---3-1-4-2-2l1 ~- 057-shy - - -- shy 32479
636490
515567 82350 00000
050 1571100
936963263 799847029
2545500
30327 905763
298666
636490 3359733
82350 00000
4078574
636490
515567 82350 00000
100 105700 63036737
53811871 5691000
1057 31589
298855
636490 5905423
82350
6624263
1075906 904102
o ~~_~~l4
2067257
951057 48171
__~675~2_ 1674511
267466 o
1676800 10000
853658900
31384 937352
2067257 11148452
267466 o
13483175
Florida Agency For Health Care Administration I 028009700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 42643
ICFMR-DD Calculation Sheet NM 69283 Rates Effective 1010 l20 11 through 033112012
SUNLAND MARIANNA 2 OvvnershipState[l]
Inflation Factor 000000000
---~-shy
6
31422 9652
63649 590542 654191
0000 0000
63649 i 590542 654191
0000 0000 0000
0000 0000 0000
1057-shy ----- -------~~- -
10000
000 000
000
~inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
--
Florida Agency For Health Care Administrationl-0_28Ol_19OO_-2Ol1lO=-j
Office ofMedicaid Cost Reimbursement Planning and Analysis I-_R_I_2_4_4_0-7_I-N--M~3--7-976--1 2727 Mahan Drive-Mail Stop 21
Tallahassee Florida 32308
TACACHALE 3 Provider Number 028011900 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 06302010
Audit Status Unaudited [3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date
7 Institutional 24099 24407 10012011
8 Non-Ambulatory amp 9 Medical 37493 37976 100112011
r=--c~--~-- - --- ---- ---------- -------- ~----~-- - ---- ------shy
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
i-BaSIS I Budget
X Unaudited Costs
Field Audited Costs Field Audit - Interiin Portion
Distribution Contract Management DPODS - DCF (3) Home Office
Desk Audited Costs
Desk Audit - Interim Portion
Desk Audit - Prospective Portion
w Rydell SueJ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
_______
Florida Agency For Health Care Administrationll-__O_28_0_1_1_9_00__---l
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 3 Provider NumbeJ 28011900 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
5 ROEUse Per Diem
B Direct Care Expense 1 Staffing
2 Total Staffmg Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
j C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 49
ColumnA ColumnB Residential Non-Ambulatory Medical Institutional
11503 6962
Column C Total
18465
430542 276993
o 05~
394287
368227 37137 00000
050 575150
452393125 149587089
1300418
11503 269061
233905 __-------
394287 1902551
37137 00000
2333974
394287
368227 37137 00000
100 696200
547606875 181070211
2600836
6950 159916
230095
394287 3199159
37137
3630582 --- ------- shy~
728051
424805 255127
o 679932
68573 o
1271350 10000
330657300
18453 428977
728051 4415482
68573 o
Florida Agency For Health Care Administration I 028011900 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 24407
ICFMR-DD Calculation Sheet NM 37976 Rates Effective 100112011 through 033112012
TACACHALE 3 OvvnershipState[l]
3 Line 1 x
4 Current Period Cost
5 Incentive Basis
of line 3 or 4
15 Prospective Rate Line II x Inflation (104648267)
39429
0000
190255 229684
0000 0000
0000
-~---~--~middot~~-_C~~~middotmiddotmiddotmiddotmiddot-l~~~~middot-
16 Interim Rate
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component -~~-----------
2 I Plus Property Interim Rate Component
-~-~
39429
0000
39429
0000
0000
319916
0000
319916
0000
359345
0000
0000
376048
0000
0000
376048
3714
0000
-~------- ----t---- -------------- - -----middot--middot-----~----I
11503 6962
25 Medicaid Utilization 10000 9983
000 000
000
nted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
------------------- ---
---l
Florida Agency For Health Care Administrationf- _0_2_8_0_1_5_10_0_-_20_1_1_1_1o_-1
Office ofMedicaid Cost Reimbursement Planning and Analysis --_R_I_2_3_8_2_0_I_N_M_3_5_8_A_9
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 4 1621 NE Waldo Road Gainesville FL 32609
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Interim
Total Interim
Interim Component
Settlement Based on Costs
X Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Provider Number 028015100 Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
23518 23820 100112011
35393 35849 100112011
x Prospective
X Total Prospective Prospective Adjusted for New Cost
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit Prospective Portion
WRydellSamuel ~ Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
PnntPfl Im OQ()RIOll ltIt ORltIIR TTina vprirm 4 1 hv 17111 Rlt(~h TDFZGVT
I
Florida Agency For Health Care AdministrationlL--___O_2_8_01_S_1_0_0__---I
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
Provider Name TACACHALE 4 Cost Report Entered by Squire Yashica Provider Numbel 28015100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 59
II Column B---middot-~~~~tl-1ColumnA Residential I[Non-Ambulatory Medical Institutional __ +L______Lj_____ __ _____0_____ - _ _ ~_~__
IA Allocation of Expenses (excluding B ampcJ 1 Resident Days
2 Operating Expenses Component A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
I 900212520
431992431992
332844332844 3433434334 0000000000
21522
472741 425478
o 31
929733
490554 225792
o ------------_
716346 73893
o
i B Direct Care Expense I Staffmg 050 100 2 Total Staffmg Required 626000 900200 1526200 3 Staffing Percent 410169047 589830953 10000 4 Allocation of Direct Care 148918599 214147801 363066400
23788915 Direct Care Expense Per Diem 1189446
C Additional Services Expense 1 Medicaid Inpatient Days 2150112520 8981
223725 5857012 Additional Services 361976 3 Additional Services Exp amp Per Diem 28911 249109
=-~=~~ =-======1=======-=+===middot=middot=========F======-=middotmiddot D Medicaid Per Diem Cost
9297334319921 Operating Component 431992 2960844 49327112 Resident Care Component 1811407
73893343343 Property Cost Component 34334 o4 ROElUse Allow Component 00000
5 Total Cost Per Diem 2277733 3427170
TACACHALE 4 OwnershipState[l]
Florida Agency For Health Care Administration I 028015100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23820
ICFMR-DD Calculation Sheet NM 35849 Rates Effective 100 1120 II through 033112012
~----------~----------- __----_ bull_-_____bull-----__--_shyi ResidentialInstitutional Non-Ambulatory Medical
Base Semester
0000000
15 Prospective Rate Line II x Inflation (104648267)
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
12520 ~----~---- shy
10000
0000
0000 0000
0000
0000
355054
3433 0000
000000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationl--0_2_8_01_6_0_0_0_-_2_0_11_I_I0_1 Office of Medicaid Cost Reimbursement Planning and Analysis I--_R_I_2_3_4_3_8__N_1_I_3_4_2_1_9--J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND l1ARIANNA 3 3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
028016000 091082011 063012010 Unaudited [3]
New Effective Rate Date
23145 23438 10012011
33788 34219 100112011
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ~___ _~~~__bull __~__________bull _~ _~_~~__________~_bullbull_Lbullbull~_____ ~~__
IBasis-__ ~----~-~--- -~~------~~-------- ----~-- ----------- --__--
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion Field Audit - Interim Portion
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Horne Office
For Infonnation only - No Change in rate
Florida Agency For Health Care Administration ___0_2_80_1_6_0_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name SUNLAND MARIANNA 3 Cost Report Entered by Squire Yashica Provider Numbel 28016000 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 shy 063012010 Date 982011 Days In Reporting Period 365
Number of Beds 44
ColumnA Residential Institutional
12849
~~-~-----T---~~-------- ~-
----C-ol-umn--B---- i I Column C Total Ii Non-Ambulatory Medical
2718 15567
237433
iA Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
~ Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
389532
551093 63945
100 271800
297292863 56006229
2060568
389532 1789055
63945 00000
--------
2242532
389532
551093 63945 00000
2718 56434
207631
389532 2819291
63945
336480 o
419225 17928
_____ 420l3~_ 857886 99543
o
914250 10000
188387400
14777 306873
606385 3048633
99543 o
Florida Agency For Health Care Administration 028016000 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23438
ICFMR-DD Calculation Sheet NM 34219 Rates Effective 100112011 through 033112012
SUNLAND MARIANNA 3 OwnershipState[1 J
Base Semester
j------- +--------+--- ---- ---------- -+---- --~_i-- -~------~
1000025 Medicaid Utilization 9385
000 000
000
inted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationf--0_2_8_0_24_1_0_0_-_2_0_11_1_10-1 Office ofMedicaid Cost Reimbursement Planning and Analysis ~_R_I_3_3_5_2_6_I_N_M_4_7_8_7_6----l
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 5 1621 NB Waldo Road Gainesville FL 32609
Provider Number Date
FYE
Audit Status
028024100
091082011 06302010 Unaudited [3]
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Current Rate
33110
47277
New Rate
33526
47876
Effective Date
100112011
1010112011
IRateType-~--~ Interim
Total Interim
Interim Component
Settlement Based on Costs
x Prospective
X Total Prospective
Prospective Adjusted for New Cost
Budget
X Unaudited Costs
Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit - Prospective Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
D t~rl A )OI)Qf)Oll t (Qmiddot1middot1 Q TTjnn cmiddot lt11 h 17111 Rltgtth rnmiddotJ7rVT
-----
Florida Agency For Health Care Administration-I ___0_28_0_2_4_1_00__--- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFIMR-DD Profile Sheet Rate P eriod( s) 042011 to 1012011
Provider Name TACACHALE 5 Provider Numbel 28024100 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 40
ColumnA ColumnB Non-Ambulatory Medical
Column C Total --___----IjI Residential Institutional
4440 2634 7074
170516 426135
o 31563
888061 888061 628214
163155 252460
o 587525 587525 415615 122108 122108 86379 00000 00000 o
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Stafflllg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense I Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
050 222000
457354759 59893807
1348960
262414
100 263400
542645241 71063193
2697919
2517 71674
284760
888061 3570204
122108
4580372
485400 10000
130957000
6428 174304
628214 1899489
86379 o
2614082- ~-- ~~-~~
Florida Agency For Health Care Administration I 028024100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 33526
ICFMR-DD Calculation Sheet NM 47876 Rates Effective 1 lI20 II through 033l120 12
TACACHALE 5 Ownership State [ 1]
I Fiscal Year Begin ----- __ _----l____
I Current Cost Report i 070112009
I Prior Cost Report LI
-------_-- ---- -~-~----- ~---~~~--=-~--
-- --------- --------j----------------1Fiscal Year End Audit Status Base Semester I
06302010 Unaudited [3] -------l I
__~~ ~~__~_~1 ____ ~~_~ ___________ J
Period Base
3 Line I x - _ -----__ -- - --~--
4 Current Period Cost
5 Incentive Basis
15 Prospective Rate Line I I x Inflation (104648267)
16 Interim Rate ~---------~-----------------
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component ---____-___ --__-shy ---- shy
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
---------- shy
88806 88806 357020
0000 0000 0000
88806 219890 308696 88806 357020
0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
0000 0000 0000 0000
0000 0000 I 0000 0000
------- --------
445826
0000
0000
33526 47876 2517
------1-----middot_--_middot_---------- shy
4440 2634 8809 955625 Medicaid Utilization
000
000
inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administrationl--0_2_8_02_6_7_0_0_-_2_0_11_I_I0---l Office ofMedicaid Cost Reimbursement Planning and Analysis --_RI_3_2_9_8_2_I_N_TM_4_6_5__4_S-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 7 Provider Number 028026700 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 063012010
Audit Status Unaudited [3]
Provider Type ICFMR~DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 32563 32982 100112011
8 Non-Ambulatory amp 9 Medical 45952 46545 100112011
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
x Unaudited Costs
Field Audited Costs Field Audit Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
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
Printpj rn flQf(llV)fl11 M fll(middotlmiddot1 l( nina vprltrm 4 1 hv 17111 Rth TnmiddotF7CiVT
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Florida Agency For Health Care Administration I 028009700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 42643
ICFMR-DD Calculation Sheet NM 69283 Rates Effective 1010 l20 11 through 033112012
SUNLAND MARIANNA 2 OvvnershipState[l]
Inflation Factor 000000000
---~-shy
6
31422 9652
63649 590542 654191
0000 0000
63649 i 590542 654191
0000 0000 0000
0000 0000 0000
1057-shy ----- -------~~- -
10000
000 000
000
~inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
--
Florida Agency For Health Care Administrationl-0_28Ol_19OO_-2Ol1lO=-j
Office ofMedicaid Cost Reimbursement Planning and Analysis I-_R_I_2_4_4_0-7_I-N--M~3--7-976--1 2727 Mahan Drive-Mail Stop 21
Tallahassee Florida 32308
TACACHALE 3 Provider Number 028011900 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 06302010
Audit Status Unaudited [3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date
7 Institutional 24099 24407 10012011
8 Non-Ambulatory amp 9 Medical 37493 37976 100112011
r=--c~--~-- - --- ---- ---------- -------- ~----~-- - ---- ------shy
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
i-BaSIS I Budget
X Unaudited Costs
Field Audited Costs Field Audit - Interiin Portion
Distribution Contract Management DPODS - DCF (3) Home Office
Desk Audited Costs
Desk Audit - Interim Portion
Desk Audit - Prospective Portion
w Rydell SueJ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
_______
Florida Agency For Health Care Administrationll-__O_28_0_1_1_9_00__---l
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 3 Provider NumbeJ 28011900 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
5 ROEUse Per Diem
B Direct Care Expense 1 Staffing
2 Total Staffmg Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
j C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 49
ColumnA ColumnB Residential Non-Ambulatory Medical Institutional
11503 6962
Column C Total
18465
430542 276993
o 05~
394287
368227 37137 00000
050 575150
452393125 149587089
1300418
11503 269061
233905 __-------
394287 1902551
37137 00000
2333974
394287
368227 37137 00000
100 696200
547606875 181070211
2600836
6950 159916
230095
394287 3199159
37137
3630582 --- ------- shy~
728051
424805 255127
o 679932
68573 o
1271350 10000
330657300
18453 428977
728051 4415482
68573 o
Florida Agency For Health Care Administration I 028011900 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 24407
ICFMR-DD Calculation Sheet NM 37976 Rates Effective 100112011 through 033112012
TACACHALE 3 OvvnershipState[l]
3 Line 1 x
4 Current Period Cost
5 Incentive Basis
of line 3 or 4
15 Prospective Rate Line II x Inflation (104648267)
39429
0000
190255 229684
0000 0000
0000
-~---~--~middot~~-_C~~~middotmiddotmiddotmiddotmiddot-l~~~~middot-
16 Interim Rate
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component -~~-----------
2 I Plus Property Interim Rate Component
-~-~
39429
0000
39429
0000
0000
319916
0000
319916
0000
359345
0000
0000
376048
0000
0000
376048
3714
0000
-~------- ----t---- -------------- - -----middot--middot-----~----I
11503 6962
25 Medicaid Utilization 10000 9983
000 000
000
nted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
------------------- ---
---l
Florida Agency For Health Care Administrationf- _0_2_8_0_1_5_10_0_-_20_1_1_1_1o_-1
Office ofMedicaid Cost Reimbursement Planning and Analysis --_R_I_2_3_8_2_0_I_N_M_3_5_8_A_9
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 4 1621 NE Waldo Road Gainesville FL 32609
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Interim
Total Interim
Interim Component
Settlement Based on Costs
X Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Provider Number 028015100 Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
23518 23820 100112011
35393 35849 100112011
x Prospective
X Total Prospective Prospective Adjusted for New Cost
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit Prospective Portion
WRydellSamuel ~ Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
PnntPfl Im OQ()RIOll ltIt ORltIIR TTina vprirm 4 1 hv 17111 Rlt(~h TDFZGVT
I
Florida Agency For Health Care AdministrationlL--___O_2_8_01_S_1_0_0__---I
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
Provider Name TACACHALE 4 Cost Report Entered by Squire Yashica Provider Numbel 28015100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 59
II Column B---middot-~~~~tl-1ColumnA Residential I[Non-Ambulatory Medical Institutional __ +L______Lj_____ __ _____0_____ - _ _ ~_~__
IA Allocation of Expenses (excluding B ampcJ 1 Resident Days
2 Operating Expenses Component A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
I 900212520
431992431992
332844332844 3433434334 0000000000
21522
472741 425478
o 31
929733
490554 225792
o ------------_
716346 73893
o
i B Direct Care Expense I Staffmg 050 100 2 Total Staffmg Required 626000 900200 1526200 3 Staffing Percent 410169047 589830953 10000 4 Allocation of Direct Care 148918599 214147801 363066400
23788915 Direct Care Expense Per Diem 1189446
C Additional Services Expense 1 Medicaid Inpatient Days 2150112520 8981
223725 5857012 Additional Services 361976 3 Additional Services Exp amp Per Diem 28911 249109
=-~=~~ =-======1=======-=+===middot=middot=========F======-=middotmiddot D Medicaid Per Diem Cost
9297334319921 Operating Component 431992 2960844 49327112 Resident Care Component 1811407
73893343343 Property Cost Component 34334 o4 ROElUse Allow Component 00000
5 Total Cost Per Diem 2277733 3427170
TACACHALE 4 OwnershipState[l]
Florida Agency For Health Care Administration I 028015100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23820
ICFMR-DD Calculation Sheet NM 35849 Rates Effective 100 1120 II through 033112012
~----------~----------- __----_ bull_-_____bull-----__--_shyi ResidentialInstitutional Non-Ambulatory Medical
Base Semester
0000000
15 Prospective Rate Line II x Inflation (104648267)
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
12520 ~----~---- shy
10000
0000
0000 0000
0000
0000
355054
3433 0000
000000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationl--0_2_8_01_6_0_0_0_-_2_0_11_I_I0_1 Office of Medicaid Cost Reimbursement Planning and Analysis I--_R_I_2_3_4_3_8__N_1_I_3_4_2_1_9--J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND l1ARIANNA 3 3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
028016000 091082011 063012010 Unaudited [3]
New Effective Rate Date
23145 23438 10012011
33788 34219 100112011
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ~___ _~~~__bull __~__________bull _~ _~_~~__________~_bullbull_Lbullbull~_____ ~~__
IBasis-__ ~----~-~--- -~~------~~-------- ----~-- ----------- --__--
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion Field Audit - Interim Portion
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Horne Office
For Infonnation only - No Change in rate
Florida Agency For Health Care Administration ___0_2_80_1_6_0_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name SUNLAND MARIANNA 3 Cost Report Entered by Squire Yashica Provider Numbel 28016000 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 shy 063012010 Date 982011 Days In Reporting Period 365
Number of Beds 44
ColumnA Residential Institutional
12849
~~-~-----T---~~-------- ~-
----C-ol-umn--B---- i I Column C Total Ii Non-Ambulatory Medical
2718 15567
237433
iA Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
~ Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
389532
551093 63945
100 271800
297292863 56006229
2060568
389532 1789055
63945 00000
--------
2242532
389532
551093 63945 00000
2718 56434
207631
389532 2819291
63945
336480 o
419225 17928
_____ 420l3~_ 857886 99543
o
914250 10000
188387400
14777 306873
606385 3048633
99543 o
Florida Agency For Health Care Administration 028016000 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23438
ICFMR-DD Calculation Sheet NM 34219 Rates Effective 100112011 through 033112012
SUNLAND MARIANNA 3 OwnershipState[1 J
Base Semester
j------- +--------+--- ---- ---------- -+---- --~_i-- -~------~
1000025 Medicaid Utilization 9385
000 000
000
inted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationf--0_2_8_0_24_1_0_0_-_2_0_11_1_10-1 Office ofMedicaid Cost Reimbursement Planning and Analysis ~_R_I_3_3_5_2_6_I_N_M_4_7_8_7_6----l
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 5 1621 NB Waldo Road Gainesville FL 32609
Provider Number Date
FYE
Audit Status
028024100
091082011 06302010 Unaudited [3]
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Current Rate
33110
47277
New Rate
33526
47876
Effective Date
100112011
1010112011
IRateType-~--~ Interim
Total Interim
Interim Component
Settlement Based on Costs
x Prospective
X Total Prospective
Prospective Adjusted for New Cost
Budget
X Unaudited Costs
Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit - Prospective Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
D t~rl A )OI)Qf)Oll t (Qmiddot1middot1 Q TTjnn cmiddot lt11 h 17111 Rltgtth rnmiddotJ7rVT
-----
Florida Agency For Health Care Administration-I ___0_28_0_2_4_1_00__--- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFIMR-DD Profile Sheet Rate P eriod( s) 042011 to 1012011
Provider Name TACACHALE 5 Provider Numbel 28024100 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 40
ColumnA ColumnB Non-Ambulatory Medical
Column C Total --___----IjI Residential Institutional
4440 2634 7074
170516 426135
o 31563
888061 888061 628214
163155 252460
o 587525 587525 415615 122108 122108 86379 00000 00000 o
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Stafflllg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense I Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
050 222000
457354759 59893807
1348960
262414
100 263400
542645241 71063193
2697919
2517 71674
284760
888061 3570204
122108
4580372
485400 10000
130957000
6428 174304
628214 1899489
86379 o
2614082- ~-- ~~-~~
Florida Agency For Health Care Administration I 028024100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 33526
ICFMR-DD Calculation Sheet NM 47876 Rates Effective 1 lI20 II through 033l120 12
TACACHALE 5 Ownership State [ 1]
I Fiscal Year Begin ----- __ _----l____
I Current Cost Report i 070112009
I Prior Cost Report LI
-------_-- ---- -~-~----- ~---~~~--=-~--
-- --------- --------j----------------1Fiscal Year End Audit Status Base Semester I
06302010 Unaudited [3] -------l I
__~~ ~~__~_~1 ____ ~~_~ ___________ J
Period Base
3 Line I x - _ -----__ -- - --~--
4 Current Period Cost
5 Incentive Basis
15 Prospective Rate Line I I x Inflation (104648267)
16 Interim Rate ~---------~-----------------
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component ---____-___ --__-shy ---- shy
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
---------- shy
88806 88806 357020
0000 0000 0000
88806 219890 308696 88806 357020
0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
0000 0000 0000 0000
0000 0000 I 0000 0000
------- --------
445826
0000
0000
33526 47876 2517
------1-----middot_--_middot_---------- shy
4440 2634 8809 955625 Medicaid Utilization
000
000
inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administrationl--0_2_8_02_6_7_0_0_-_2_0_11_I_I0---l Office ofMedicaid Cost Reimbursement Planning and Analysis --_RI_3_2_9_8_2_I_N_TM_4_6_5__4_S-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 7 Provider Number 028026700 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 063012010
Audit Status Unaudited [3]
Provider Type ICFMR~DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 32563 32982 100112011
8 Non-Ambulatory amp 9 Medical 45952 46545 100112011
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
x Unaudited Costs
Field Audited Costs Field Audit Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
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
Printpj rn flQf(llV)fl11 M fll(middotlmiddot1 l( nina vprltrm 4 1 hv 17111 Rth TnmiddotF7CiVT
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
--
Florida Agency For Health Care Administrationl-0_28Ol_19OO_-2Ol1lO=-j
Office ofMedicaid Cost Reimbursement Planning and Analysis I-_R_I_2_4_4_0-7_I-N--M~3--7-976--1 2727 Mahan Drive-Mail Stop 21
Tallahassee Florida 32308
TACACHALE 3 Provider Number 028011900 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 06302010
Audit Status Unaudited [3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date
7 Institutional 24099 24407 10012011
8 Non-Ambulatory amp 9 Medical 37493 37976 100112011
r=--c~--~-- - --- ---- ---------- -------- ~----~-- - ---- ------shy
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
i-BaSIS I Budget
X Unaudited Costs
Field Audited Costs Field Audit - Interiin Portion
Distribution Contract Management DPODS - DCF (3) Home Office
Desk Audited Costs
Desk Audit - Interim Portion
Desk Audit - Prospective Portion
w Rydell SueJ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
_______
Florida Agency For Health Care Administrationll-__O_28_0_1_1_9_00__---l
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 3 Provider NumbeJ 28011900 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
5 ROEUse Per Diem
B Direct Care Expense 1 Staffing
2 Total Staffmg Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
j C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 49
ColumnA ColumnB Residential Non-Ambulatory Medical Institutional
11503 6962
Column C Total
18465
430542 276993
o 05~
394287
368227 37137 00000
050 575150
452393125 149587089
1300418
11503 269061
233905 __-------
394287 1902551
37137 00000
2333974
394287
368227 37137 00000
100 696200
547606875 181070211
2600836
6950 159916
230095
394287 3199159
37137
3630582 --- ------- shy~
728051
424805 255127
o 679932
68573 o
1271350 10000
330657300
18453 428977
728051 4415482
68573 o
Florida Agency For Health Care Administration I 028011900 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 24407
ICFMR-DD Calculation Sheet NM 37976 Rates Effective 100112011 through 033112012
TACACHALE 3 OvvnershipState[l]
3 Line 1 x
4 Current Period Cost
5 Incentive Basis
of line 3 or 4
15 Prospective Rate Line II x Inflation (104648267)
39429
0000
190255 229684
0000 0000
0000
-~---~--~middot~~-_C~~~middotmiddotmiddotmiddotmiddot-l~~~~middot-
16 Interim Rate
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component -~~-----------
2 I Plus Property Interim Rate Component
-~-~
39429
0000
39429
0000
0000
319916
0000
319916
0000
359345
0000
0000
376048
0000
0000
376048
3714
0000
-~------- ----t---- -------------- - -----middot--middot-----~----I
11503 6962
25 Medicaid Utilization 10000 9983
000 000
000
nted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
------------------- ---
---l
Florida Agency For Health Care Administrationf- _0_2_8_0_1_5_10_0_-_20_1_1_1_1o_-1
Office ofMedicaid Cost Reimbursement Planning and Analysis --_R_I_2_3_8_2_0_I_N_M_3_5_8_A_9
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 4 1621 NE Waldo Road Gainesville FL 32609
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Interim
Total Interim
Interim Component
Settlement Based on Costs
X Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Provider Number 028015100 Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
23518 23820 100112011
35393 35849 100112011
x Prospective
X Total Prospective Prospective Adjusted for New Cost
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit Prospective Portion
WRydellSamuel ~ Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
PnntPfl Im OQ()RIOll ltIt ORltIIR TTina vprirm 4 1 hv 17111 Rlt(~h TDFZGVT
I
Florida Agency For Health Care AdministrationlL--___O_2_8_01_S_1_0_0__---I
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
Provider Name TACACHALE 4 Cost Report Entered by Squire Yashica Provider Numbel 28015100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 59
II Column B---middot-~~~~tl-1ColumnA Residential I[Non-Ambulatory Medical Institutional __ +L______Lj_____ __ _____0_____ - _ _ ~_~__
IA Allocation of Expenses (excluding B ampcJ 1 Resident Days
2 Operating Expenses Component A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
I 900212520
431992431992
332844332844 3433434334 0000000000
21522
472741 425478
o 31
929733
490554 225792
o ------------_
716346 73893
o
i B Direct Care Expense I Staffmg 050 100 2 Total Staffmg Required 626000 900200 1526200 3 Staffing Percent 410169047 589830953 10000 4 Allocation of Direct Care 148918599 214147801 363066400
23788915 Direct Care Expense Per Diem 1189446
C Additional Services Expense 1 Medicaid Inpatient Days 2150112520 8981
223725 5857012 Additional Services 361976 3 Additional Services Exp amp Per Diem 28911 249109
=-~=~~ =-======1=======-=+===middot=middot=========F======-=middotmiddot D Medicaid Per Diem Cost
9297334319921 Operating Component 431992 2960844 49327112 Resident Care Component 1811407
73893343343 Property Cost Component 34334 o4 ROElUse Allow Component 00000
5 Total Cost Per Diem 2277733 3427170
TACACHALE 4 OwnershipState[l]
Florida Agency For Health Care Administration I 028015100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23820
ICFMR-DD Calculation Sheet NM 35849 Rates Effective 100 1120 II through 033112012
~----------~----------- __----_ bull_-_____bull-----__--_shyi ResidentialInstitutional Non-Ambulatory Medical
Base Semester
0000000
15 Prospective Rate Line II x Inflation (104648267)
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
12520 ~----~---- shy
10000
0000
0000 0000
0000
0000
355054
3433 0000
000000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationl--0_2_8_01_6_0_0_0_-_2_0_11_I_I0_1 Office of Medicaid Cost Reimbursement Planning and Analysis I--_R_I_2_3_4_3_8__N_1_I_3_4_2_1_9--J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND l1ARIANNA 3 3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
028016000 091082011 063012010 Unaudited [3]
New Effective Rate Date
23145 23438 10012011
33788 34219 100112011
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ~___ _~~~__bull __~__________bull _~ _~_~~__________~_bullbull_Lbullbull~_____ ~~__
IBasis-__ ~----~-~--- -~~------~~-------- ----~-- ----------- --__--
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion Field Audit - Interim Portion
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Horne Office
For Infonnation only - No Change in rate
Florida Agency For Health Care Administration ___0_2_80_1_6_0_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name SUNLAND MARIANNA 3 Cost Report Entered by Squire Yashica Provider Numbel 28016000 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 shy 063012010 Date 982011 Days In Reporting Period 365
Number of Beds 44
ColumnA Residential Institutional
12849
~~-~-----T---~~-------- ~-
----C-ol-umn--B---- i I Column C Total Ii Non-Ambulatory Medical
2718 15567
237433
iA Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
~ Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
389532
551093 63945
100 271800
297292863 56006229
2060568
389532 1789055
63945 00000
--------
2242532
389532
551093 63945 00000
2718 56434
207631
389532 2819291
63945
336480 o
419225 17928
_____ 420l3~_ 857886 99543
o
914250 10000
188387400
14777 306873
606385 3048633
99543 o
Florida Agency For Health Care Administration 028016000 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23438
ICFMR-DD Calculation Sheet NM 34219 Rates Effective 100112011 through 033112012
SUNLAND MARIANNA 3 OwnershipState[1 J
Base Semester
j------- +--------+--- ---- ---------- -+---- --~_i-- -~------~
1000025 Medicaid Utilization 9385
000 000
000
inted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationf--0_2_8_0_24_1_0_0_-_2_0_11_1_10-1 Office ofMedicaid Cost Reimbursement Planning and Analysis ~_R_I_3_3_5_2_6_I_N_M_4_7_8_7_6----l
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 5 1621 NB Waldo Road Gainesville FL 32609
Provider Number Date
FYE
Audit Status
028024100
091082011 06302010 Unaudited [3]
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Current Rate
33110
47277
New Rate
33526
47876
Effective Date
100112011
1010112011
IRateType-~--~ Interim
Total Interim
Interim Component
Settlement Based on Costs
x Prospective
X Total Prospective
Prospective Adjusted for New Cost
Budget
X Unaudited Costs
Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit - Prospective Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
D t~rl A )OI)Qf)Oll t (Qmiddot1middot1 Q TTjnn cmiddot lt11 h 17111 Rltgtth rnmiddotJ7rVT
-----
Florida Agency For Health Care Administration-I ___0_28_0_2_4_1_00__--- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFIMR-DD Profile Sheet Rate P eriod( s) 042011 to 1012011
Provider Name TACACHALE 5 Provider Numbel 28024100 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 40
ColumnA ColumnB Non-Ambulatory Medical
Column C Total --___----IjI Residential Institutional
4440 2634 7074
170516 426135
o 31563
888061 888061 628214
163155 252460
o 587525 587525 415615 122108 122108 86379 00000 00000 o
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Stafflllg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense I Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
050 222000
457354759 59893807
1348960
262414
100 263400
542645241 71063193
2697919
2517 71674
284760
888061 3570204
122108
4580372
485400 10000
130957000
6428 174304
628214 1899489
86379 o
2614082- ~-- ~~-~~
Florida Agency For Health Care Administration I 028024100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 33526
ICFMR-DD Calculation Sheet NM 47876 Rates Effective 1 lI20 II through 033l120 12
TACACHALE 5 Ownership State [ 1]
I Fiscal Year Begin ----- __ _----l____
I Current Cost Report i 070112009
I Prior Cost Report LI
-------_-- ---- -~-~----- ~---~~~--=-~--
-- --------- --------j----------------1Fiscal Year End Audit Status Base Semester I
06302010 Unaudited [3] -------l I
__~~ ~~__~_~1 ____ ~~_~ ___________ J
Period Base
3 Line I x - _ -----__ -- - --~--
4 Current Period Cost
5 Incentive Basis
15 Prospective Rate Line I I x Inflation (104648267)
16 Interim Rate ~---------~-----------------
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component ---____-___ --__-shy ---- shy
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
---------- shy
88806 88806 357020
0000 0000 0000
88806 219890 308696 88806 357020
0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
0000 0000 0000 0000
0000 0000 I 0000 0000
------- --------
445826
0000
0000
33526 47876 2517
------1-----middot_--_middot_---------- shy
4440 2634 8809 955625 Medicaid Utilization
000
000
inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administrationl--0_2_8_02_6_7_0_0_-_2_0_11_I_I0---l Office ofMedicaid Cost Reimbursement Planning and Analysis --_RI_3_2_9_8_2_I_N_TM_4_6_5__4_S-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 7 Provider Number 028026700 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 063012010
Audit Status Unaudited [3]
Provider Type ICFMR~DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 32563 32982 100112011
8 Non-Ambulatory amp 9 Medical 45952 46545 100112011
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
x Unaudited Costs
Field Audited Costs Field Audit Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
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
Printpj rn flQf(llV)fl11 M fll(middotlmiddot1 l( nina vprltrm 4 1 hv 17111 Rth TnmiddotF7CiVT
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
_______
Florida Agency For Health Care Administrationll-__O_28_0_1_1_9_00__---l
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 3 Provider NumbeJ 28011900 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
5 ROEUse Per Diem
B Direct Care Expense 1 Staffing
2 Total Staffmg Required 3 Staffing Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
j C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 49
ColumnA ColumnB Residential Non-Ambulatory Medical Institutional
11503 6962
Column C Total
18465
430542 276993
o 05~
394287
368227 37137 00000
050 575150
452393125 149587089
1300418
11503 269061
233905 __-------
394287 1902551
37137 00000
2333974
394287
368227 37137 00000
100 696200
547606875 181070211
2600836
6950 159916
230095
394287 3199159
37137
3630582 --- ------- shy~
728051
424805 255127
o 679932
68573 o
1271350 10000
330657300
18453 428977
728051 4415482
68573 o
Florida Agency For Health Care Administration I 028011900 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 24407
ICFMR-DD Calculation Sheet NM 37976 Rates Effective 100112011 through 033112012
TACACHALE 3 OvvnershipState[l]
3 Line 1 x
4 Current Period Cost
5 Incentive Basis
of line 3 or 4
15 Prospective Rate Line II x Inflation (104648267)
39429
0000
190255 229684
0000 0000
0000
-~---~--~middot~~-_C~~~middotmiddotmiddotmiddotmiddot-l~~~~middot-
16 Interim Rate
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component -~~-----------
2 I Plus Property Interim Rate Component
-~-~
39429
0000
39429
0000
0000
319916
0000
319916
0000
359345
0000
0000
376048
0000
0000
376048
3714
0000
-~------- ----t---- -------------- - -----middot--middot-----~----I
11503 6962
25 Medicaid Utilization 10000 9983
000 000
000
nted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
------------------- ---
---l
Florida Agency For Health Care Administrationf- _0_2_8_0_1_5_10_0_-_20_1_1_1_1o_-1
Office ofMedicaid Cost Reimbursement Planning and Analysis --_R_I_2_3_8_2_0_I_N_M_3_5_8_A_9
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 4 1621 NE Waldo Road Gainesville FL 32609
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Interim
Total Interim
Interim Component
Settlement Based on Costs
X Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Provider Number 028015100 Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
23518 23820 100112011
35393 35849 100112011
x Prospective
X Total Prospective Prospective Adjusted for New Cost
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit Prospective Portion
WRydellSamuel ~ Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
PnntPfl Im OQ()RIOll ltIt ORltIIR TTina vprirm 4 1 hv 17111 Rlt(~h TDFZGVT
I
Florida Agency For Health Care AdministrationlL--___O_2_8_01_S_1_0_0__---I
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
Provider Name TACACHALE 4 Cost Report Entered by Squire Yashica Provider Numbel 28015100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 59
II Column B---middot-~~~~tl-1ColumnA Residential I[Non-Ambulatory Medical Institutional __ +L______Lj_____ __ _____0_____ - _ _ ~_~__
IA Allocation of Expenses (excluding B ampcJ 1 Resident Days
2 Operating Expenses Component A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
I 900212520
431992431992
332844332844 3433434334 0000000000
21522
472741 425478
o 31
929733
490554 225792
o ------------_
716346 73893
o
i B Direct Care Expense I Staffmg 050 100 2 Total Staffmg Required 626000 900200 1526200 3 Staffing Percent 410169047 589830953 10000 4 Allocation of Direct Care 148918599 214147801 363066400
23788915 Direct Care Expense Per Diem 1189446
C Additional Services Expense 1 Medicaid Inpatient Days 2150112520 8981
223725 5857012 Additional Services 361976 3 Additional Services Exp amp Per Diem 28911 249109
=-~=~~ =-======1=======-=+===middot=middot=========F======-=middotmiddot D Medicaid Per Diem Cost
9297334319921 Operating Component 431992 2960844 49327112 Resident Care Component 1811407
73893343343 Property Cost Component 34334 o4 ROElUse Allow Component 00000
5 Total Cost Per Diem 2277733 3427170
TACACHALE 4 OwnershipState[l]
Florida Agency For Health Care Administration I 028015100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23820
ICFMR-DD Calculation Sheet NM 35849 Rates Effective 100 1120 II through 033112012
~----------~----------- __----_ bull_-_____bull-----__--_shyi ResidentialInstitutional Non-Ambulatory Medical
Base Semester
0000000
15 Prospective Rate Line II x Inflation (104648267)
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
12520 ~----~---- shy
10000
0000
0000 0000
0000
0000
355054
3433 0000
000000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationl--0_2_8_01_6_0_0_0_-_2_0_11_I_I0_1 Office of Medicaid Cost Reimbursement Planning and Analysis I--_R_I_2_3_4_3_8__N_1_I_3_4_2_1_9--J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND l1ARIANNA 3 3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
028016000 091082011 063012010 Unaudited [3]
New Effective Rate Date
23145 23438 10012011
33788 34219 100112011
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ~___ _~~~__bull __~__________bull _~ _~_~~__________~_bullbull_Lbullbull~_____ ~~__
IBasis-__ ~----~-~--- -~~------~~-------- ----~-- ----------- --__--
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion Field Audit - Interim Portion
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Horne Office
For Infonnation only - No Change in rate
Florida Agency For Health Care Administration ___0_2_80_1_6_0_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name SUNLAND MARIANNA 3 Cost Report Entered by Squire Yashica Provider Numbel 28016000 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 shy 063012010 Date 982011 Days In Reporting Period 365
Number of Beds 44
ColumnA Residential Institutional
12849
~~-~-----T---~~-------- ~-
----C-ol-umn--B---- i I Column C Total Ii Non-Ambulatory Medical
2718 15567
237433
iA Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
~ Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
389532
551093 63945
100 271800
297292863 56006229
2060568
389532 1789055
63945 00000
--------
2242532
389532
551093 63945 00000
2718 56434
207631
389532 2819291
63945
336480 o
419225 17928
_____ 420l3~_ 857886 99543
o
914250 10000
188387400
14777 306873
606385 3048633
99543 o
Florida Agency For Health Care Administration 028016000 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23438
ICFMR-DD Calculation Sheet NM 34219 Rates Effective 100112011 through 033112012
SUNLAND MARIANNA 3 OwnershipState[1 J
Base Semester
j------- +--------+--- ---- ---------- -+---- --~_i-- -~------~
1000025 Medicaid Utilization 9385
000 000
000
inted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationf--0_2_8_0_24_1_0_0_-_2_0_11_1_10-1 Office ofMedicaid Cost Reimbursement Planning and Analysis ~_R_I_3_3_5_2_6_I_N_M_4_7_8_7_6----l
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 5 1621 NB Waldo Road Gainesville FL 32609
Provider Number Date
FYE
Audit Status
028024100
091082011 06302010 Unaudited [3]
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Current Rate
33110
47277
New Rate
33526
47876
Effective Date
100112011
1010112011
IRateType-~--~ Interim
Total Interim
Interim Component
Settlement Based on Costs
x Prospective
X Total Prospective
Prospective Adjusted for New Cost
Budget
X Unaudited Costs
Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit - Prospective Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
D t~rl A )OI)Qf)Oll t (Qmiddot1middot1 Q TTjnn cmiddot lt11 h 17111 Rltgtth rnmiddotJ7rVT
-----
Florida Agency For Health Care Administration-I ___0_28_0_2_4_1_00__--- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFIMR-DD Profile Sheet Rate P eriod( s) 042011 to 1012011
Provider Name TACACHALE 5 Provider Numbel 28024100 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 40
ColumnA ColumnB Non-Ambulatory Medical
Column C Total --___----IjI Residential Institutional
4440 2634 7074
170516 426135
o 31563
888061 888061 628214
163155 252460
o 587525 587525 415615 122108 122108 86379 00000 00000 o
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Stafflllg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense I Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
050 222000
457354759 59893807
1348960
262414
100 263400
542645241 71063193
2697919
2517 71674
284760
888061 3570204
122108
4580372
485400 10000
130957000
6428 174304
628214 1899489
86379 o
2614082- ~-- ~~-~~
Florida Agency For Health Care Administration I 028024100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 33526
ICFMR-DD Calculation Sheet NM 47876 Rates Effective 1 lI20 II through 033l120 12
TACACHALE 5 Ownership State [ 1]
I Fiscal Year Begin ----- __ _----l____
I Current Cost Report i 070112009
I Prior Cost Report LI
-------_-- ---- -~-~----- ~---~~~--=-~--
-- --------- --------j----------------1Fiscal Year End Audit Status Base Semester I
06302010 Unaudited [3] -------l I
__~~ ~~__~_~1 ____ ~~_~ ___________ J
Period Base
3 Line I x - _ -----__ -- - --~--
4 Current Period Cost
5 Incentive Basis
15 Prospective Rate Line I I x Inflation (104648267)
16 Interim Rate ~---------~-----------------
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component ---____-___ --__-shy ---- shy
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
---------- shy
88806 88806 357020
0000 0000 0000
88806 219890 308696 88806 357020
0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
0000 0000 0000 0000
0000 0000 I 0000 0000
------- --------
445826
0000
0000
33526 47876 2517
------1-----middot_--_middot_---------- shy
4440 2634 8809 955625 Medicaid Utilization
000
000
inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administrationl--0_2_8_02_6_7_0_0_-_2_0_11_I_I0---l Office ofMedicaid Cost Reimbursement Planning and Analysis --_RI_3_2_9_8_2_I_N_TM_4_6_5__4_S-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 7 Provider Number 028026700 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 063012010
Audit Status Unaudited [3]
Provider Type ICFMR~DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 32563 32982 100112011
8 Non-Ambulatory amp 9 Medical 45952 46545 100112011
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
x Unaudited Costs
Field Audited Costs Field Audit Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
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
Printpj rn flQf(llV)fl11 M fll(middotlmiddot1 l( nina vprltrm 4 1 hv 17111 Rth TnmiddotF7CiVT
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Florida Agency For Health Care Administration I 028011900 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 24407
ICFMR-DD Calculation Sheet NM 37976 Rates Effective 100112011 through 033112012
TACACHALE 3 OvvnershipState[l]
3 Line 1 x
4 Current Period Cost
5 Incentive Basis
of line 3 or 4
15 Prospective Rate Line II x Inflation (104648267)
39429
0000
190255 229684
0000 0000
0000
-~---~--~middot~~-_C~~~middotmiddotmiddotmiddotmiddot-l~~~~middot-
16 Interim Rate
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component -~~-----------
2 I Plus Property Interim Rate Component
-~-~
39429
0000
39429
0000
0000
319916
0000
319916
0000
359345
0000
0000
376048
0000
0000
376048
3714
0000
-~------- ----t---- -------------- - -----middot--middot-----~----I
11503 6962
25 Medicaid Utilization 10000 9983
000 000
000
nted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
------------------- ---
---l
Florida Agency For Health Care Administrationf- _0_2_8_0_1_5_10_0_-_20_1_1_1_1o_-1
Office ofMedicaid Cost Reimbursement Planning and Analysis --_R_I_2_3_8_2_0_I_N_M_3_5_8_A_9
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 4 1621 NE Waldo Road Gainesville FL 32609
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Interim
Total Interim
Interim Component
Settlement Based on Costs
X Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Provider Number 028015100 Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
23518 23820 100112011
35393 35849 100112011
x Prospective
X Total Prospective Prospective Adjusted for New Cost
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit Prospective Portion
WRydellSamuel ~ Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
PnntPfl Im OQ()RIOll ltIt ORltIIR TTina vprirm 4 1 hv 17111 Rlt(~h TDFZGVT
I
Florida Agency For Health Care AdministrationlL--___O_2_8_01_S_1_0_0__---I
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
Provider Name TACACHALE 4 Cost Report Entered by Squire Yashica Provider Numbel 28015100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 59
II Column B---middot-~~~~tl-1ColumnA Residential I[Non-Ambulatory Medical Institutional __ +L______Lj_____ __ _____0_____ - _ _ ~_~__
IA Allocation of Expenses (excluding B ampcJ 1 Resident Days
2 Operating Expenses Component A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
I 900212520
431992431992
332844332844 3433434334 0000000000
21522
472741 425478
o 31
929733
490554 225792
o ------------_
716346 73893
o
i B Direct Care Expense I Staffmg 050 100 2 Total Staffmg Required 626000 900200 1526200 3 Staffing Percent 410169047 589830953 10000 4 Allocation of Direct Care 148918599 214147801 363066400
23788915 Direct Care Expense Per Diem 1189446
C Additional Services Expense 1 Medicaid Inpatient Days 2150112520 8981
223725 5857012 Additional Services 361976 3 Additional Services Exp amp Per Diem 28911 249109
=-~=~~ =-======1=======-=+===middot=middot=========F======-=middotmiddot D Medicaid Per Diem Cost
9297334319921 Operating Component 431992 2960844 49327112 Resident Care Component 1811407
73893343343 Property Cost Component 34334 o4 ROElUse Allow Component 00000
5 Total Cost Per Diem 2277733 3427170
TACACHALE 4 OwnershipState[l]
Florida Agency For Health Care Administration I 028015100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23820
ICFMR-DD Calculation Sheet NM 35849 Rates Effective 100 1120 II through 033112012
~----------~----------- __----_ bull_-_____bull-----__--_shyi ResidentialInstitutional Non-Ambulatory Medical
Base Semester
0000000
15 Prospective Rate Line II x Inflation (104648267)
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
12520 ~----~---- shy
10000
0000
0000 0000
0000
0000
355054
3433 0000
000000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationl--0_2_8_01_6_0_0_0_-_2_0_11_I_I0_1 Office of Medicaid Cost Reimbursement Planning and Analysis I--_R_I_2_3_4_3_8__N_1_I_3_4_2_1_9--J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND l1ARIANNA 3 3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
028016000 091082011 063012010 Unaudited [3]
New Effective Rate Date
23145 23438 10012011
33788 34219 100112011
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ~___ _~~~__bull __~__________bull _~ _~_~~__________~_bullbull_Lbullbull~_____ ~~__
IBasis-__ ~----~-~--- -~~------~~-------- ----~-- ----------- --__--
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion Field Audit - Interim Portion
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Horne Office
For Infonnation only - No Change in rate
Florida Agency For Health Care Administration ___0_2_80_1_6_0_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name SUNLAND MARIANNA 3 Cost Report Entered by Squire Yashica Provider Numbel 28016000 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 shy 063012010 Date 982011 Days In Reporting Period 365
Number of Beds 44
ColumnA Residential Institutional
12849
~~-~-----T---~~-------- ~-
----C-ol-umn--B---- i I Column C Total Ii Non-Ambulatory Medical
2718 15567
237433
iA Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
~ Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
389532
551093 63945
100 271800
297292863 56006229
2060568
389532 1789055
63945 00000
--------
2242532
389532
551093 63945 00000
2718 56434
207631
389532 2819291
63945
336480 o
419225 17928
_____ 420l3~_ 857886 99543
o
914250 10000
188387400
14777 306873
606385 3048633
99543 o
Florida Agency For Health Care Administration 028016000 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23438
ICFMR-DD Calculation Sheet NM 34219 Rates Effective 100112011 through 033112012
SUNLAND MARIANNA 3 OwnershipState[1 J
Base Semester
j------- +--------+--- ---- ---------- -+---- --~_i-- -~------~
1000025 Medicaid Utilization 9385
000 000
000
inted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationf--0_2_8_0_24_1_0_0_-_2_0_11_1_10-1 Office ofMedicaid Cost Reimbursement Planning and Analysis ~_R_I_3_3_5_2_6_I_N_M_4_7_8_7_6----l
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 5 1621 NB Waldo Road Gainesville FL 32609
Provider Number Date
FYE
Audit Status
028024100
091082011 06302010 Unaudited [3]
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Current Rate
33110
47277
New Rate
33526
47876
Effective Date
100112011
1010112011
IRateType-~--~ Interim
Total Interim
Interim Component
Settlement Based on Costs
x Prospective
X Total Prospective
Prospective Adjusted for New Cost
Budget
X Unaudited Costs
Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit - Prospective Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
D t~rl A )OI)Qf)Oll t (Qmiddot1middot1 Q TTjnn cmiddot lt11 h 17111 Rltgtth rnmiddotJ7rVT
-----
Florida Agency For Health Care Administration-I ___0_28_0_2_4_1_00__--- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFIMR-DD Profile Sheet Rate P eriod( s) 042011 to 1012011
Provider Name TACACHALE 5 Provider Numbel 28024100 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 40
ColumnA ColumnB Non-Ambulatory Medical
Column C Total --___----IjI Residential Institutional
4440 2634 7074
170516 426135
o 31563
888061 888061 628214
163155 252460
o 587525 587525 415615 122108 122108 86379 00000 00000 o
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Stafflllg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense I Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
050 222000
457354759 59893807
1348960
262414
100 263400
542645241 71063193
2697919
2517 71674
284760
888061 3570204
122108
4580372
485400 10000
130957000
6428 174304
628214 1899489
86379 o
2614082- ~-- ~~-~~
Florida Agency For Health Care Administration I 028024100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 33526
ICFMR-DD Calculation Sheet NM 47876 Rates Effective 1 lI20 II through 033l120 12
TACACHALE 5 Ownership State [ 1]
I Fiscal Year Begin ----- __ _----l____
I Current Cost Report i 070112009
I Prior Cost Report LI
-------_-- ---- -~-~----- ~---~~~--=-~--
-- --------- --------j----------------1Fiscal Year End Audit Status Base Semester I
06302010 Unaudited [3] -------l I
__~~ ~~__~_~1 ____ ~~_~ ___________ J
Period Base
3 Line I x - _ -----__ -- - --~--
4 Current Period Cost
5 Incentive Basis
15 Prospective Rate Line I I x Inflation (104648267)
16 Interim Rate ~---------~-----------------
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component ---____-___ --__-shy ---- shy
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
---------- shy
88806 88806 357020
0000 0000 0000
88806 219890 308696 88806 357020
0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
0000 0000 0000 0000
0000 0000 I 0000 0000
------- --------
445826
0000
0000
33526 47876 2517
------1-----middot_--_middot_---------- shy
4440 2634 8809 955625 Medicaid Utilization
000
000
inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administrationl--0_2_8_02_6_7_0_0_-_2_0_11_I_I0---l Office ofMedicaid Cost Reimbursement Planning and Analysis --_RI_3_2_9_8_2_I_N_TM_4_6_5__4_S-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 7 Provider Number 028026700 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 063012010
Audit Status Unaudited [3]
Provider Type ICFMR~DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 32563 32982 100112011
8 Non-Ambulatory amp 9 Medical 45952 46545 100112011
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
x Unaudited Costs
Field Audited Costs Field Audit Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
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
Printpj rn flQf(llV)fl11 M fll(middotlmiddot1 l( nina vprltrm 4 1 hv 17111 Rth TnmiddotF7CiVT
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
------------------- ---
---l
Florida Agency For Health Care Administrationf- _0_2_8_0_1_5_10_0_-_20_1_1_1_1o_-1
Office ofMedicaid Cost Reimbursement Planning and Analysis --_R_I_2_3_8_2_0_I_N_M_3_5_8_A_9
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 4 1621 NE Waldo Road Gainesville FL 32609
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Interim
Total Interim
Interim Component
Settlement Based on Costs
X Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Provider Number 028015100 Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
23518 23820 100112011
35393 35849 100112011
x Prospective
X Total Prospective Prospective Adjusted for New Cost
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit Prospective Portion
WRydellSamuel ~ Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
PnntPfl Im OQ()RIOll ltIt ORltIIR TTina vprirm 4 1 hv 17111 Rlt(~h TDFZGVT
I
Florida Agency For Health Care AdministrationlL--___O_2_8_01_S_1_0_0__---I
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
Provider Name TACACHALE 4 Cost Report Entered by Squire Yashica Provider Numbel 28015100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 59
II Column B---middot-~~~~tl-1ColumnA Residential I[Non-Ambulatory Medical Institutional __ +L______Lj_____ __ _____0_____ - _ _ ~_~__
IA Allocation of Expenses (excluding B ampcJ 1 Resident Days
2 Operating Expenses Component A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
I 900212520
431992431992
332844332844 3433434334 0000000000
21522
472741 425478
o 31
929733
490554 225792
o ------------_
716346 73893
o
i B Direct Care Expense I Staffmg 050 100 2 Total Staffmg Required 626000 900200 1526200 3 Staffing Percent 410169047 589830953 10000 4 Allocation of Direct Care 148918599 214147801 363066400
23788915 Direct Care Expense Per Diem 1189446
C Additional Services Expense 1 Medicaid Inpatient Days 2150112520 8981
223725 5857012 Additional Services 361976 3 Additional Services Exp amp Per Diem 28911 249109
=-~=~~ =-======1=======-=+===middot=middot=========F======-=middotmiddot D Medicaid Per Diem Cost
9297334319921 Operating Component 431992 2960844 49327112 Resident Care Component 1811407
73893343343 Property Cost Component 34334 o4 ROElUse Allow Component 00000
5 Total Cost Per Diem 2277733 3427170
TACACHALE 4 OwnershipState[l]
Florida Agency For Health Care Administration I 028015100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23820
ICFMR-DD Calculation Sheet NM 35849 Rates Effective 100 1120 II through 033112012
~----------~----------- __----_ bull_-_____bull-----__--_shyi ResidentialInstitutional Non-Ambulatory Medical
Base Semester
0000000
15 Prospective Rate Line II x Inflation (104648267)
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
12520 ~----~---- shy
10000
0000
0000 0000
0000
0000
355054
3433 0000
000000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationl--0_2_8_01_6_0_0_0_-_2_0_11_I_I0_1 Office of Medicaid Cost Reimbursement Planning and Analysis I--_R_I_2_3_4_3_8__N_1_I_3_4_2_1_9--J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND l1ARIANNA 3 3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
028016000 091082011 063012010 Unaudited [3]
New Effective Rate Date
23145 23438 10012011
33788 34219 100112011
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ~___ _~~~__bull __~__________bull _~ _~_~~__________~_bullbull_Lbullbull~_____ ~~__
IBasis-__ ~----~-~--- -~~------~~-------- ----~-- ----------- --__--
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion Field Audit - Interim Portion
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Horne Office
For Infonnation only - No Change in rate
Florida Agency For Health Care Administration ___0_2_80_1_6_0_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name SUNLAND MARIANNA 3 Cost Report Entered by Squire Yashica Provider Numbel 28016000 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 shy 063012010 Date 982011 Days In Reporting Period 365
Number of Beds 44
ColumnA Residential Institutional
12849
~~-~-----T---~~-------- ~-
----C-ol-umn--B---- i I Column C Total Ii Non-Ambulatory Medical
2718 15567
237433
iA Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
~ Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
389532
551093 63945
100 271800
297292863 56006229
2060568
389532 1789055
63945 00000
--------
2242532
389532
551093 63945 00000
2718 56434
207631
389532 2819291
63945
336480 o
419225 17928
_____ 420l3~_ 857886 99543
o
914250 10000
188387400
14777 306873
606385 3048633
99543 o
Florida Agency For Health Care Administration 028016000 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23438
ICFMR-DD Calculation Sheet NM 34219 Rates Effective 100112011 through 033112012
SUNLAND MARIANNA 3 OwnershipState[1 J
Base Semester
j------- +--------+--- ---- ---------- -+---- --~_i-- -~------~
1000025 Medicaid Utilization 9385
000 000
000
inted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationf--0_2_8_0_24_1_0_0_-_2_0_11_1_10-1 Office ofMedicaid Cost Reimbursement Planning and Analysis ~_R_I_3_3_5_2_6_I_N_M_4_7_8_7_6----l
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 5 1621 NB Waldo Road Gainesville FL 32609
Provider Number Date
FYE
Audit Status
028024100
091082011 06302010 Unaudited [3]
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Current Rate
33110
47277
New Rate
33526
47876
Effective Date
100112011
1010112011
IRateType-~--~ Interim
Total Interim
Interim Component
Settlement Based on Costs
x Prospective
X Total Prospective
Prospective Adjusted for New Cost
Budget
X Unaudited Costs
Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit - Prospective Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
D t~rl A )OI)Qf)Oll t (Qmiddot1middot1 Q TTjnn cmiddot lt11 h 17111 Rltgtth rnmiddotJ7rVT
-----
Florida Agency For Health Care Administration-I ___0_28_0_2_4_1_00__--- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFIMR-DD Profile Sheet Rate P eriod( s) 042011 to 1012011
Provider Name TACACHALE 5 Provider Numbel 28024100 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 40
ColumnA ColumnB Non-Ambulatory Medical
Column C Total --___----IjI Residential Institutional
4440 2634 7074
170516 426135
o 31563
888061 888061 628214
163155 252460
o 587525 587525 415615 122108 122108 86379 00000 00000 o
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Stafflllg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense I Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
050 222000
457354759 59893807
1348960
262414
100 263400
542645241 71063193
2697919
2517 71674
284760
888061 3570204
122108
4580372
485400 10000
130957000
6428 174304
628214 1899489
86379 o
2614082- ~-- ~~-~~
Florida Agency For Health Care Administration I 028024100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 33526
ICFMR-DD Calculation Sheet NM 47876 Rates Effective 1 lI20 II through 033l120 12
TACACHALE 5 Ownership State [ 1]
I Fiscal Year Begin ----- __ _----l____
I Current Cost Report i 070112009
I Prior Cost Report LI
-------_-- ---- -~-~----- ~---~~~--=-~--
-- --------- --------j----------------1Fiscal Year End Audit Status Base Semester I
06302010 Unaudited [3] -------l I
__~~ ~~__~_~1 ____ ~~_~ ___________ J
Period Base
3 Line I x - _ -----__ -- - --~--
4 Current Period Cost
5 Incentive Basis
15 Prospective Rate Line I I x Inflation (104648267)
16 Interim Rate ~---------~-----------------
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component ---____-___ --__-shy ---- shy
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
---------- shy
88806 88806 357020
0000 0000 0000
88806 219890 308696 88806 357020
0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
0000 0000 0000 0000
0000 0000 I 0000 0000
------- --------
445826
0000
0000
33526 47876 2517
------1-----middot_--_middot_---------- shy
4440 2634 8809 955625 Medicaid Utilization
000
000
inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administrationl--0_2_8_02_6_7_0_0_-_2_0_11_I_I0---l Office ofMedicaid Cost Reimbursement Planning and Analysis --_RI_3_2_9_8_2_I_N_TM_4_6_5__4_S-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 7 Provider Number 028026700 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 063012010
Audit Status Unaudited [3]
Provider Type ICFMR~DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 32563 32982 100112011
8 Non-Ambulatory amp 9 Medical 45952 46545 100112011
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
x Unaudited Costs
Field Audited Costs Field Audit Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
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
Printpj rn flQf(llV)fl11 M fll(middotlmiddot1 l( nina vprltrm 4 1 hv 17111 Rth TnmiddotF7CiVT
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
I
Florida Agency For Health Care AdministrationlL--___O_2_8_01_S_1_0_0__---I
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
Provider Name TACACHALE 4 Cost Report Entered by Squire Yashica Provider Numbel 28015100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 59
II Column B---middot-~~~~tl-1ColumnA Residential I[Non-Ambulatory Medical Institutional __ +L______Lj_____ __ _____0_____ - _ _ ~_~__
IA Allocation of Expenses (excluding B ampcJ 1 Resident Days
2 Operating Expenses Component A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem 5 ROEUse Per Diem
I 900212520
431992431992
332844332844 3433434334 0000000000
21522
472741 425478
o 31
929733
490554 225792
o ------------_
716346 73893
o
i B Direct Care Expense I Staffmg 050 100 2 Total Staffmg Required 626000 900200 1526200 3 Staffing Percent 410169047 589830953 10000 4 Allocation of Direct Care 148918599 214147801 363066400
23788915 Direct Care Expense Per Diem 1189446
C Additional Services Expense 1 Medicaid Inpatient Days 2150112520 8981
223725 5857012 Additional Services 361976 3 Additional Services Exp amp Per Diem 28911 249109
=-~=~~ =-======1=======-=+===middot=middot=========F======-=middotmiddot D Medicaid Per Diem Cost
9297334319921 Operating Component 431992 2960844 49327112 Resident Care Component 1811407
73893343343 Property Cost Component 34334 o4 ROElUse Allow Component 00000
5 Total Cost Per Diem 2277733 3427170
TACACHALE 4 OwnershipState[l]
Florida Agency For Health Care Administration I 028015100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23820
ICFMR-DD Calculation Sheet NM 35849 Rates Effective 100 1120 II through 033112012
~----------~----------- __----_ bull_-_____bull-----__--_shyi ResidentialInstitutional Non-Ambulatory Medical
Base Semester
0000000
15 Prospective Rate Line II x Inflation (104648267)
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
12520 ~----~---- shy
10000
0000
0000 0000
0000
0000
355054
3433 0000
000000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationl--0_2_8_01_6_0_0_0_-_2_0_11_I_I0_1 Office of Medicaid Cost Reimbursement Planning and Analysis I--_R_I_2_3_4_3_8__N_1_I_3_4_2_1_9--J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND l1ARIANNA 3 3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
028016000 091082011 063012010 Unaudited [3]
New Effective Rate Date
23145 23438 10012011
33788 34219 100112011
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ~___ _~~~__bull __~__________bull _~ _~_~~__________~_bullbull_Lbullbull~_____ ~~__
IBasis-__ ~----~-~--- -~~------~~-------- ----~-- ----------- --__--
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion Field Audit - Interim Portion
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Horne Office
For Infonnation only - No Change in rate
Florida Agency For Health Care Administration ___0_2_80_1_6_0_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name SUNLAND MARIANNA 3 Cost Report Entered by Squire Yashica Provider Numbel 28016000 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 shy 063012010 Date 982011 Days In Reporting Period 365
Number of Beds 44
ColumnA Residential Institutional
12849
~~-~-----T---~~-------- ~-
----C-ol-umn--B---- i I Column C Total Ii Non-Ambulatory Medical
2718 15567
237433
iA Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
~ Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
389532
551093 63945
100 271800
297292863 56006229
2060568
389532 1789055
63945 00000
--------
2242532
389532
551093 63945 00000
2718 56434
207631
389532 2819291
63945
336480 o
419225 17928
_____ 420l3~_ 857886 99543
o
914250 10000
188387400
14777 306873
606385 3048633
99543 o
Florida Agency For Health Care Administration 028016000 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23438
ICFMR-DD Calculation Sheet NM 34219 Rates Effective 100112011 through 033112012
SUNLAND MARIANNA 3 OwnershipState[1 J
Base Semester
j------- +--------+--- ---- ---------- -+---- --~_i-- -~------~
1000025 Medicaid Utilization 9385
000 000
000
inted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationf--0_2_8_0_24_1_0_0_-_2_0_11_1_10-1 Office ofMedicaid Cost Reimbursement Planning and Analysis ~_R_I_3_3_5_2_6_I_N_M_4_7_8_7_6----l
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 5 1621 NB Waldo Road Gainesville FL 32609
Provider Number Date
FYE
Audit Status
028024100
091082011 06302010 Unaudited [3]
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Current Rate
33110
47277
New Rate
33526
47876
Effective Date
100112011
1010112011
IRateType-~--~ Interim
Total Interim
Interim Component
Settlement Based on Costs
x Prospective
X Total Prospective
Prospective Adjusted for New Cost
Budget
X Unaudited Costs
Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit - Prospective Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
D t~rl A )OI)Qf)Oll t (Qmiddot1middot1 Q TTjnn cmiddot lt11 h 17111 Rltgtth rnmiddotJ7rVT
-----
Florida Agency For Health Care Administration-I ___0_28_0_2_4_1_00__--- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFIMR-DD Profile Sheet Rate P eriod( s) 042011 to 1012011
Provider Name TACACHALE 5 Provider Numbel 28024100 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 40
ColumnA ColumnB Non-Ambulatory Medical
Column C Total --___----IjI Residential Institutional
4440 2634 7074
170516 426135
o 31563
888061 888061 628214
163155 252460
o 587525 587525 415615 122108 122108 86379 00000 00000 o
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Stafflllg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense I Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
050 222000
457354759 59893807
1348960
262414
100 263400
542645241 71063193
2697919
2517 71674
284760
888061 3570204
122108
4580372
485400 10000
130957000
6428 174304
628214 1899489
86379 o
2614082- ~-- ~~-~~
Florida Agency For Health Care Administration I 028024100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 33526
ICFMR-DD Calculation Sheet NM 47876 Rates Effective 1 lI20 II through 033l120 12
TACACHALE 5 Ownership State [ 1]
I Fiscal Year Begin ----- __ _----l____
I Current Cost Report i 070112009
I Prior Cost Report LI
-------_-- ---- -~-~----- ~---~~~--=-~--
-- --------- --------j----------------1Fiscal Year End Audit Status Base Semester I
06302010 Unaudited [3] -------l I
__~~ ~~__~_~1 ____ ~~_~ ___________ J
Period Base
3 Line I x - _ -----__ -- - --~--
4 Current Period Cost
5 Incentive Basis
15 Prospective Rate Line I I x Inflation (104648267)
16 Interim Rate ~---------~-----------------
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component ---____-___ --__-shy ---- shy
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
---------- shy
88806 88806 357020
0000 0000 0000
88806 219890 308696 88806 357020
0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
0000 0000 0000 0000
0000 0000 I 0000 0000
------- --------
445826
0000
0000
33526 47876 2517
------1-----middot_--_middot_---------- shy
4440 2634 8809 955625 Medicaid Utilization
000
000
inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administrationl--0_2_8_02_6_7_0_0_-_2_0_11_I_I0---l Office ofMedicaid Cost Reimbursement Planning and Analysis --_RI_3_2_9_8_2_I_N_TM_4_6_5__4_S-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 7 Provider Number 028026700 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 063012010
Audit Status Unaudited [3]
Provider Type ICFMR~DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 32563 32982 100112011
8 Non-Ambulatory amp 9 Medical 45952 46545 100112011
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
x Unaudited Costs
Field Audited Costs Field Audit Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
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
Printpj rn flQf(llV)fl11 M fll(middotlmiddot1 l( nina vprltrm 4 1 hv 17111 Rth TnmiddotF7CiVT
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
TACACHALE 4 OwnershipState[l]
Florida Agency For Health Care Administration I 028015100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23820
ICFMR-DD Calculation Sheet NM 35849 Rates Effective 100 1120 II through 033112012
~----------~----------- __----_ bull_-_____bull-----__--_shyi ResidentialInstitutional Non-Ambulatory Medical
Base Semester
0000000
15 Prospective Rate Line II x Inflation (104648267)
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
12520 ~----~---- shy
10000
0000
0000 0000
0000
0000
355054
3433 0000
000000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationl--0_2_8_01_6_0_0_0_-_2_0_11_I_I0_1 Office of Medicaid Cost Reimbursement Planning and Analysis I--_R_I_2_3_4_3_8__N_1_I_3_4_2_1_9--J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND l1ARIANNA 3 3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
028016000 091082011 063012010 Unaudited [3]
New Effective Rate Date
23145 23438 10012011
33788 34219 100112011
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ~___ _~~~__bull __~__________bull _~ _~_~~__________~_bullbull_Lbullbull~_____ ~~__
IBasis-__ ~----~-~--- -~~------~~-------- ----~-- ----------- --__--
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion Field Audit - Interim Portion
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Horne Office
For Infonnation only - No Change in rate
Florida Agency For Health Care Administration ___0_2_80_1_6_0_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name SUNLAND MARIANNA 3 Cost Report Entered by Squire Yashica Provider Numbel 28016000 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 shy 063012010 Date 982011 Days In Reporting Period 365
Number of Beds 44
ColumnA Residential Institutional
12849
~~-~-----T---~~-------- ~-
----C-ol-umn--B---- i I Column C Total Ii Non-Ambulatory Medical
2718 15567
237433
iA Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
~ Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
389532
551093 63945
100 271800
297292863 56006229
2060568
389532 1789055
63945 00000
--------
2242532
389532
551093 63945 00000
2718 56434
207631
389532 2819291
63945
336480 o
419225 17928
_____ 420l3~_ 857886 99543
o
914250 10000
188387400
14777 306873
606385 3048633
99543 o
Florida Agency For Health Care Administration 028016000 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23438
ICFMR-DD Calculation Sheet NM 34219 Rates Effective 100112011 through 033112012
SUNLAND MARIANNA 3 OwnershipState[1 J
Base Semester
j------- +--------+--- ---- ---------- -+---- --~_i-- -~------~
1000025 Medicaid Utilization 9385
000 000
000
inted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationf--0_2_8_0_24_1_0_0_-_2_0_11_1_10-1 Office ofMedicaid Cost Reimbursement Planning and Analysis ~_R_I_3_3_5_2_6_I_N_M_4_7_8_7_6----l
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 5 1621 NB Waldo Road Gainesville FL 32609
Provider Number Date
FYE
Audit Status
028024100
091082011 06302010 Unaudited [3]
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Current Rate
33110
47277
New Rate
33526
47876
Effective Date
100112011
1010112011
IRateType-~--~ Interim
Total Interim
Interim Component
Settlement Based on Costs
x Prospective
X Total Prospective
Prospective Adjusted for New Cost
Budget
X Unaudited Costs
Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit - Prospective Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
D t~rl A )OI)Qf)Oll t (Qmiddot1middot1 Q TTjnn cmiddot lt11 h 17111 Rltgtth rnmiddotJ7rVT
-----
Florida Agency For Health Care Administration-I ___0_28_0_2_4_1_00__--- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFIMR-DD Profile Sheet Rate P eriod( s) 042011 to 1012011
Provider Name TACACHALE 5 Provider Numbel 28024100 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 40
ColumnA ColumnB Non-Ambulatory Medical
Column C Total --___----IjI Residential Institutional
4440 2634 7074
170516 426135
o 31563
888061 888061 628214
163155 252460
o 587525 587525 415615 122108 122108 86379 00000 00000 o
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Stafflllg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense I Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
050 222000
457354759 59893807
1348960
262414
100 263400
542645241 71063193
2697919
2517 71674
284760
888061 3570204
122108
4580372
485400 10000
130957000
6428 174304
628214 1899489
86379 o
2614082- ~-- ~~-~~
Florida Agency For Health Care Administration I 028024100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 33526
ICFMR-DD Calculation Sheet NM 47876 Rates Effective 1 lI20 II through 033l120 12
TACACHALE 5 Ownership State [ 1]
I Fiscal Year Begin ----- __ _----l____
I Current Cost Report i 070112009
I Prior Cost Report LI
-------_-- ---- -~-~----- ~---~~~--=-~--
-- --------- --------j----------------1Fiscal Year End Audit Status Base Semester I
06302010 Unaudited [3] -------l I
__~~ ~~__~_~1 ____ ~~_~ ___________ J
Period Base
3 Line I x - _ -----__ -- - --~--
4 Current Period Cost
5 Incentive Basis
15 Prospective Rate Line I I x Inflation (104648267)
16 Interim Rate ~---------~-----------------
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component ---____-___ --__-shy ---- shy
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
---------- shy
88806 88806 357020
0000 0000 0000
88806 219890 308696 88806 357020
0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
0000 0000 0000 0000
0000 0000 I 0000 0000
------- --------
445826
0000
0000
33526 47876 2517
------1-----middot_--_middot_---------- shy
4440 2634 8809 955625 Medicaid Utilization
000
000
inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administrationl--0_2_8_02_6_7_0_0_-_2_0_11_I_I0---l Office ofMedicaid Cost Reimbursement Planning and Analysis --_RI_3_2_9_8_2_I_N_TM_4_6_5__4_S-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 7 Provider Number 028026700 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 063012010
Audit Status Unaudited [3]
Provider Type ICFMR~DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 32563 32982 100112011
8 Non-Ambulatory amp 9 Medical 45952 46545 100112011
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
x Unaudited Costs
Field Audited Costs Field Audit Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
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
Printpj rn flQf(llV)fl11 M fll(middotlmiddot1 l( nina vprltrm 4 1 hv 17111 Rth TnmiddotF7CiVT
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Florida Agency For Health Care Administrationl--0_2_8_01_6_0_0_0_-_2_0_11_I_I0_1 Office of Medicaid Cost Reimbursement Planning and Analysis I--_R_I_2_3_4_3_8__N_1_I_3_4_2_1_9--J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
SUNLAND l1ARIANNA 3 3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number Date FYE
Audit Status
Current Rate
028016000 091082011 063012010 Unaudited [3]
New Effective Rate Date
23145 23438 10012011
33788 34219 100112011
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ~___ _~~~__bull __~__________bull _~ _~_~~__________~_bullbull_Lbullbull~_____ ~~__
IBasis-__ ~----~-~--- -~~------~~-------- ----~-- ----------- --__--
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion Field Audit - Interim Portion
w Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Horne Office
For Infonnation only - No Change in rate
Florida Agency For Health Care Administration ___0_2_80_1_6_0_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name SUNLAND MARIANNA 3 Cost Report Entered by Squire Yashica Provider Numbel 28016000 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 shy 063012010 Date 982011 Days In Reporting Period 365
Number of Beds 44
ColumnA Residential Institutional
12849
~~-~-----T---~~-------- ~-
----C-ol-umn--B---- i I Column C Total Ii Non-Ambulatory Medical
2718 15567
237433
iA Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
~ Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
389532
551093 63945
100 271800
297292863 56006229
2060568
389532 1789055
63945 00000
--------
2242532
389532
551093 63945 00000
2718 56434
207631
389532 2819291
63945
336480 o
419225 17928
_____ 420l3~_ 857886 99543
o
914250 10000
188387400
14777 306873
606385 3048633
99543 o
Florida Agency For Health Care Administration 028016000 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23438
ICFMR-DD Calculation Sheet NM 34219 Rates Effective 100112011 through 033112012
SUNLAND MARIANNA 3 OwnershipState[1 J
Base Semester
j------- +--------+--- ---- ---------- -+---- --~_i-- -~------~
1000025 Medicaid Utilization 9385
000 000
000
inted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationf--0_2_8_0_24_1_0_0_-_2_0_11_1_10-1 Office ofMedicaid Cost Reimbursement Planning and Analysis ~_R_I_3_3_5_2_6_I_N_M_4_7_8_7_6----l
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 5 1621 NB Waldo Road Gainesville FL 32609
Provider Number Date
FYE
Audit Status
028024100
091082011 06302010 Unaudited [3]
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Current Rate
33110
47277
New Rate
33526
47876
Effective Date
100112011
1010112011
IRateType-~--~ Interim
Total Interim
Interim Component
Settlement Based on Costs
x Prospective
X Total Prospective
Prospective Adjusted for New Cost
Budget
X Unaudited Costs
Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit - Prospective Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
D t~rl A )OI)Qf)Oll t (Qmiddot1middot1 Q TTjnn cmiddot lt11 h 17111 Rltgtth rnmiddotJ7rVT
-----
Florida Agency For Health Care Administration-I ___0_28_0_2_4_1_00__--- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFIMR-DD Profile Sheet Rate P eriod( s) 042011 to 1012011
Provider Name TACACHALE 5 Provider Numbel 28024100 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 40
ColumnA ColumnB Non-Ambulatory Medical
Column C Total --___----IjI Residential Institutional
4440 2634 7074
170516 426135
o 31563
888061 888061 628214
163155 252460
o 587525 587525 415615 122108 122108 86379 00000 00000 o
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Stafflllg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense I Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
050 222000
457354759 59893807
1348960
262414
100 263400
542645241 71063193
2697919
2517 71674
284760
888061 3570204
122108
4580372
485400 10000
130957000
6428 174304
628214 1899489
86379 o
2614082- ~-- ~~-~~
Florida Agency For Health Care Administration I 028024100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 33526
ICFMR-DD Calculation Sheet NM 47876 Rates Effective 1 lI20 II through 033l120 12
TACACHALE 5 Ownership State [ 1]
I Fiscal Year Begin ----- __ _----l____
I Current Cost Report i 070112009
I Prior Cost Report LI
-------_-- ---- -~-~----- ~---~~~--=-~--
-- --------- --------j----------------1Fiscal Year End Audit Status Base Semester I
06302010 Unaudited [3] -------l I
__~~ ~~__~_~1 ____ ~~_~ ___________ J
Period Base
3 Line I x - _ -----__ -- - --~--
4 Current Period Cost
5 Incentive Basis
15 Prospective Rate Line I I x Inflation (104648267)
16 Interim Rate ~---------~-----------------
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component ---____-___ --__-shy ---- shy
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
---------- shy
88806 88806 357020
0000 0000 0000
88806 219890 308696 88806 357020
0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
0000 0000 0000 0000
0000 0000 I 0000 0000
------- --------
445826
0000
0000
33526 47876 2517
------1-----middot_--_middot_---------- shy
4440 2634 8809 955625 Medicaid Utilization
000
000
inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administrationl--0_2_8_02_6_7_0_0_-_2_0_11_I_I0---l Office ofMedicaid Cost Reimbursement Planning and Analysis --_RI_3_2_9_8_2_I_N_TM_4_6_5__4_S-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 7 Provider Number 028026700 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 063012010
Audit Status Unaudited [3]
Provider Type ICFMR~DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 32563 32982 100112011
8 Non-Ambulatory amp 9 Medical 45952 46545 100112011
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
x Unaudited Costs
Field Audited Costs Field Audit Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
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
Printpj rn flQf(llV)fl11 M fll(middotlmiddot1 l( nina vprltrm 4 1 hv 17111 Rth TnmiddotF7CiVT
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Florida Agency For Health Care Administration ___0_2_80_1_6_0_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name SUNLAND MARIANNA 3 Cost Report Entered by Squire Yashica Provider Numbel 28016000 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 shy 063012010 Date 982011 Days In Reporting Period 365
Number of Beds 44
ColumnA Residential Institutional
12849
~~-~-----T---~~-------- ~-
----C-ol-umn--B---- i I Column C Total Ii Non-Ambulatory Medical
2718 15567
237433
iA Allocation of Expenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Staffmg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
~ Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
389532
551093 63945
100 271800
297292863 56006229
2060568
389532 1789055
63945 00000
--------
2242532
389532
551093 63945 00000
2718 56434
207631
389532 2819291
63945
336480 o
419225 17928
_____ 420l3~_ 857886 99543
o
914250 10000
188387400
14777 306873
606385 3048633
99543 o
Florida Agency For Health Care Administration 028016000 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23438
ICFMR-DD Calculation Sheet NM 34219 Rates Effective 100112011 through 033112012
SUNLAND MARIANNA 3 OwnershipState[1 J
Base Semester
j------- +--------+--- ---- ---------- -+---- --~_i-- -~------~
1000025 Medicaid Utilization 9385
000 000
000
inted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationf--0_2_8_0_24_1_0_0_-_2_0_11_1_10-1 Office ofMedicaid Cost Reimbursement Planning and Analysis ~_R_I_3_3_5_2_6_I_N_M_4_7_8_7_6----l
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 5 1621 NB Waldo Road Gainesville FL 32609
Provider Number Date
FYE
Audit Status
028024100
091082011 06302010 Unaudited [3]
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Current Rate
33110
47277
New Rate
33526
47876
Effective Date
100112011
1010112011
IRateType-~--~ Interim
Total Interim
Interim Component
Settlement Based on Costs
x Prospective
X Total Prospective
Prospective Adjusted for New Cost
Budget
X Unaudited Costs
Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit - Prospective Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
D t~rl A )OI)Qf)Oll t (Qmiddot1middot1 Q TTjnn cmiddot lt11 h 17111 Rltgtth rnmiddotJ7rVT
-----
Florida Agency For Health Care Administration-I ___0_28_0_2_4_1_00__--- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFIMR-DD Profile Sheet Rate P eriod( s) 042011 to 1012011
Provider Name TACACHALE 5 Provider Numbel 28024100 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 40
ColumnA ColumnB Non-Ambulatory Medical
Column C Total --___----IjI Residential Institutional
4440 2634 7074
170516 426135
o 31563
888061 888061 628214
163155 252460
o 587525 587525 415615 122108 122108 86379 00000 00000 o
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Stafflllg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense I Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
050 222000
457354759 59893807
1348960
262414
100 263400
542645241 71063193
2697919
2517 71674
284760
888061 3570204
122108
4580372
485400 10000
130957000
6428 174304
628214 1899489
86379 o
2614082- ~-- ~~-~~
Florida Agency For Health Care Administration I 028024100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 33526
ICFMR-DD Calculation Sheet NM 47876 Rates Effective 1 lI20 II through 033l120 12
TACACHALE 5 Ownership State [ 1]
I Fiscal Year Begin ----- __ _----l____
I Current Cost Report i 070112009
I Prior Cost Report LI
-------_-- ---- -~-~----- ~---~~~--=-~--
-- --------- --------j----------------1Fiscal Year End Audit Status Base Semester I
06302010 Unaudited [3] -------l I
__~~ ~~__~_~1 ____ ~~_~ ___________ J
Period Base
3 Line I x - _ -----__ -- - --~--
4 Current Period Cost
5 Incentive Basis
15 Prospective Rate Line I I x Inflation (104648267)
16 Interim Rate ~---------~-----------------
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component ---____-___ --__-shy ---- shy
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
---------- shy
88806 88806 357020
0000 0000 0000
88806 219890 308696 88806 357020
0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
0000 0000 0000 0000
0000 0000 I 0000 0000
------- --------
445826
0000
0000
33526 47876 2517
------1-----middot_--_middot_---------- shy
4440 2634 8809 955625 Medicaid Utilization
000
000
inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administrationl--0_2_8_02_6_7_0_0_-_2_0_11_I_I0---l Office ofMedicaid Cost Reimbursement Planning and Analysis --_RI_3_2_9_8_2_I_N_TM_4_6_5__4_S-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 7 Provider Number 028026700 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 063012010
Audit Status Unaudited [3]
Provider Type ICFMR~DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 32563 32982 100112011
8 Non-Ambulatory amp 9 Medical 45952 46545 100112011
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
x Unaudited Costs
Field Audited Costs Field Audit Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
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
Printpj rn flQf(llV)fl11 M fll(middotlmiddot1 l( nina vprltrm 4 1 hv 17111 Rth TnmiddotF7CiVT
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Florida Agency For Health Care Administration 028016000 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 23438
ICFMR-DD Calculation Sheet NM 34219 Rates Effective 100112011 through 033112012
SUNLAND MARIANNA 3 OwnershipState[1 J
Base Semester
j------- +--------+--- ---- ---------- -+---- --~_i-- -~------~
1000025 Medicaid Utilization 9385
000 000
000
inted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
Florida Agency For Health Care Administrationf--0_2_8_0_24_1_0_0_-_2_0_11_1_10-1 Office ofMedicaid Cost Reimbursement Planning and Analysis ~_R_I_3_3_5_2_6_I_N_M_4_7_8_7_6----l
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 5 1621 NB Waldo Road Gainesville FL 32609
Provider Number Date
FYE
Audit Status
028024100
091082011 06302010 Unaudited [3]
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Current Rate
33110
47277
New Rate
33526
47876
Effective Date
100112011
1010112011
IRateType-~--~ Interim
Total Interim
Interim Component
Settlement Based on Costs
x Prospective
X Total Prospective
Prospective Adjusted for New Cost
Budget
X Unaudited Costs
Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit - Prospective Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
D t~rl A )OI)Qf)Oll t (Qmiddot1middot1 Q TTjnn cmiddot lt11 h 17111 Rltgtth rnmiddotJ7rVT
-----
Florida Agency For Health Care Administration-I ___0_28_0_2_4_1_00__--- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFIMR-DD Profile Sheet Rate P eriod( s) 042011 to 1012011
Provider Name TACACHALE 5 Provider Numbel 28024100 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 40
ColumnA ColumnB Non-Ambulatory Medical
Column C Total --___----IjI Residential Institutional
4440 2634 7074
170516 426135
o 31563
888061 888061 628214
163155 252460
o 587525 587525 415615 122108 122108 86379 00000 00000 o
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Stafflllg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense I Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
050 222000
457354759 59893807
1348960
262414
100 263400
542645241 71063193
2697919
2517 71674
284760
888061 3570204
122108
4580372
485400 10000
130957000
6428 174304
628214 1899489
86379 o
2614082- ~-- ~~-~~
Florida Agency For Health Care Administration I 028024100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 33526
ICFMR-DD Calculation Sheet NM 47876 Rates Effective 1 lI20 II through 033l120 12
TACACHALE 5 Ownership State [ 1]
I Fiscal Year Begin ----- __ _----l____
I Current Cost Report i 070112009
I Prior Cost Report LI
-------_-- ---- -~-~----- ~---~~~--=-~--
-- --------- --------j----------------1Fiscal Year End Audit Status Base Semester I
06302010 Unaudited [3] -------l I
__~~ ~~__~_~1 ____ ~~_~ ___________ J
Period Base
3 Line I x - _ -----__ -- - --~--
4 Current Period Cost
5 Incentive Basis
15 Prospective Rate Line I I x Inflation (104648267)
16 Interim Rate ~---------~-----------------
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component ---____-___ --__-shy ---- shy
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
---------- shy
88806 88806 357020
0000 0000 0000
88806 219890 308696 88806 357020
0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
0000 0000 0000 0000
0000 0000 I 0000 0000
------- --------
445826
0000
0000
33526 47876 2517
------1-----middot_--_middot_---------- shy
4440 2634 8809 955625 Medicaid Utilization
000
000
inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administrationl--0_2_8_02_6_7_0_0_-_2_0_11_I_I0---l Office ofMedicaid Cost Reimbursement Planning and Analysis --_RI_3_2_9_8_2_I_N_TM_4_6_5__4_S-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 7 Provider Number 028026700 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 063012010
Audit Status Unaudited [3]
Provider Type ICFMR~DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 32563 32982 100112011
8 Non-Ambulatory amp 9 Medical 45952 46545 100112011
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
x Unaudited Costs
Field Audited Costs Field Audit Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
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
Printpj rn flQf(llV)fl11 M fll(middotlmiddot1 l( nina vprltrm 4 1 hv 17111 Rth TnmiddotF7CiVT
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Florida Agency For Health Care Administrationf--0_2_8_0_24_1_0_0_-_2_0_11_1_10-1 Office ofMedicaid Cost Reimbursement Planning and Analysis ~_R_I_3_3_5_2_6_I_N_M_4_7_8_7_6----l
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 5 1621 NB Waldo Road Gainesville FL 32609
Provider Number Date
FYE
Audit Status
028024100
091082011 06302010 Unaudited [3]
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Current Rate
33110
47277
New Rate
33526
47876
Effective Date
100112011
1010112011
IRateType-~--~ Interim
Total Interim
Interim Component
Settlement Based on Costs
x Prospective
X Total Prospective
Prospective Adjusted for New Cost
Budget
X Unaudited Costs
Field Audited Costs
Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
Desk Audited Costs
Desk Audit Interim Portion
Desk Audit - Prospective Portion
W Rydell Samuel ~ Medicaid Cost Reimbursement Analysis
For Infonnation only - No Change in rate
D t~rl A )OI)Qf)Oll t (Qmiddot1middot1 Q TTjnn cmiddot lt11 h 17111 Rltgtth rnmiddotJ7rVT
-----
Florida Agency For Health Care Administration-I ___0_28_0_2_4_1_00__--- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFIMR-DD Profile Sheet Rate P eriod( s) 042011 to 1012011
Provider Name TACACHALE 5 Provider Numbel 28024100 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 40
ColumnA ColumnB Non-Ambulatory Medical
Column C Total --___----IjI Residential Institutional
4440 2634 7074
170516 426135
o 31563
888061 888061 628214
163155 252460
o 587525 587525 415615 122108 122108 86379 00000 00000 o
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Stafflllg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense I Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
050 222000
457354759 59893807
1348960
262414
100 263400
542645241 71063193
2697919
2517 71674
284760
888061 3570204
122108
4580372
485400 10000
130957000
6428 174304
628214 1899489
86379 o
2614082- ~-- ~~-~~
Florida Agency For Health Care Administration I 028024100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 33526
ICFMR-DD Calculation Sheet NM 47876 Rates Effective 1 lI20 II through 033l120 12
TACACHALE 5 Ownership State [ 1]
I Fiscal Year Begin ----- __ _----l____
I Current Cost Report i 070112009
I Prior Cost Report LI
-------_-- ---- -~-~----- ~---~~~--=-~--
-- --------- --------j----------------1Fiscal Year End Audit Status Base Semester I
06302010 Unaudited [3] -------l I
__~~ ~~__~_~1 ____ ~~_~ ___________ J
Period Base
3 Line I x - _ -----__ -- - --~--
4 Current Period Cost
5 Incentive Basis
15 Prospective Rate Line I I x Inflation (104648267)
16 Interim Rate ~---------~-----------------
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component ---____-___ --__-shy ---- shy
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
---------- shy
88806 88806 357020
0000 0000 0000
88806 219890 308696 88806 357020
0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
0000 0000 0000 0000
0000 0000 I 0000 0000
------- --------
445826
0000
0000
33526 47876 2517
------1-----middot_--_middot_---------- shy
4440 2634 8809 955625 Medicaid Utilization
000
000
inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administrationl--0_2_8_02_6_7_0_0_-_2_0_11_I_I0---l Office ofMedicaid Cost Reimbursement Planning and Analysis --_RI_3_2_9_8_2_I_N_TM_4_6_5__4_S-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 7 Provider Number 028026700 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 063012010
Audit Status Unaudited [3]
Provider Type ICFMR~DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 32563 32982 100112011
8 Non-Ambulatory amp 9 Medical 45952 46545 100112011
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
x Unaudited Costs
Field Audited Costs Field Audit Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
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
Printpj rn flQf(llV)fl11 M fll(middotlmiddot1 l( nina vprltrm 4 1 hv 17111 Rth TnmiddotF7CiVT
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
-----
Florida Agency For Health Care Administration-I ___0_28_0_2_4_1_00__--- Office of Medicaid Cost Reimbursement Planning and Analysis
ICFIMR-DD Profile Sheet Rate P eriod( s) 042011 to 1012011
Provider Name TACACHALE 5 Provider Numbel 28024100 Audit Status Unaudited [3] Date 982011
A Allocation of Expenses (excluding B amp C) I Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 40
ColumnA ColumnB Non-Ambulatory Medical
Column C Total --___----IjI Residential Institutional
4440 2634 7074
170516 426135
o 31563
888061 888061 628214
163155 252460
o 587525 587525 415615 122108 122108 86379 00000 00000 o
B Direct Care Expense 1 Staffing 2 Total Staffing Required 3 Stafflllg Percent 4 Allocation of Direct Care 5 Direct Care Expense Per Diem
C Additional Services Expense I Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
050 222000
457354759 59893807
1348960
262414
100 263400
542645241 71063193
2697919
2517 71674
284760
888061 3570204
122108
4580372
485400 10000
130957000
6428 174304
628214 1899489
86379 o
2614082- ~-- ~~-~~
Florida Agency For Health Care Administration I 028024100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 33526
ICFMR-DD Calculation Sheet NM 47876 Rates Effective 1 lI20 II through 033l120 12
TACACHALE 5 Ownership State [ 1]
I Fiscal Year Begin ----- __ _----l____
I Current Cost Report i 070112009
I Prior Cost Report LI
-------_-- ---- -~-~----- ~---~~~--=-~--
-- --------- --------j----------------1Fiscal Year End Audit Status Base Semester I
06302010 Unaudited [3] -------l I
__~~ ~~__~_~1 ____ ~~_~ ___________ J
Period Base
3 Line I x - _ -----__ -- - --~--
4 Current Period Cost
5 Incentive Basis
15 Prospective Rate Line I I x Inflation (104648267)
16 Interim Rate ~---------~-----------------
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component ---____-___ --__-shy ---- shy
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
---------- shy
88806 88806 357020
0000 0000 0000
88806 219890 308696 88806 357020
0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
0000 0000 0000 0000
0000 0000 I 0000 0000
------- --------
445826
0000
0000
33526 47876 2517
------1-----middot_--_middot_---------- shy
4440 2634 8809 955625 Medicaid Utilization
000
000
inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administrationl--0_2_8_02_6_7_0_0_-_2_0_11_I_I0---l Office ofMedicaid Cost Reimbursement Planning and Analysis --_RI_3_2_9_8_2_I_N_TM_4_6_5__4_S-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 7 Provider Number 028026700 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 063012010
Audit Status Unaudited [3]
Provider Type ICFMR~DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 32563 32982 100112011
8 Non-Ambulatory amp 9 Medical 45952 46545 100112011
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
x Unaudited Costs
Field Audited Costs Field Audit Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
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
Printpj rn flQf(llV)fl11 M fll(middotlmiddot1 l( nina vprltrm 4 1 hv 17111 Rth TnmiddotF7CiVT
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Florida Agency For Health Care Administration I 028024100 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 33526
ICFMR-DD Calculation Sheet NM 47876 Rates Effective 1 lI20 II through 033l120 12
TACACHALE 5 Ownership State [ 1]
I Fiscal Year Begin ----- __ _----l____
I Current Cost Report i 070112009
I Prior Cost Report LI
-------_-- ---- -~-~----- ~---~~~--=-~--
-- --------- --------j----------------1Fiscal Year End Audit Status Base Semester I
06302010 Unaudited [3] -------l I
__~~ ~~__~_~1 ____ ~~_~ ___________ J
Period Base
3 Line I x - _ -----__ -- - --~--
4 Current Period Cost
5 Incentive Basis
15 Prospective Rate Line I I x Inflation (104648267)
16 Interim Rate ~---------~-----------------
17 NA
18 Total amp Residential Care Rate
19 Property Rate Component ---____-___ --__-shy ---- shy
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
---------- shy
88806 88806 357020
0000 0000 0000
88806 219890 308696 88806 357020
0000 0000 0000 0000 0000
0000 0000 0000 0000 0000
0000 0000 0000 0000
0000 0000 I 0000 0000
------- --------
445826
0000
0000
33526 47876 2517
------1-----middot_--_middot_---------- shy
4440 2634 8809 955625 Medicaid Utilization
000
000
inted on 09082011 at 085118 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administrationl--0_2_8_02_6_7_0_0_-_2_0_11_I_I0---l Office ofMedicaid Cost Reimbursement Planning and Analysis --_RI_3_2_9_8_2_I_N_TM_4_6_5__4_S-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 7 Provider Number 028026700 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 063012010
Audit Status Unaudited [3]
Provider Type ICFMR~DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 32563 32982 100112011
8 Non-Ambulatory amp 9 Medical 45952 46545 100112011
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
x Unaudited Costs
Field Audited Costs Field Audit Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
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
Printpj rn flQf(llV)fl11 M fll(middotlmiddot1 l( nina vprltrm 4 1 hv 17111 Rth TnmiddotF7CiVT
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Florida Agency For Health Care Administrationl--0_2_8_02_6_7_0_0_-_2_0_11_I_I0---l Office ofMedicaid Cost Reimbursement Planning and Analysis --_RI_3_2_9_8_2_I_N_TM_4_6_5__4_S-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE 7 Provider Number 028026700 1621 NE Waldo Road Date 091082011 Gainesville FL 32609 FYE 063012010
Audit Status Unaudited [3]
Provider Type ICFMR~DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 32563 32982 100112011
8 Non-Ambulatory amp 9 Medical 45952 46545 100112011
Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs
Budget
x Unaudited Costs
Field Audited Costs Field Audit Interim Portion
Distribution Contract Management DPODS DCF (3) Home Office
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
Printpj rn flQf(llV)fl11 M fll(middotlmiddot1 l( nina vprltrm 4 1 hv 17111 Rth TnmiddotF7CiVT
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Florida Agency For Health Care AdministrationL-___0_2_8_02_6_7_0_0__-- Office ofMedicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Profile Sheet Rate Period(s) 0412011 to 1012011
Provider Name TACACHALE 7 Provider Numbel 28026700 Audit Status Unaudited [3] Date 982011
1--_middotmiddot__ middotmiddot_- --_-__-_-_ _
I A Allocation ofExpenses (excluding B amp C) 1 Resident Days 2 Operating Expenses Component
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROEUse Per Diem
B Direct Care Expense I Staffing 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5middot Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost I Operating Component
2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
0
489483489483
956414 956414 39559 39559
00000
050 100 000 1058100
1000000000 000 274279500
1296094 2592189
0 10484 0 389913
3719 371912
489483 489483 2624421 3920516
39559 39559 00000
3153463
Cost Report Entered by Squire Yasmca Rate Semester October 2011 Cost Report 07012009 - 06302010 Days In Reporting Period 365 Number of Beds 30
10581
Column C Total
10581
357134 149700
0 _ ____ lQ~_
517922
235045 776937
_ 0 - bullshy
1011982 41857
0
1058100 10000
274279500
10484 389913
517922 4144690
41857 0
----~---
~704plusmn~__
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Florida Agency For Health Care Administration I 028026700 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 32982
ICFIMR-DD Calculation Sheet NM 46545 Rates Effective 1001120 II through 033112012
TACACHALE 7 OwnershipState[l]
r Fiscal Year Be c~CurrefltmiddotCost Report--o7012
I I Prior Cost Report [
15 Prospective Rate Line II x Inflation (104648267)
16 Interim Rate
17 NA
18 Total
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
Audit Status
48948
0000
0000
10581 NA 990825 Medicaid Utilization
000 000
000
)rinted on 09082011 at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Florida Agency For Health Care Administrationf--0_2_8_0_55_1_0_0_-_2_0_11_I_lO~ Office of Medicaid Cost Reimbursement Planning and Analysis L-_R_1_=3_7_6_6_1_I_N_M_5_9_6_2_3-J
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
TACACHALE FACILITY 8 1621 NE WALDO ROAD GAINESVILLE FL 32609
Provider Type ICFIMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
IRate-Type------middot-middot--middotmiddot- --- - -----shy
Provider Number 028055100 Date 091082011 FYE 063012010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
37180 37661 100112011
58860 59623 100112011
I __ Interim x Prospective
Total Interim X Total Prospective
Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs ___bull_ _______bull__ __ _____ ___ bull _ bull____ __ _____ bull_ _____bull _ _bull__ bullbullbull___________ J
X
___-__-_
Distribution Contract Management DPODS - DCF (3) Home Office
Budget
Unaudited Costs Field Audited Costs
Field Audit - Interim Portion
Desk Audited Costs Desk Audit - Interim Portion
Desk Audit - Prospective Portion
-__--_______-____-__---_-- - shy
w Rydell samuel~ Medicaid Cost Reimbursement Analysis
For Infonnation only No Change in rate
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Florida Agency For Health Care Administrationll-___O_2_80_5_5_1_0_0__--J
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Provider Name TACACHALE FACILITY 8 Cost Report Entered by Squire Yashica Provider Numbel 28055100 Rate Semester October 2011 Audit Status Unaudited [3] Cost Report 070112009 - 063012010 Date 982011 Days In Reporting Period 365
Number ofBeds 56
ColumnA ColumnB Colunm C Total Residential Non-Ambulatory Medical Institutional
I A Allocation of Expenses (excluding B amp C) 13500 6907 204071 Resident Days
2 Operating Expenses Component A Administration 758176
607952B Plant Operation C Laundry o D Housekeeping 45030
1411158691507691507E Operating Expense Component amp Per Diem 3 Resident Care
467170A Dietary 386691B Other
oC Nursing 418416 418416 853861
~rop Exp amp Per Diem D Resident Care amp Per Diem
22438 22438 45790 00000 oJ ROEtUse Per Diem
B Direct Care Expense 050 1001 Staffing
3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost
302511
1365700675000 6907002 Total Staffing Required 494252032 100005057479683 Staffing Percent
294487483 5822811004 Allocation of Direct Care 287793617 5 Direct Care Expense Per Diem 2131805 4263609
C Additional Services Expense 6850 203181 Medicaid Inpatient Days 13468
207220 6592842 Additional Services 452064
691507 14111581 Operating Component 691507 2 Resident Care Component 2885878 3 Property Cost Component 22438 4 ROElUse Allow Component 00000
5 Total Cost Per Diem 3599823
4984536 22438
5698481
7335956 45790
o 8792904
~--~-~~ ~--~~----~-- -
Printprl on nQflRO 11 M ORmiddot 1middot J 4 T T(1 vpro 4 1 hv R~khTnmiddotF7rVT
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Calculation Sheet
Rates Effective 1010 I12011 through 031312012
RI 37661
NM 59623
TACACHALE FACIOwnershipState[l]
LITY 8
Florida Agency For Health Care Administration l 028055100 - 2011110
Base Semester
498454 I
0000
498454
0000
6850 -~- ------~~-
13500 690724 Resident ~-~~~-~----------~~ -+----- ~ -------~-~-----------
9976 991725 Medicaid Utilization
000
000
rinted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGVJ
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Florida Agency For Health Care Administration 028058500 - 201110 Office of Medicaid Cost Reimbursement Planning and Analysis RI25019 I NM35064
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
Sunland Marianna 4 Provider Number 028058500 3700 Williams Road Date 091082011 Marianna FL 32446 FYE 06302010
Audit Status Unaudited (3]
Provider Type ICFMR-DD Current New Effective
Level of Care Rate Rate Date 7 Institutional 24708 25019 100112011 8 Non-Ambulatory amp 9 Medical 34624 35064 t0012011
iRate Type-~~- ~
i Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost
Settlement Based on Costs - -~---- --~~----~--bull~ ~~---~~- ~-~-- -____ - -~- - ----- ----- ~ ---- ---bullbull----
Budget Desk Audited Costs X Unaudited Costs Desk Audit - Interim Portion
Field Audited Costs Desk Audit - Prospective Portion
Field Audit - Interim Portion L__~__===_ __
w Ryden Samuel ~ Medicaid Cost Reimbursement Analysis
Distribution Contract Management DPODS - DCF (2) Home Office
For Information only - No Change in rate
Jrinted on 09082011 at 085118 Usinrr version 41 hv 17111 Batch IDFZGVJ
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Florida Agency For Health Care Administration--__O_2_80_5_8_5_0_0__---l
Office of Medicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 1012011
Column C Total r
1 Resident Days 2 Operating Expenses Componenj
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem
Prop Exp amp Per Diem J ROEUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffmg Required 3 Staffmg Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
~------ -~ -~
C Additional Services Exgense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROEUse Allow Component
5 Total Cost Per Diem
Provider Name Sunland Marianna 4 Cost Report Entered by Squire Yashica Provider Numbel 28058500 Rate Semester October 2011 Audit Status Unaudited (3] Cost Report 070112009 - 06302010 Date 982011 Days In Reporting Period 365
Number of Beds 20
5932
443929
467602 82298 00000
050 296600
730361980 56559524
953465
5850 261571
4471
1095
443929
467602 82298 00000
100 109500
269638020 20880876
1906929
1095 49661
453525
443929 443929 1868197 2828057
82298 82298 00000
------_~--------~
2394424 3354284 ~--~------
7027
97602 195482
deg 1 311949
212040 10415
57831 0
406100 10000
77440400
6945 311232
311949 1414220
57831 0
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Florida Agency For Health Care Administration I 028058500 - 2011110 Office of Medicaid Cost Reimbursement Planning and Analysis RI 25019
ICFMR-DD Calculation Sheet NM 35064 Rates Effective 100 1120 11 through 0331120 12
Sunland Marianna 4 OvvnershipState[l]
Base Semester
----~-~----- ---_ shy --- shy
I Prior Period Base
Inflation Factor 000000000
5 Incentive Basis
7 Incentive Line 5
~-----~---~-
15 Prospective Rate Line 1 I x Inflation (104648267)
I6 Interim Rate
17NAI---- ---------- ---~-~ ---- ---~-- shy
FI8bullTot=a--l=r=_CLamp=--=-Re=-s=-idsectlJ_ia_l_C_ar~_R_at_e ___ _ 19 Property Rate Component
20 ROE Component + ROE Interim Component
21 Plus Property Interim Rate Component
25 Medicaid Utilization
0000
44393 186820
0000 0000
0000 0000
----~ _------_-shy _-_---
5932 9862
000
0000
44393
0000
0000
282806
0000
282806
0000
0000
1095-0060--shy
327199
0000
0000
342408
8230 0000
000
000
rinted on 090820 I I at 0851 18 Using version 41 by 17111 Batch IDFZGV J
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
-----shy
Florida Agency For Health Care Administratioll--O_2_8_S6_2_S_0_0_-_20_1_1_11_0_1 Office of Medicaid Cost Reimbursement Planning and Analysis ~_RI_2_4_6_6_4_I_N_M__3_8_2_5_8---
2727 Mahan Drive-Mail Stop 21 Tallahassee Florida 32308
I-Rate Type--~----~-
Interim x Prospective
Total Interim X Total Prospective Interim Component Prospective Adjusted for New Cost Settlement Based on Costs
----~---~--- -~---------- ---~--------- ------------------------------~-----------------
SUNLAND MARIANNA 5
3700 Williams Drive Marianna FL 32446
Provider Type ICFMR-DD
Level of Care
7 Institutional
8 Non-Ambulatory amp 9 Medical
Provider Number 028562500 -Date 091082011 FYE 06302010
Audit Status Unaudited [3]
Current New Effective Rate Rate Date
24357 24664 100112011
37776 38258 100112011
Budget x Unaudited Costs
Field Audited Costs Field Audit - Interim Portion
Distribution Contract Management DPODS DCF (2) Home Office
Desk Audited Costs
Desk Audit - Interim Portion Desk Audit - Prospective Portion
--------~-----~-- ---------~------~- ---~-------- ---- ---shy
w Rydell Samuel Medicaid Cost Reimbursement Analysis
For Information only - No Change in rate
Printed on 09082011 at 0851 18 Using version 4_1 bv 17111 Batch IDFZGVJ
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Florida Agency For Health Care AdministrationL- ___0_2_8_5_62_5_0_0__---1
Office ofMedicaid Cost Reimbursement Planning and Analysis ICFMR-DD Profile Sheet
Rate Period(s) 042011 to 102011
-~---
2360234 3659305
Provider Name SUNLAND MARIANNA 5 Provider Numbel 28562500 Audit Status Unaudited [3] Date 982011
i
i I
A-Nl~~~icm middot~-f-E~~~~se~(excluding B amp Cmiddot-)-~~middot-~-middotI
1 Resident Days 2 Operating Expenses Componenl
A Administration B Plant Operation C Laundry D Housekeeping E Operating Expense Component amp Per Diem
3 Resident Care A Dietary B Other C Nursing D Resident Care amp Per Diem Prop Exp amp Per Diem
J ROElUse Per Diem
B Direct Care Expense 1 Staffmg 2 Total Staffing Required 3 Staffing Percent 4 Allocation ofDirect Care 5 Direct Care Expense Per Diem
C Additional Services Expense 1 Medicaid Inpatient Days 2 Additional Services 3 Additional Services Exp amp Per Diem
i D Medicaid Per Diem Cost 1 Operating Component 2 Resident Care Component 3 Property Cost Component 4 ROElUse Allow Component
5 Total Cost Per Diem
Cost Report Entered by Squire Yashica Rate Semester October 2011 Cost Report 070112009 - 06302010 Days In Reporting Period 365 Number of Beds 49
Column C Total ~~middot--~-middotmiddot~--middot-middotmiddot~--middot~-middotmiddotl~middot----middotmiddot-middotmiddotmiddotmiddot-~~middot--middot
Column A Residential Institutional
5319
509692 509692
549186 77035 i 77035
549186
00000
100 1099200 8051
233589924
Column B Non-Ambulatory Medical
i
~--~-~~~ ~- ~---~--
10992 16311
365635 424735
o ------plusmnQ2~~
831358
404865 22630
~46812~ 895777 125652
o
1365150 10000
290106700
15942 509165
831358 4306009
125652 o
5319 86049
161
509692 1773508
77035 00000
10623 423116
398302
509692 3072578
77035
Printpcl nn OOO)(1011 gtIt 0)( 1 middot14 nno prifln lt1 1 h RMfhTOF7GVT
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
Office of Medicaid Cost Reimbursement Planning and Analysis
ICFMR-DD Calculation Sheet Rates Effective 1001120 II through 03312012
RI 24664
NM 38258
SUNLAND MARIANOwnership State[ 1]
NA 5
Florida Agency For Health Care Administration I 028562500 - 2011110
Base Semester
50969
0000
307258 358227
0000
307258 358227
0000 0000
0000 i 0000 I 0000
IS Prospective Rate Line II X Inflation (104648267) ~ -~~~+~~~~--+~~~
16 Interim R~at~e~JlEltEe~__~ _____ _ _____-+--___O_O_O_O__+___f_____+ ____--~t_--bull-----------I
17 NA 0000 0000
18 Total amp Residential Care Rate
19 Property Rate Component
20 ROE Component + ROE Interim Component --__ __ shy
21 Plus Property Interim Rate Component
5319_----_- I----~--------~- -~--------
1000025 Medicaid Utilization
10992 ~ ---~-----~--~-- ~--~-
9664
000
000
[nted on 090820 II at 0851 18 Using version 41 by 17111 Batch IDFZGV J
000
