MANAGEMENT SERVICES DIVISION OFFICE OF RATES MANAGEMENT

1. MANAGEMENT SERVICES DIVISIONOFFICE OF RATES MANAGEMENT Reporting Year 2007 DDD RESIDENTIAL SUPPORT PROGRAMS ANNUAL COST REPORTING

2. PURPOSE OF COST REPORTING • Provide program cost data to division regional managers and residential providers, • Provide information to establish rates and/or allocate appropriated funds, • Determine end-of-year settlement for the ISS staff cost centers • Provide information to the legislature and department management for budget development and policydecisions.

3. SCHEDULE AGENERAL INFORMATION AND CERTIFICATION • PART A – PROVIDER IDENTIFYING INFORMATION • This schedule is used to provide basic information about the agency and Cost Report contact individuals. • Not all information requested on Schedule A will apply to all providers. Complete only those sections that pertain to your specific program or programs. • On Sections 7 and 17, of Schedule A, please furnish your current e-mail addresses. Any changes that occurred prior to completion of your 2007 cost report should be reflected here. If your e-mail changes anytime during the year, please send us a message using your new e-mail address.

4. Schedule A, Part A

5. Schedule BROGRAM INFORMATION This schedule provides agency business and program information. • Line 18: Indicate if you provide or purchase medical services. This would include medical personnel such as nurses and doctor on staff or contracted. • Line 19: Indicate your type of business organization • Line 20: Indicate the type of accounting method used for this report.

6. Schedule B • Identify the provider number(s) for each program • Identify the Program Type for each program • Regular ISS hours worked • Sleep hours if any • Identify the program, Supported Living, Group Home or Others • Total Hours Worked (i.e., total of all the ISS Hours provided) • Call-back hours • Annual Resident Days • Average Hours Per Resident Day

7. SSP Clients Note • During the latter part of 2002, a number of contracted residential clients began receiving SSP funds to pay for their services. If you served clients during 2005 who paid for their cost of care with SSP funds, please account for all the expenses and revenues separately on Schedule C or D. • Also, please note the reporting requirements identified in the instructions for service hours and costs for these clients.

8. Schedule CAGENCY ALLOCATED COSTS • Include agency expenses for the provider’s contracts and other business activities. • When paid hours worked is used as the allocation method; the hours indicated on Schedule B will be used to allocate expenses that cannot be identified with specific program/s. • On this schedule, enter the amounts in the total column.. • The allocated amounts for each program will auto-fill based on the percentages of total hours worked.

9. SCHEDULE DDIRECT CHARGED COSTS • Same cost categories as Schedule C • Used to distribute identifiable and specific agency Direct Charged costs to the applicable program(s). • On this schedule, enter amounts in the program columns – the Total column will auto fill.

10. SCHEDULE EPROGRAM SUMMARY and DIRECT CARE RELATED COSTS • Records client services costs and accumulates expenses at the program level. • Costs from Schedules C and D are brought forward (lines 1 and 2) to this schedule to arrive at the total program/s Administrative/Overhead cost. • Enter amounts in columns for program cost & amounts will sum in the Total column.

11. Schedule E (cont) Highlights Staff Lodging Expense • ISS Compensation Expense: In the section, “Direct Care Staff Compensation”, report lodging expenses that are the cost of providing the primary residence of the staff person. This cost is compensation for the staff person and reported as income to the IRS. (Report these costs on Schedule J).

12. Schedule E (cont) Staff Lodging Expense • Non-ISS Lodging Expense: In the section, “Other Client Related Expenses”, report lodging expenses that are the cost of maintaining a residential unit for on-duty overnight staff when it is not the primary residence of the staff person. (This is not a staff compensation expense, therefore, do not report these costs on Schedule J). Note: this cost may become a component of the reimbursement rate for clients with this service model.

13. SCHEDULE E (cont) Maintenance/Laundry/Housekeeping/Dietary • This is typically a Group Home cost category. • Supported Living Programs might have costs in this category if there is a staff person or contractor whose job duties are to maintain/repair client’s homes.Note: this cost may become a component of the reimbursement rate for individual clients.

14. SCHEDULE FPROPERTY AND RELATED EXPENSES Used to detail the depreciation information for owned buildings, equipment, furniture and vehicles. • You may choose to use schedule F or attach a depreciation schedule that provides The required information. • Record assets at their purchase price from unrelated, arm’s length transactions. • If the asset was donated or acquired at below market value, record the asset at the appraised value. • The beginning balances should equal the ending balances from prior year’s report. • Records the accumulated depreciation expense amounts for the assets. • If asset/s is fully depreciated, accumulated depreciation equals the cost less salvage value (if any).

15. Schedule F(sample) • Note that the depreciation expense equals the total depreciation amount entered on schedules C, D and the depreciation amount included on Schedule E for “Other Transportation”.

16. SCHEDULE GDEBT EXPENSE • Used as a worksheet to detail the debt expense for Working Capital, Property and Other Related Debt, and Vehicle Debt. • Record the debt obligation/s for which interest expense was incurred during the report period by the following categories; Column A: Date of Loan Column B: Creditor Column C: Purpose and Security Column D: Original Term of the Loan Column E: Annual Interest Rate Column F: Original Loan Amount Column G: Balance at Beginning of the Period Column H: Report Period Payments – Principal Column I: Report Period Payments – Interest Column J: Balance at the End of the Period

17. Schedule G

18. SCHEDULE HPROGRAM REVENUES REVENUE RECEIVED OR EARNED DURING THE REPORT PERIOD (The revenue for residential services must be reported on an accrual basis). • Reported amounts must be earned during the reporting year regardless of when they were received. • Revenues reported in the Other Operating Revenue and Non-Operating Revenue Categories may be on either the accrual or cash basis. • Revenue identified with SSP client/s should be reported on Line 5 “Other”

19. Schedule H

20. Schedule H (cont)

21. Schedule JProgram Settlement • Used for settlement calculation for facility and/or non-facility programs that are subject to the settlement process as explained in DDD policy 6.04, Section VII.. • Use Schedule J Worksheets, pages 1 – 4 (30 lines each) to enter each unique rate your agency had during the year as needed. • The totals from the Schedule J Worksheets are entered on the Schedule J summary page.

22. Schedule J (Continued) Column G: Benchmark Rates: • The January 1st through June 30th rate was $14.53 for Non-MSA counties, $14.82 for MSA counties and $15.13 for King county. • The July 1st through December 31st rate was $15.18 for Non-MSA, $15.49 for MSA, and $16.11 for King county. Use Schedule J Worksheets, pages 1 – 4 (30 lines each) to enter each unique rate your agency had during the year as needed. Make additional copies of the worksheet required. Note: If you need help adding a page to the EXCEL file, feel free to call Ron Sherman or one of the Analysts. DO NOT INCLUDE RATES FOR CLIENTS WHO PAID WITH SSP FUNDS.

23. Schedule J (cont)Program Settlement This section of Schedule J records the professional services, Nurse Delegation Training and Staff Add-On hours.

24. Schedule J(notes) • If your agency utilized staff Add-On or Nurse Delegation training hours during the reporting year, enter these hours in lines 12 through 19, column C and multiply by the benchmark rate paid for those hours. • In the Settlement B section, include the ISS staff compensation, administrator as ISS hours and staff lodging costs that pertain to Non-SSP clients only. These costs should agree with the amounts reported on Schedule E, line 3 plus line 4. • When entering rates, include the reimbursement rate information for Non-SSP residential clients only. In the Settlement A section, line 22, include only the number of hours paid for Non-SSP contracted clients. • In the Settlement B section, include the ISS staff compensation for administrator if applicable.

25. SCHEDULE J(cont) Settlement A The settlement involves a comparison of actual hours worked by ISS staff (and hours worked as ISS by Administrator, if eligible), to ISS staff hours reimbursed, multiplied by the average compensation (benchmark) rate for the period.

26. Schedule J(cont) Settlement B A comparison of the actual ISS staff costs incurred by the provider to the ISS staff reimbursement received from the Division during the period The actual settlement is the greater of Settlement A or B.

27. SCHEDULE KADMIN. & NON-STAFF LOSS WORKSHEET Used for the calculation of a loss in the administration and non-staff cost centers which may be used to off-set a settlement due. • Completion of this schedule is optional. • The Total Itemized Cost should exclude the SSP cost identified on Schedule E. • The Administrative and Non-Staff rate section should exclude rates for the clients with SSP funding. • The number of resident days included in this section should match the Paid Resident Days shown on Schedule B (excluding SSP or private pay clients) The use of Non-staff loss to offset a settlement has to be requested and is subject to the approval of the Regional Administrator per DD Policy 6.04

28. SCHEDULE LOTHER EXPENSES DESCIPTIONS Used to describe those expenses listed in “other” categories when amounts are in excess of $1,000.00. • The purpose of this schedule is to enable identification of major expenditures group or items that do not fall into the category titles provided on Schedules D or E. • Indicate the expense schedule and the account number for each instance in which the “other” amount is over $1,000.00. • Provide a brief explanation of the expenditure amount.

29. Schedule MOWNER AND RELATED INDIVIDUALS COMPENSATION This schedule is used to report ISS salary, wages and other compensation for owner(s) and/or related individuals. (Policy 6.04 II.J. 1 – 4) This schedule is used to report ISS salary, wages and other compensation for owner(s) and/or related individuals. (Policy 6.04 II.J. 1 – 4) This schedule is used to report ISS salary, wages and other compensation for owner(s) and/or related individuals. (Policy 6.04 II.J. 1 – 4)

30. For more information, visit us at:http://www.dshs.wa.gov/ddd/index.shtml For Questions About Completing the Cost Report - contact: Ron Sherman - Reimbursement Section Manager (360) 725-3207 E-Mail Address shermrd@dshs.wa.gov Dave Cook – Analyst for Region 4 (360) 725-3206 E-Mail Address cookds@dshs.wa.gov Hector Garcia – Analyst for Regions 3 and 6 (360) 725-3205 E-Mail Address garciah@dshs.wa.gov Mernilo Cruz – Analyst for Regions 1, 2 and 5 (360) 725-2514 E-Mail Address cruzma@dshs.wa.gov