AGENCY: Box Elder County (Utah). Pioneer Care Center

SERIES: 4469
TITLE: Facility cost profile report
DATES: 1994.
ARRANGEMENT: Chronological by year

DESCRIPTION: This annual financial report is required by the Utah Division of Health Care Financing. It is used as the basis for establishing a data base for rate calculations and is due two months after the end of the reporting period. The report includes balance sheets (containing current assets, description and amount, with handwritten notations), a statement of revenues and expenditures (description, current year, year to date, totals); and the facility cost profile report form.

The profile report form resembles an income tax form and consists of four individual schedules (Schedules A, C, D, and E). The report's cover sheet includes the name and address of the facility, type of facility, total number of licensed beds, type of ownership, and a certification attesting to the accuracy of the report signed by the center's administrator and report's preparer.__Schedule A includes the provider number, name of auditing firm and dates of last audit, questions concerning ownership, changes in rates, an attached balance sheet for the beginning and ending of period covered (expenses per general ledger, adjustments, facility cost profile reported expenses, audit adjustments and reclassifications), audited cost, patient days by type (private, Medicaid, Medicare, and Veterans Administration), total days reported, capacity (number of beds, days at capacity, total days), classification of facility and totals. Schedule C reports on Medicare revenue and includes period covered, facility cost profile reported revenue, totals, private revenue relating to period, other revenue not offset against cost, total revenue not offset against operating cost. Schedule C-2 includes the checklist of adjustments made to operating expenses and reported adjustments (income from patients, and miscellaneous income).

Schedule D reports on rental property, and Schedule E is a compilation of return on equity capital of proprietary procedures. The Pioneer Care Center does not use schedules D and E.

RETENTION

DISPOSITION

RETENTION AND DISPOSITION AUTHORIZATION

Retention and disposition for this series were specifically approved by the State Records Committee.

APPROVED: 12/1990

FORMAT MANAGEMENT

Paper copy: Retain in Office for 5 years and then destroy.

APPRAISAL

Administrative Legal

This disposition is based on the administrative needs expressed by the center's administrator and the requirements of the Utah Division of Health Care Financing stated on the report itself, whereby the administrator agrees "to keep for a period of 5 years such records as necessary to disclose fully the information contained herein."