Provider Cost & Wage Survey Instructions. Survey release date: April 30, 2018 Survey due date: June 5, 2018

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1 Provider Cost & Wage Survey Instructions Survey release date: April 30, 2018 Survey due date: June 5, 2018 Aging and Adult Services Division ( The Division )

2 Survey Overview Do you have a question concerning the Cost and Wage Survey? You may Navigant at MN_aging_services@navigant.com. Navigant staff will respond to you as soon as possible. Note: It is important to read the instructions in their entirety before completing the survey. The 2017 MN Legislature established a new methodology for determining rates for a number of services provided under the state s Elderly Waiver (EW), Alternative Care (AC), and Essential Community Supports (ECS) programs, effective January 1, The following services are subject to the new methodology: adult day service, chore, home delivered meals, and homemaker under EW, AC, and ECS; companion and respite under EW and AC; and customized living and foster care under EW. Customized living under the Brain Injury (BI) and Community Access for Disability Inclusion (CADI) waivers is also subject to the new methodology. The legislature directed DHS to evaluate the new methodology, and to submit a report to the legislature by January 1, 2019: (Laws of Minnesota, st Special Session, Chapter 6, Article 3, Section 19). The data collected from the survey will help inform this report. For purposes of this survey, a provider is defined as a controlling entity, agency or corporate organization that provides any of the services referenced above. This survey should be completed by any providers that provide any combination of these services. Providers that only provide home-delivered meals should complete the separate Home-Delivered Meals survey. The survey website provides additional copies of the surveys and corresponding instructions along with a list of frequently asked questions. Please visit the project website at: PLEASE NOTE THAT INDIVIDUALS COMPLETING THIS SURVEY MUST HAVE A WORKING KNOWLEDGE OF PROVIDER OPERATIONS, AND A THOROUGH UNDERSTANDING OF THE ACCOUNTING RECORDS OF THE ORGANIZATION. Overview The individual schedules included in this survey provide a mechanism for translating costs and other information reported in your accounting and other operating records into a consistently Survey Navigant 4/30/2018 Page 1

3 Survey Overview reported format that can be easily analyzed for purposes of this study. The instructions explain the information that we are seeking on each line item. Please complete the survey exactly as requested. Note that some questions of this survey may pertain to services that you do not provide or personnel you do not employ. Please skip such questions. We request you provide data as completely and accurately as possible for the services that you offer and the personnel you employ. Survey Reporting Time Schedule Please submit your survey to Navigant Consulting by Tuesday, June 5, Reporting Period The reporting period for this survey should be the provider s most recently completed fiscal year. Therefore, if your agency s fiscal year follows the calendar year, you would report for the period ending December 31, If you report data on the State s fiscal year, you would report for the period ending June 30, Review of Surveys DHS or its agents may perform a desk review on surveys to determine if the financial and statistical information submitted conforms to applicable rules and instructions. How to Submit The Survey Please complete the survey in Excel and it to MN_Aging_Services@navigant.com. If you do not have Excel capabilities, you may choose to complete a printed paper copy of the PDFbased survey and then either scan and it to the address above or mail it to Greg Weinstock (address below). Please ensure that paper-based surveys are legible. Greg Weinstock, Consultant Navigant Consulting, Inc. 150 North Riverside Plaza, Suite 2100 Chicago, IL If your survey is not properly completed, the Division or Navigant staff may contact you for clarification. Resubmission of Surveys If you have already submitted your completed survey, but wish to submit a revised version for whatever reason (correction of error, more current data, etc.), you may do so by sending a Survey Navigant 4/30/2018 Page 2

4 Survey Overview revised version to the abovementioned or mail address. At the close date of the survey submission process, we will identify the survey file most recently received from organization and discard any versions submitted previously. The latest version we receive from your organization will be the version used for purposes of the rate rebasing process. How to Complete this Survey if Your Organization has Multiple Sites Providers with multiple locations/sites can submit one survey that encompasses data for all of their locations/sites or one survey per location/site. Specific Instructions, by Worksheet The following table provides a brief description of each of the Worksheets included in the survey. All applicable forms must be completed. Table 1: Cost and Wage Survey Worksheets (press ctrl then click on the link to be taken directly to the hyperlink location) Worksheet A. Provider Information B. Services C. Provider/Supervisor Services D. Wages Description General information about the provider, including locations, service area, revenues and total staffing Services being studied in this evaluation that your organization delivers Identify the direct care provider types and supervisors that deliver aging services Direct care employee wages, hours and benefits incurred by the provider for services, broken down by employee type E. Employee Costs Total full- and part-time salaries, benefits, taxes, and benefits F. Non-Program Employee Costs G. Adult Day Services Total non-payroll, program, service delivery administrative expenses, and transportation costs Summary of adult day services, including costs and group information. Survey Navigant 4/30/2018 Page 3

5 Survey Overview Worksheet H. Health Insurance Benefits Description Health insurance benefit costs and details Specific instructions for each of the above Worksheets are provided on the following pages. Survey Navigant 4/30/2018 Page 4

6 Worksheet A: Provider Information WORKSHEET A: PROVIDER INFORMATION The purpose of this worksheet is to identify the provider organization and collect information on the provider sites, including number of participants served and service radius. Provider Identification Line 1: Provider Name. Enter provider s full name, as submitted on claims billed under the specific Medicaid provider number for which you are responding for this survey. Line 2: Are you owned by a larger organization or umbrella company? (this question relates to ownership and not management services) Select yes or no from the dropdown list to the right. Line 3: If the answer to question 2 is yes, what is the name of that organization? Enter the name of the umbrella organization. Line 4: Are you responding for one location/site within a larger organization or for multiple locations/sites within an organization? Select one location or multiple locations from the drop-down list to the right. Line 5: Provider ID. Enter the primary Provider ID Number for the provider organization for which you will be submitting data. If you are a provider that uses several Provider ID Numbers for billing purposes, please submit survey data related to all services provided by your controlling agency on a single survey form and list all associated Provider ID Numbers on Line 5 (separated by a comma). Line 6: City. Enter the primary city associated with the Medicaid provider number Line 7: County. Enter the primary county associated with the Medicaid provider number Line 8: Provider Fiscal Year Beginning: Enter start date (MM/DD/YY) of the provider s fiscal year represented in survey. This date should be no earlier than January 1, 2016 Line 9: Provider Fiscal Year Ending. Enter end date (MM/DD/YY) of provider s fiscal year represented in survey. This date should be no later than December 31, 2017 Contact Information Line 10: Contact Person. Enter name of person responsible for completing this survey. Survey Navigant 4/30/2018 Page 5

7 Worksheet A: Provider Information Line 11: Title. Enter title of person responsible for completing this survey. Line 12: Phone Number. Enter phone number (XXX-XXX-XXXX) of person responsible for completing this survey. Line 13: Address. Enter address of person responsible for completing this survey. Organizational Details Line 14: Where do you provide most of your services? Select urban, rural, or suburban from the drop-down list to the right. Line 15: How many counties do you serve? Enter the number of counties the provider serves. Line 16: Do you serve in Minnesota Tribal areas? Select yes or no from the drop-down list to the right. Line 17: How many sites do you have? Enter the number of service locations the provider operates. Line 18: How many sites provide services to Medicaid recipients? Enter the number of service locations that provide services to Medicaid recipients. Line 19: Number of current unduplicated active clients at the time of the survey. Enter the number of active clients. Organizational Revenues Line 20: Total revenue EW, AC, ECS. All services except for home-delivered meals. Line 21: Total revenue Home-Delivered Meals. Revenue from any funding stream. Line 22: Total revenue disability waivers (BI, CAC, CADI, DD). Line 23: All other revenue. Include all other revenues not included in Lines 20 through 22. Line 24: Total revenue. This will be a sum of Lines 20 through 23. Survey Navigant 4/30/2018 Page 6

8 Worksheet B: Services WORKSHEET B: SERVICES This worksheet is used to identify the services your organization provided to waiver participants and other non-waiver clients in the provider fiscal year entered on Worksheet A. Please check all that apply. Survey Navigant 4/30/2018 Page 7

9 Worksheet C: Provider/Supervisor Services WORKSHEET C: PROVIDER/SUPERVISOR SERVICES The purpose of this worksheet is to identify the direct care providers and supervisors that are providing the services being reviewed. This information should be based upon a snapshot date of March 29, Line Description The lines in this Worksheet represent different employee types. Direct Care Provider/Employee, Lines 1 through 12 Lines 1 through 12 capture services performed by employees who provided direct hands on support to people you serve (waiver participants and other non-waiver clients) In Lines 1 through 12 add an x if the provider type listed in the Description column provides or supervises that service. The titles in Lines 1 through 12 may not correspond to your agency s titles for direct service workers. Please choose the rows that best correspond to your agency s staffing practices. If there are Other Program Employees not listed in Lines 1 through 11, please enter the relevant provider type for these employees in Line 12 and put an x to indicate the service they provide. Supervisor Services, Lines 13 through 22 Lines 13 through 22 capture services performed by employees who perform a supervisor role for direct services (to waiver participants and other non-waiver clients). Supervisor Time Delivering Services, Lines 23 through 32 Lines 23 through 32 capture the percent of time on average each supervisor spends face-toface with clients as opposed to time spent supervising. Column Description The columns in this Worksheet represent services delivered or supervised. Put an x in the column for a service that correlates to the row of a provider. Services Delivered or Supervised, Columns 1 through 11 Services Delivered or Supervised in a Residential Setting, Columns 12 through 19 Survey Navigant 4/30/2018 Page 8

10 Worksheet D: Wages WORKSHEET D: PROGRAM EMPLOYEE WAGES This worksheet captures wage, paid time off, training hours, and filled/unfilled positions for program (direct care) employees and supervisors as of March 29, Line Description The lines in this Worksheet represent different employee types. If a staff type listed does not apply to your organization, leave the row blank. Each row summarizes wages for all employees of that staff type (not one row for each employee). Direct Care Provider/Employee Hourly Wages, Lines 1 through 12 Lines 1 through 12 capture employee hourly wages paid to employees who provided direct hands on support for services delivered (to waiver participants and other non-waiver clients). If your employees are paid on a salary basis, you can calculate hourly wages by dividing the annual salary by 2,080 (the number of working hours in a year based on a 40- hour work week), or for part-time salaried positions, a reasonable estimate of the number of hours worked over the course of a year. If your employees regularly work overtime, you may divide the salary by more than 2,080 as appropriate. Enter wage information for each employee type on lines 1 through 11 (the same employee types as listed in Worksheet C). If there are Other Program Employees that you identified on Worksheet C, please enter the relevant wages for these employees in aggregate on line 12. Supervisor Hourly Wages, Lines 13 through 22 Lines 13 through 22 capture supervisor hourly wages paid to employees who provided supervisory role support for services delivered (to waiver participants and other non-waiver clients). If your employees are paid on a salary basis, you can calculate hourly wages by dividing the annual salary by 2,080 (the number of working hours in a year based on a 40- hour work week), or for part-time salaried positions, a reasonable estimate of the number of hours worked over the course of a year. If your employees regularly work overtime, you may divide the salary by more than 2,080 as appropriate. Column Description Please fill out Columns 1 9, described below, for each of the employee types you employ. Survey Navigant 4/30/2018 Page 9

11 Worksheet D: Wages Hourly Wage: Column 1: Average Hourly Wage. Enter the average hourly regular wage paid among all employees for each employee type. Column 2: Lowest Hourly Wage. Enter the lowest hourly wage rate (actual, not average) among all employees for each employee type. Column 3: Highest Hourly Wage. Enter the highest hourly wage rate (actual, not average) among all employees for each employee type. Column 4: Paid Time Off for Full-Time Employees: Allowed Annual Hours per FTE including Vacation, Holiday, and Sick Time. Enter the total number of hours of paid time off you allow for each employee type, including vacation, holiday, sick, and other time off, on an annual basis. Complete only if agency policy includes a set amount of hours per year. Column 5: Average Annual Paid Training. Enter the total number of hours of paid training time you allow for each employee type on an annual basis. Do not include travel time. Full-time Positions as of March 29, 2018 (30 hours/week or 130 hours/month or more): Column 6: Number of Total Filled Full-Time Positions: Enter the total number of filled fulltime positions, as of 3/29/2018, for each employee type. Column 7: Number of Unfilled Full-Time Positions: Enter the number of unfilled full-time positions, as of 3/29/2018, for each employee type. Part-time Positions as of March 29, 2018 (less than 30 hours/week or 130 hours/month): Column 8: Number of Total Filled Part-Time Positions: Enter the total number of filled parttime positions, as of 3/29/2018, for each employee type. Column 9: Number of Unfilled Part-Time Positions: Enter the number of unfilled part-time positions, as of 3/29/2018, for each employee type. Survey Navigant 4/30/2018 Page 10

12 Worksheet E: Program Employee Costs WORKSHEET E: EMPLOYEE COSTS The purpose of this worksheet is to report the total costs of the Provider and to determine the service portion of total costs. For the purposes of completing Sheets E and F, it will be necessary to make reasonable allocations between categories of costs. Salaries and wages may be allocated based on an estimate of actual time spent by employees between each service activities, and facility-related costs (rent, interest expense, utilities, property maintenance, etc.) may be allocated based on reasonable estimates of property square footage used for each service. Other costs, such as administrative supplies, can be allocated based on reasonable estimates of their use. Program costs are defined as the reasonable costs necessary to provide services related to the services that are being evaluated. Federal guidance on reasonable costs can be found in PRM-15, Section 2103, which states the following: The prudent and cost conscious buyer not only refuses to pay more than the going price for an item or service, he/she also seeks to economize by minimizing cost. This is especially so when the buyer is an institution or organization which makes bulk purchases and can, therefore, often gain discounts because of the size of its purchases. In addition, bulk purchase of items or services often gives the buyer leverage in bargaining with suppliers for other items or services. Another way to minimize cost is to obtain free replacements or reduced charges under warranties for medical devices. Any alert and cost conscious buyer seeks such advantages, and it is expected that Medicare providers of services will also seek them. While this federal guidance does not apply specifically to services reimbursed by states, it is consistent with how the Division is requesting providers to report their costs in this survey. In other words, the Division is requesting that providers report only the reasonable and necessary costs of providing the specified services. In principal, the term reasonable relates to the prudent and cost conscious buyer concept that purchasers of services will seek to economize and minimize costs whenever possible. The term necessary relates to the necessity of the service. To be necessary, it must be a required element for providing care to participants as specified by the approved federal waivers. The Social Security Act section 1861(v)(1)(A) provides additional guidance, stating that reasonable costs must be the following: Cost actually incurred Necessary in the efficient delivery of needed health services Determined in accordance with regulations establishing the methods to be used and the items to be included Survey Navigant 4/30/2018 Page 11

13 Worksheet E: Program Employee Costs Please complete only the light yellow cells that are applicable to the services you provide. For example, if you only provide adult day services and home delivered meals, you will only allocate a percent of costs to those columns. Cells that are not applicable can be left blank. Do not enter any values in the white cells as they will automatically calculate. Column Descriptions Column 1: Cost Centers Each cost center line represents a particular type of expenditure. The cost center line is described in Column 1. Cost centers are classified into three major groups: Salaries and Wages Employee Taxes, Insurance and Benefits Contracted Services Please see the Lines Descriptions section in Appendix A for further discussion of each cost center under the three major groupings. Column 2: All Costs from Provider General Ledger Enter all costs of the Provider in Column 2 by cost center. The total expenses reported on Line 72 of Column 2 must be equal to the total expenses reported in the Provider s general ledger. For costs recorded in the Provider s general ledger that do not match the listed cost center descriptions, lines are provided for other expenses within each of the major cost groups. Providers who utilize the other expense lines must enter in a description of the expense in the line. The description must include explanations of the types of costs being reported and the amounts of any such costs. Columns 3 through 6: Percent of Time Allocated to Services Being Evaluated Column 3: Adult Day Services. Enter the percent of time the employee(s) in each row allocates to Adult Day Services. Column 4: Chore, Companion, Homemaker, Individual Community Living Support, and Respite Services. Enter the percent of time the employee(s) in each row allocates to Chore, Companion, Homemaker, Individual Community Living Support, and Respite services. Survey Navigant 4/30/2018 Page 12

14 Worksheet E: Program Employee Costs Column 5: Customized Living, Foster Care Services and Non-Medical Transportation (excluding room and board). Enter the percent of time the employee(s) in each row allocates to Customized Living and Foster Care Services (excluding room and board). Column 6: Home-Delivered Meals (HDM). Enter the percent of time the employee(s) in each row allocates to home-delivered meal services. Column 7: Room and Board and Services Not Listed in Columns 3-6. Enter the percent of time the employee(s) in each row allocates to other services (those not being evaluated) and room and board. See note below about policy surrounding Room and Board costs. Room and Board Costs For Medicaid-covered services, costs related to room and board for participants, as well as facility maintenance, upkeep and improvement related to residential program services are neither allowable nor are they program costs, and therefore should be reported in the Other Services (column 7). In accordance with 42 CFR (a)(2), FFP is not claimed for the cost of room and board except when: (a) provided as part of respite services in a facility approved by the State that is not a private residence or (b) claimed as a portion of the rent and food that may be reasonably attributed to an unrelated caregiver who resides in the same household as the participant. Column 8: Total Column 3 through 7. This column will calculate automatically and shows the percent of time that has been allocated for each provider type. The total in column 8 must equal 100%. If the total in column 8 does not sum to 100% it will appear in red and should be adjusted to total to 100%. Line Descriptions Please see Appendix A Cost Types for detailed definitions of the costs associated with each line. We understand that you may incur certain costs on a non-recurring basis. In other words, you may have incurred costs in the current year for which the benefit may span more than the current year. Conversely, you may have incurred costs in previous years that benefit the current year, but are not reflected in your current general ledger costs. If you have one-time cost in this year s expenses or incur costs on a regular basis that are not in the current general ledger (i.e., a multi-year license that is expensed when it is renewed), please provide that information in separate documentation so that it may be considered as part of the survey Survey Navigant 4/30/2018 Page 13

15 Worksheet E: Program Employee Costs process. Such information can be provided via the address shown on page 1 of these instructions (please include your Provider ID in the body of the ). Salaries and Wages, Lines 1 through 38 Lines 1 through 38 capture total salaries and wages paid and accrued by employees. Do not include fees associated with contracted services staff (these costs should be included in the Contracted Services section of the survey). For employees who perform multiple functions (direct care, administration, program support, etc.), you must allocate gross salaries and wages to each of the appropriate lines. Direct Care Provider/Employee Salaries and Wages, Lines 1 through 9 These cost center lines capture program employee total gross salaries and wages paid and accrued, including bonuses, by employee category. Program Employee Salaries and Wages are defined as costs associated with employees who provide direct hands-on support for participants. This includes Home Health Aides; Nurses (CAN, RN, LPN); Unlicensed Personnel (Personal Care Assistants, Waiver Companions, Home Care Aides, Support Service Providers, Homemaker/Housekeepers, Family Adult Day Service Providers); Drivers, and Recreation/Activity Workers. Enter amounts, by employee category, on Lines 1 through 7. Enter amounts for other program employees on Line 8; and a description of the expense in Column 1. If a provider hires direct care employees that provide services outside of this evaluation (for example, nurses providing direct care at a large campus and the services are not being evaluated), the costs should be added to Line 9. These costs cannot and should be allocated to the services being evaluated (columns 3 through 8). The survey will automatically sum Lines 1 through 9 on Line 17. Do not enter data into this line. Supervisor Salaries and Wages, Lines 10 through 16 These cost center lines capture total gross salaries and wages of supervisors, including bonuses, by employee category. Supervisor Salaries and Wages are defined as costs associated with employees who provide support of participant programs, such as case managers, social workers, and volunteer coordinators. The survey will automatically sum Lines 1 through 16 on Line 17. Do not enter data into this line. Employee Salaries and Wages for Home-Delivered Meals (HDM) and Meal Prep Lines 18 through 22 Survey Navigant 4/30/2018 Page 14

16 Worksheet E: Program Employee Costs These cost center lines capture the costs to prepare and cook meals for adult day services and home-delivered meals. Salaries and wages for these services are defined as costs associated with employees who prepare meals, such as food preparation workers, chefs, dieticians, and dietician supervisors. Maintenance Employee Salaries and Wages, Lines 23 through 25 These cost center lines capture maintenance employee total gross salaries and wages, including bonuses, by employee category. Maintenance Employee Salaries and Wages are defined as costs associated with employees who repair and maintain vehicles, equipment, buildings and property. Enter vehicle maintenance employee salaries and wages on Line 23. Enter all other maintenance employee salaries and wages expenses on Line 24. The survey will automatically sum Lines 23 and 24 on Line 25; as such, do not enter data into this line. Administration Employee Salaries and Wages, Lines 26 through 34 These cost center lines capture administration employee total gross salaries and wages, including bonuses, by employee category, on Lines 26 through 34. Administration Employee Salaries and Wages are defined as costs associated with employees who provide management, accounting, information technology, and human resource services. Enter administration employee salaries and wages by category, on Lines 26 through 34. Only include administration costs incurred at the provider or local level. If administrative services are provided at a central corporate office outside of the provider s principal place of business, then enter the allocated portion of administrative employee salaries and wages applicable to the local level (not entered elsewhere in this section) in Line 31 ( Central Corporate Office Administration Staff Allocated to Local Level ). Enter other administration employee salaries and wages on Line 33. Enter a description of the expenses in Column 1. The survey will automatically sum Lines 26 through 33 on Line 34. Do not enter data into this line. Other Salaries and Wages, Lines 35 through 37 Survey Navigant 4/30/2018 Page 15

17 Worksheet E: Program Employee Costs Enter the estimated monetary value of donated services on Line 35. Donated services must involve specialized skills, be performed by qualified individuals and be services typically purchased if not performed by volunteers. Enter other salaries and wages on Line 36. Enter a description of the expenses in Column 1. The survey will automatically sum Lines 35 and 36 on Line 37. Do not enter data into this line. The survey will automatically sum Lines 17, 22, 25, 34, and 37 on Line 38, Total Salaries and Wages; as such, do not enter data into this line. Employee Taxes, Insurance and Benefits, Lines 39 through 55 Lines 39 through 55 capture costs incurred by the Provider related to employee payroll taxes, insurance and benefits. Only the portion of the employee benefits and payroll taxes paid and accrued by the provider must be reported on these lines. Please also include any non-wage compensation (e.g., monetary and non-monetary gifts). Do not include costs which are paid and accrued by withholding a portion of the employee s salary or wages (these costs should be included in the appropriate Salaries and Wages cost center lines). Employee Payroll Taxes, Lines 39 through 43 These cost center lines capture the employer s portion of any FICA, FUI, SUI, and other payroll related taxes. Enter the total amount spent on the employer s portion of premiums paid and accrued for the state workers compensation fund or other workers compensation insurance and other payroll taxes plan on Lines 42. If a Provider is self-insured, only include the cost of actual claims paid or accrued. Enter amounts, by category, on Lines 39 through 42. The survey will automatically sum Lines 39 through 42 on Line 43; do not enter data into this line. Employee Insurance, Lines 44 through 51 Survey Navigant 4/30/2018 Page 16

18 Worksheet E: Program Employee Costs These cost center lines capture the employer s portion of any costs related to employee health insurance, vision insurance, dental insurance, life insurance, disability insurance and participant fringe benefits. Enter amounts, by category, on Lines 44 through 50. Amounts reported on Lines 49 and 50 must be accompanied by a description of reported costs. The survey will automatically enter the sum of Lines 44 through 50 on Line 51; therefore, do not enter data into Line 51. Employee Other Benefits, Lines 52 through 54 These cost center lines capture the employer s costs related to retirement and any other employee benefits not recorded elsewhere in rows 52 through 54. Enter the employer s portion of any costs related to employee retirement programs on Line 52. These costs could include employer contributions to pension plans, employer contributions to 401k plans, or other retirement-related programs. Enter any other benefits costs not reported on Line 52 should be reported on Line 53. Enter a description of the costs in Column 1. The survey will automatically sum Lines 52 and 53 on Line 54. Do not enter data into this line. The survey will automatically enter the sum of Lines 43, 51 and 54 on Line 55, Total Employee Taxes, Insurance and Benefits. Do not enter data into this line. Contracted Services, Lines 56 through 71 Lines 56 through 71 capture expenditures for contracted services, by type of contracted service. Amounts entered must be for contracted services only, and must exclude any amounts paid and accrued to employees of the Provider. Contracted Program Services, Lines 56 through 67 These cost center lines capture expenditures for contracted program services, by type of contracted service. Enter amounts, by type of contracted service, on Lines 56 through 65. Enter other contracted program services on Line 66. Enter a description of the expense in Column 1. Survey Navigant 4/30/2018 Page 17

19 Worksheet E: Program Employee Costs The survey will automatically sum Lines 56 through 66 on Line 67. Do not enter data into this line. Contracted Maintenance Services Equipment/Plant, Line 68 This cost center line captures expenditures for contracted maintenance services for equipment/plant. Enter total amount spent on contracted maintenance services for equipment/plant on line 68. Contracted Maintenance Services Vehicle, Line 69 This cost center line captures expenditures for contracted maintenance services for vehicle. Enter total amount spent on contracted maintenance services for vehicle on line 69. The percent of costs for home-delivered meals will populate from Worksheet F (Table A, Line 3e Home-delivered meals ) Contracted Administration Services, Lines 70 These cost center lines capture expenditures for contracted administration services. Enter total amount spent on contracted administration services on line 70. The survey will automatically sum Lines 67 through 70 on Line 71, Total Contracted Services. Do not enter data into this line. Donated Services, Lines 73a through 73j Lines 73a through 73j capture the services for which your organization uses donated services. Select Yes or No from the drop down for each service depending on if your organization uses donated services for that service. If possible, please include the number of donated hours for the fiscal year used to report the costs above on this worksheet. If you do not have donated hours available, you may leave the number of donated hours column blank. Please note that donated hours for Chore, Companion, Individual Community Living Support, and Respite services should be summed into the one cell that is provided. Survey Navigant 4/30/2018 Page 18

20 Worksheet F: Non-Program Employee Costs WORKSHEET F: NON-PROGRAM EMPLOYEE COSTS The purpose of this worksheet is to report the total non-program costs and to determine the service portion of total costs (when necessary). Non-Payroll Administration Expenses, Lines 1 through 17 Lines 1 through 17 capture administration expenses not relating to payroll. Only the portion paid and accrued by the provider must be reported on these lines. Administration Expenses, Lines 1 through 9 These cost center lines capture expenditures for non-payroll related provider administrative services, including office supplies, postage, membership dues and information technology expenses. Do not report the costs associated with contracted services (these costs must be reported in the appropriate contracted services cost center lines). Enter all administration expenses, by type of administration expense, on Lines 1 through 9. Enter Other Administrative Expenses on Line 9. Enter a detailed description of the expense(s) in Row 9. In Column 7 allocate the costs associated with home-delivered meals associated with costs in Lines 1 through 9. Licenses/Taxes, Line 10 This cost center line captures non-payroll taxes incurred by the provider. Enter amounts for license and taxes, such as ad valorem property taxes and vehicle license and registration expenses on Line 10. Non-Vehicle Related Insurance, Line 11 This cost center line captures non-payroll non-vehicle related insurance expenses incurred by the provider. This may include general liability, directors and officers, property, and malpractice insurance. Non-Payroll Related Personnel Expenses, Lines 12 through 16 Survey Navigant 4/30/2018 Page 19

21 Worksheet F: Non-Program Employee Costs These cost center lines capture all non-payroll expenditures for employees, including costs relating to hiring and training of new workers. Enter the non-payroll personnel costs of background check and drug testing on Line 12. Enter the non-payroll personnel costs of recruitment on Line 13. Enter the non-payroll personnel costs of training related to the provision of consumer care on Line 14. Do not report the payroll costs associated with providing or participating in training (these costs must be reported in the appropriate salaries and wages category). Enter any non-payroll personnel expenses that have been donated, including miles, in Line 15. Enter other non-payroll personnel expenses on Line 16. Enter a description of the expenses in Line 16. The survey will automatically sum Lines 1 through 16 on Line 17. Do not enter data into this line. Other Non-Payroll Expenses, Lines 18 through 22 Lines 18 through 22 capture non-payroll expenditures made for the support of participant programs. Supplies (related to materials used in client care or program support services), Line 18 and 19 These cost center lines capture expenditures for materials used in participant care or programs support services. Enter the meal/snack supply costs, including food and food service supplies, special dietary supplements/supplies, other dietary supplies on line 18. Costs associated with meal prep for customized living and respite should be allocated to room and board costs. Enter other supplies on line 19. Transportation, Lines 20 through 21 Survey Navigant 4/30/2018 Page 20

22 Worksheet F: Non-Program Employee Costs These cost center lines capture the costs of transportation, including transportation reimbursements made to program staff. Report the costs associated with vehicle purchases or leases, licenses or insurance. Enter transportation expenses on Line 20 (service-related and non-service related). Transportation costs include rental, depreciation, maintenance and repair, and fuel expenses and mileage reimbursements made to program staff for transportation directly relating to client services. A client does not have to be inside of the vehicle for the transportation to be service related (i.e., a program employee traveling to see a client). Vehicle maintenance and repair expenses should be included in the appropriate maintenance line. Providers must maintain detailed mileage records to support the reported service related expenses. Enter vehicle related insurance costs on line 21. The survey will automatically sum Lines 18 through 21, Total Non-Payroll Program Administration Expenses. Facility and Equipment Related Expenses, Lines 23 through 32 Lines 23 through 32 capture non-payroll related facility and equipment expenses. Do not include costs associated with contracted services (these costs should be reported in the appropriate contracted cost center lines). Note that these expenses may include those related to donated assets. For example, if an agency is given space to use from another organization, costs related to that space maybe reported, for example, depreciation, costs of janitorial services, maintenance and repairs. These costs should be appropriately allocated between Program Administration (Lines 23 through 26) and Service Delivery (Lines 27 through 31). Rentals/Property, Line 23 and 27 These cost center lines capture rental and property expenses related to facilities and equipment, by category. Enter rental and property expenses, by type of expense, on Lines 23 and 27. Maintenance and Repairs, Line 24 and 28 These cost center lines capture all non-payroll maintenance and repair expenses related to facilities and equipment, by category. Survey Navigant 4/30/2018 Page 21

23 Worksheet F: Non-Program Employee Costs Enter maintenance repair expenses, by type of expense, on Lines 24 and 28 Depreciation and Amortization, Line 25 and 29 These cost center lines capture depreciation for provider-owned facilities and equipment. Providers must submit, along with the survey, a description of their capitalization policy and threshold amount(s). A capitalization threshold is a cost under which an asset should not be depreciated. If an asset has a useful life of at least two years and a historical cost of at least $5,000, its cost must be capitalized. Assets under the set threshold amount should be expensed in the year acquired. A provider may set a lower capitalization threshold if it does not materially affect reported costs. Utilities, Lines 26 and 30 These cost center lines capture expenses related to utilities and disposal services. Vehicle Related Insurance, Line 31 This costs center line captures expenses related to vehicle insurance. Please provide your best estimate even if they are not recorded separately on financial statement. The survey will automatically sum Lines 23 through 31 on Total Facility, Vehicle and Equipment Related Expenses. Do not enter data into this line. The survey will automatically sum all costs on Line 32, Total Costs. Do not enter data into this line. Donated Service Costs, If Recorded in General Ledger, Line 33 Enter the donated service costs on line 33 if they are recorded in your general ledger. Specify the type of cost in the box provided. Please note that Table B on this worksheet provides additional opportunities to record use of donated services that are outside of your general ledger. Table A: Additional Questions Regarding Transportation Costs These questions provide context to better define transportation costs. Question 1: For non-medical transportation services provided in residential settings, what is the average round trip mileage (include return trip), for the most recent provider fiscal year? Enter the average round trip mileage per trip in the box to the right. Survey Navigant 4/30/2018 Page 22

24 Worksheet F: Non-Program Employee Costs Question 2: For non-medical transportation services provided in residential settings, what is the number of miles traveled (round trips) for the most recent provider fiscal year? Enter the number of miles traveled (round trips) for the most recent provider fiscal year. Question 3: Please provide a percentage breakdown below of transportation costs: a. Admin non-service related transportation: Enter the percent of transportation costs related to program administration. b. Adult day transportation: Enter the percent of transportation costs related to adult day transportation. c. Chore, Companion, Homemaker, Individual Community Living Support, and Respite Services: Enter the percent of transportation costs related to chore, companion, homemaker, individual community living support, and respite services. d. Non-medical transportation in a residential setting (customized living and adult foster care): Enter the percent of transportation costs related to nonmedical transportation in a residential setting. e. Home-delivered meals: Enter the percent of transportation costs related to home-delivered meals. f. Room and board: Enter the percent of transportation costs related to room and board. g. Other: Enter the percent of transportation costs related to other services. Please specify in the box provided. Total: This field is automatically calculated and should equal 100 Table B: Additional Questions Regarding Donations Related to Non-Payroll Expenses These questions provide context to better understand donations related to non-payroll expenses. Question 1: Does your organization receive donations for non-payroll related expenses? If yes, complete the remainder of this table. If no, leave remaining questions blank. Please select yes or no from the drop-down list provided. Survey Navigant 4/30/2018 Page 23

25 Worksheet F: Non-Program Employee Costs Question 2: Does your organization use donated facility space? If yes, indicate the approximate number of square feet for each service grouping, if available. Please select yes or no from the drop-down list provided. If yes, please complete question 2 rows a, b, c, and d by indicating the approximate number of square feet for each available service. If you are unable to estimate the number of square feet for each service grouping, please leave blank. Question 3: Does your organization use donated supplies? If yes, check the services for which you use donated supplies. Please select yes or no from the drop-down list provided. If yes, please complete question 3 rows a, b, c, and d by checking the appropriate box if you use donated supplies for that particular service. Question 4: Does your organization use donated transportation services? Please select yes or no from the drop-down list provided. If yes, please complete question 4 rows a and b by checking the appropriate box if you use donated transportation services for that particular service. Survey Navigant 4/30/2018 Page 24

26 Worksheet G: Adult Day Services Costs WORKSHEET G: ADULT DAY SERVICES COSTS The purpose of this worksheet is to collect information about Adult Day Services. If you do not provide adult day services, this worksheet can be skipped. This worksheet collects information about Adult Day Services by site. If you only operate one site for Adult Day Services, you will only complete the table for Adult Day Site 1. Complete Adult Day Site 2 or Adult Day Site 3 if you operate two or three sites. For each site, please provide information about your adult day groups. Should there be no variance in groups in terms of staffing, you can report all the information for the site under one group. For each group reported, please use the dropdown box to indicate if the group is specific to Alzheimer s/dementia. Line 1: Address Enter the address of adult day service location (including street number, apt./unit number, and street name) Line 2: City/Zip Code Enter the city and zip code Line 3: Square Feet of Program Space - Report total square feet of program space for each adult day services site Line 4: Operating Costs per Square Foot Report the total operating costs per square foot. Line 5: Do you have separate groups based on type of need? Select yes or no from the drop-down Line 6: Is this site specific to Alzheimer s/dementia? Select yes or no from the drop-down Absence and Utilization Group 1 Line 7: Is this group specific to Alzheimer s/dementia? Select yes or no from the dropdown Line 8: Typical Scheduled Consumers For group 1, list how many clients are typically scheduled Line 9: Typical Attendance For group 1, list how many clients typically attend the service Line 10: Scheduled Staff For group 1, state how many staff are typically assigned for that group Absence and Utilization Group 2 Line 11: Is this group specific to Alzheimer s/dementia? Select yes or no from the dropdown Survey Navigant 4/30/2018 Page 25

27 Worksheet G: Adult Day Services Costs Line 12: Typical Scheduled Consumers For group 2, list how many clients are typically scheduled in that group Line 13: Typical Attendance For group 2, list how many clients typically attend the service Line 14: Scheduled Staff For group 2, state how many staff are typically assigned for that group Absence and Utilization Group 3 Line 15: Is this group specific to Alzheimer s/dementia? Select yes or no from the dropdown Line 16: Typical Scheduled Consumers For group 3, list how many clients are typically scheduled in that group Line 17: Typical Attendance For group 3, list how many clients typically attend the service Line 18: Scheduled Staff For group 3, state how many staff are typically assigned Survey Navigant 4/30/2018 Page 26

28 Worksheet H Health Insurance WORKSHEET H: HEALTH INSURANCE This worksheet assesses the health insurance benefits that an agency does or does not offer. If your organization offers health insurance, please complete Table 1 only. If your organization does not currently offer health insurance benefits, complete Table 2 only. Please enter your response to each question in Column 1 in Column 3. Follow the example in Column 2. This worksheet assesses variation in time spent serving participants and reasons that might affect the variation. Survey Navigant 4/30/2018 Page 27

29 Appendix A Cost Types Appendix A describes the cost categories and types that are referenced throughout the cost and wage survey. The column on the right gives the definitions of the costs and guidance about costs that are included in each category. Cost Categories/Types Direct Care Provider/Employee Salaries and Wages Home Health Aides (HHA) Salaries and Wages Certified Nursing Assistants (CNA) Salaries and Wages Registered Nurses (RN) Salaries and Wages Licensed Practical Nurses (LPN) Salaries and Wages Family Adult Day Services (FADS) Provider Salaries and Wages Unlicensed Service Provider Salaries and Wages Chef/Cook Driver Salaries and Wages Recreation Activity Worker Salaries and Wages Definition These accounts capture program provider/employee total gross salaries and wages paid and accrued, including bonuses, by provider/employee category. Program provider/employees provide direct hands-on care for clients. If a program provider/employee fulfills other functions such as administration services, the provider/employee's salary and wages should be allocated to the appropriate accounts. Salaries and wages for Home Health Aides. Home Health Aides provide medically oriented tasks to maintain health or to facilitate treatment of an illness or injury provided in a person s place of residence. Salaries and wages for Certified Nursing Assistants (CNA). Salaries and wages for Registered Nurses (RN). Salaries and wages for Licensed Practical Nurses (LPN). Salaries and wages for Family Adult Day Services (FADS) providers. Salaries and wages for Unlicensed Service Providers. Salaries and wages for Chefs or Cooks. Salaries and wages for Drivers. Salaries and wages for Recreation Activity Workers. Survey Navigant 4/30/2018 Page 28

30 Appendix A Cost Types Cost Categories/Types Other Program Employees Salaries and Wages Other Direct Service Providers Not Delivering Services being Reviewed Definition Salaries and wages for other program employees not described elsewhere. Include a description of the costs included in this account. Salaries and wages for other direct service providers not delivering services being reviewed. Include a description of the costs included in this account. Supervisor Salaries and Wages Case Managers Salaries and Wages Care Coordinators Salaries and Wages Social Workers Primarily Supervisor Salaries and Wages Registered Nurses (RN) - Primarily Supervisor Salaries and Wages Volunteer Coordinator Salaries and Wages Executive/Program Director Salaries and Wages These accounts capture supervisor total gross salaries and wages paid and accrued, including bonuses, by supervisor category. Program supervisors provide direct hands-on supervision for employees. If a program supervisor fulfills other functions such as care provider services, the supervisor s salary and wages should be allocated to the appropriate accounts. Salaries and wages for Case Managers. Case Managers assist clients who receive waiver services in gaining access to needed waiver and other State plan services, as well as needed medical, social, educational and other services. Case Managers are responsible for ongoing monitoring of the provision of services included in the individual's level of care. Case Managers initiate and oversee the process of assessment and reassessment of the individual's plan of care and periodically review the plan of care. Salaries and wages for Care Coordinators. Salaries and wages for Social Workers primarily in a supervisory role. Salaries and wages for Registered Nurses (RN) primarily in a supervisory role. Salaries and wages for Volunteer Coordinators. Salaries and wages for Executive/Program Directors. Survey Navigant 4/30/2018 Page 29