Alcohol and Drug Program Administration

= l

= lCOST REPORT ORIENTATION <= /i>

= l

= lNON DRUG MEDI-CAL FUNDED CONTRACTS <= /b>

= l

= lFISCAL YEAR 2008-2009
= l

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lVERY IMPORTANT

l = ;

= lSUBMITTING YOUR COST REPORT:

l

lPLEASE MAKE SURE THE UNIT OF SERVICE SUBMITTED = AGREE WITH THE PDR.&= nbsp; FAILURE TO DO SO WILL IMPACT YOUR&= nbsp; COST SET= TLEMENT. (PLEASE REPORT ANY DISCREPANCIES TO EDITA = MENDOZA AT 626-299-3206).

l<= b>

lAll COST REPORT MUST PROVIDE UNIT OF SERVICE OR STAFF HOURS. THIS INCLUDES NON-PROVISION RATE CONTRAC= T.

l<= span style=3D'font-size:63%;display:none'>

lATTACH THE MOST CURRENT BUDGET SUMMARY TO COST = REPORT (COST REPORT = WILL BE CONSIDERED INCOMPLETE WITHOUT SAID = DOCUMENT).

l

lSEND SIGNED ORIGINAL COST REPORT WITH A COPY BY= MAIL FOR ALL ACTIVE CON= TRACTS WITH AND WITHOUT ACTIVITIES.

l<= span style=3D'font-size:63%;display:none'>

l

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<= span style=3D'font-size:87%;font-weight:normal'>
Topics of Discussion

<= span style=3D'font-size:83%'>1.Objectives

<= span style=3D'font-size:83%'>2.Source Documents

<= span style=3D'font-size:83%'>3.Type of Contracts

<= span style=3D'font-size:83%'>4.Type of Forms

<= span style=3D'font-size:83%'>5.Instructions for Completing the Forms <= /span>

<= span style=3D'font-size:96%'>ØODF (Outpatient Drug Free) Form

<= span style=3D'font-size:96%'>ØRegular= - Non ODF Form

<= span style=3D'font-size:96%'>ØProp 36=

<= span style=3D'font-size:96%'>ØCal-WOR= KS

<= span style=3D'font-size:83%'>6.Common Errors

<= span style=3D'font-size:83%'>7.Deadline

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Objectives

A.To help you complete your cost report timely and <= /span>accurately

<= span style=3D'font-size:83%;visibility:hidden'>B.

<= span style=3D'font-size:83%'>B.To inform of any changes for FY 2008-09

<= span style=3D'font-size:83%;visibility:hidden'>C.

<= span style=3D'font-size:83%'>C.To answer your questions and concerns

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Source Documents

1.CONTRACT BUDGET (Line Item Contract)

2.

2.PERFORMANCE DATA REPORT= (PDR)

3.

3.TEN PERCENT (10%) GROSS BUDGET ADJUSTMENT WORK= SHEET (Budget Line Item Shifting Worksheet). This applies to Non-Provisional <= /span>rate contract only and has to document with cost L= ine item budget when submitting cost report.

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Type of Contracts (FFS, PR, NPR)

1= .Fee for Service (FFS)

2.
ØContracts a= re reimbursed for units of service rendered multiplied by the contract unit rate up to the max= imum contract amount.

&Os= lash;

2= .Cost Reimbursement Provisional Rate (PR) = ;

3.
ØContracts a= re reimbursed based on the lesser amount of actual cost or contract amount. The negotiated = provisional rate is an approximation provided for = processing provider’s monthly claims for reimbursement.

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Type of Contract, cont.

3= .Cost Reimbursement Non-Provisional Rate =

Ø (NPR= ) Line Item

Ø =

ØCosts are reimbursed for actual costs in accordance with the line items, as provided in the budget/contract= .

Ø The contract provision allows providers to revise a total <= span style=3D'position:absolute;top:55.75%;left:15.16%;width:91.01%;height:4.75= %'>amount of all existing line item(s) by a maximum o= f 10% of the gross budget without prior written approval= from the ADPA Director, provided that any increase in a= ny line item(s) is offset= by a corresponding decrease in the other line item(s) of the budget or as provided in the contract.
l

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Type of Forms

<= span style=3D'font-size:83%'>1.ODF (Outpatie= nt Drug Free)

<= span style=3D'font-size:83%'>2.Non-ODF (DCH = and Residential)

<= span style=3D'font-size:83%'>3.Prop 36 ODF (Outpatient Drug Free)

<= span style=3D'font-size:83%'>4. Prop 36 Non-ODF <= /span>

<= span style=3D'font-size:83%'>5.Cal-WORKS - O= DF

<= span style=3D'font-size:83%'>6.Cal-WORKS - Non-ODF

7.

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Type of Forms (ODF, Non-ODF)

l

ØODF = form and Non-ODF form are very similar except that in the…

Ø

<= span style=3D'font-size:93%'>ØODF = form, Expenditures MUST be allocated into:
Ø

Ø<= /span>Individual (IND) and

Ø<= /span>Group (GRP)

1.
<= span style=3D'font-size:93%'>ØUnit= s of service SHOULD be reported as follows:

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ODF Form Instructions

ØUNITS OF SERVICE OVERVIEW
Ø

1= .ONTPDTX: Reported as “Slot Day.”   Whereas, s= lot day is one “face to face” day of service, provided to a client by staff licensed to prescribe and administer medication.

2.

2= .Service Staff Hours: For ODF, this is the = direct service hours only (Couns= eling Hours).

3.

Ø= Group Counseling – 90 minutes per session

Ø= Individual Counseling – 50 minutes per session =

v

3.= Individual Face to Face Visits: Th= e number of individuals attending individual counseling sessions.

4.

4= .Group Face-to-Face Visits: Th= e total number of individuals in the group attending group sessions.

5.

5= .Group Sessions: The total number of ses= sions held for providing group counseling during the year.

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ODF Form and Non-ODF Form
Instructions

lSCHEDULE P1 – SALARIES AND EMPLOYEE BENEFITS

l

1.HEADING: Ch= eck type of program. Fill in agency n= ame and mode of service and the date the schedule was prepared.

<= span style=3D'font-size:62%;visibility:hidden'>2.

2.TITLE OF POSITION (A): List each staff personnel working= on the contract by title.= Exclude those members for whom no= taxes or employee benefits were paid. &nbs= p; Non-employee expenditures should be shown on Schedule P4, page 1 of 2, on the line for Consultants.

<= span style=3D'font-size:62%;visibility:hidden'>3.

3.MONTHLY SA= LARY (B): For each position (A) indicate the monthly salary based on a 40 hours work-week as if the individual had worked for the company 100% of the time.

<= span style=3D'font-size:62%;visibility:hidden'>4.

4.PERCENTAGE= OF TIME EMPLOYED BY AGENCY (C): Indicate the total = percentage of time an employee worked for the organization. Full time =3D = 100%, half time =3D 50%, quarter time =3D 25% (number of= hours per week divided by 40). = This percentage should not exceed 100% or 40 hours= per week.

<= span style=3D'font-size:62%;visibility:hidden'>5.

5.PERCENTAGE= OF TIME SPENT ON CONTRACT SERVICES (D): Percentage of time spent on this contract.

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ODF Form and Non-ODF Form
Instructions

l= SCHEDULE P1 – SALARIES AND EMPLOYEE BENEFITS

6.

= 6.PERCENTAGE= OF TIME SPENT ON DIRECT SERVICES (E): Percentage of time charged to this contract based on column (B). Direct services are those that deal directly with clients.

<= span style=3D'font-size:62%;visibility:hidden'>7.

7.TOTAL ANNU= AL SALARY (F): Enter amounts from financial reco= rds of this position.

<= span style=3D'font-size:62%;visibility:hidden'>8.

8.ACTUAL EXPENDITURES ODF IND (G): Actual cost from payroll or gener= al ledger charged to ODF Individual Services.

<= span style=3D'font-size:62%;visibility:hidden'>9.

9.ACTUAL EXPENDITUES ODF GRP (H): Actual cost from payroll or gener= al ledger charged to ODF Group Services. <= /span>

<= span style=3D'font-size:62%;visibility:hidden'>10.

10.COUNTY AP= PROVED BUDGET (I): Enter the amount for each positio= n from the latest County Approved Budget for the specific contract.

6.

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= ODF Form and Non-ODF Form
Instructions

lSCHEDULE P2 – FACILITY RENT/LEASE OR DEPRECIATION<= /span>

l

nI. RENT/LEASE

n

= 1.FACILITY ADDRESS: Please provide complete address.&= #13;

2.TOTAL ANNU= AL RENT/LEASE (A): Enter actual rent/lease from fina= ncial records for the contract period.

= 3.

3.TOTAL GROSS SQUARE FOOTAGE (B): Enter actual square footage of th= e facility.

= 4.COST PER S= QUARE FOOT (C): Divide column (A) by column (B).&= #13;

5.PROGRAM SQ= UARE FOOTAGE (D) and (E): Enter square footage charged to <= /span>Individual and Group Services. <= /div>
= 6.

6.ACTUAL EXPENDITURES-ODF Individual (F):<= span style=3D'mso-spacerun:yes'> Multiply column (C) by column (D)= . This amount should agree with your financial records.

7.ACTUAL EXPENDITURES-ODF Group (G): Multiply column (C) by column (E)= . This amount should agree with your financial recor= ds.

= 8.

8.COUNTY APPROV= ED BUDGET (H): Amount from the = latest County Approved Budge= t.

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=
ODF Form and Non-ODF Form
Instructions

nSCHEDULE P2 – FACILITY RENT/LEASE OR DEPRECIATION, cont.
n=
II.FACILITY OWNED

III.

1. ACTUAL EXPENDITURES (I): Enter amount of actual depreciation charged to ODF Individual Services.

2. ACTUAL EXPENDITURES (J): Enter amount of actual depreciation charged to ODF Group Services.

3. COUNTY OF APPROVED BUDGET(K): Post the amount        from the latest County Approved Budget =

4. FILL IN columns (A) through (H): Do not include land in facility cost. Ca= lculate depreciable cost (E) as: fac= ility cost (B), increased by facility improvement (C), less salvage value (D).

1.

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= ODF Form and Non-ODF Form
Instructions

lSCHEDULE P3 – EQUIPMENT AND O= THER ASSET LEASES

l
1.DESCRIPTIO= N OF LEASES (A): The Los Angeles County, Departmen= t of Public Health encou= rages the leasing of items classified as Fixed Assets Equipment. For this column, itemize those assets classified as fixed assets, equipment or any asset regardless of classification costing over $5,000 per leased unit and has an expected service life of more than three years. Leased items costing less than the above must be itemized in the Miscellaneous Services and Supply Items section of Schedule P4, page 2.= 3;

<= span style=3D'font-size:54%;visibility:hidden'>

2.VALUE OF EQUIPMENT (B): Enter the lesser of the purchase = price or market value of the l= eased equipment.

<= span style=3D'font-size:54%;visibility:hidden'>

<= span style=3D'font-size:61%'>3.NUMBER OF = ITEMS (C ): Enter the actual number of leased= items from column (A).

<= span style=3D'font-size:54%;visibility:hidden'>

4.ACTUAL EXPENDITURES ODF IND (D): Enter the actual cost for leased equipment and/or other asse= ts charged to the ODF Individual services.

<= span style=3D'font-size:54%;visibility:hidden'>

5.ACTUAL EXPENDITURES ODF GRP (E): Enter the actual cost for leased equipment and/or other asse= ts charged to ODF Group services.

<= span style=3D'font-size:54%;visibility:hidden'>

6.COUNTY APP= ROVED BUDGET (F): Enter the amount from the latest = County Approved Budget.

<= span style=3D'font-size:54%;visibility:hidden'>1.

<= span style=3D'font-size:54%;font-weight:bold;visibility:hidden'>= 1.

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= ODF Form and Non-ODF Form = Instructions

lSCHEDULE P4 – SERVICE, SUPPLIES & =

lEQUIPMENT DEPRECIATION

l

1.ACTUAL EXPENDITURES-ODF IND (B): For each item in column (A) indic= ate the actual cost to yo= ur agency applicable to ODF Individual Services.

<= span style=3D'font-size:54%;visibility:hidden'>2.

2.ACTUAL EXPENDITURES-ODF GRP (C): For each item in column (A) indic= ate the actual cost to your agen= cy applicable to ODF Group Services.

<= span style=3D'font-size:54%;visibility:hidden'>3.

3.ITEM (A): Re= view this column for appropriateness and accuracy in terms of service and supplies used by your agency. Please note that space is provide= d for bookkeeping fees which are separate from consultant services.

<= span style=3D'font-size:54%;visibility:hidden'>4.

4.COUNTY APP= ROVED BUDGET (D): Enter the amount from the latest = County Approved Budget.

&= Oslash; SCHEDULE P4, PAGE 2

Ø

l=       5. = MISCELLANEOUS SERVICE AND SUPPLY ITEM (A): In= this column, itemize expenditures not found under column (A), page 1, including leased equipment not = = included in Schedule P3 because of the program cost limitations. =

l=

&= Oslash; 6. ACTUAL EXPENDITURES-ODF IND (B): En= ter the actual cost of miscellaneous services and supply items listed in column (A) for ODF Individual Services.

<= span style=3D'font-size:62%;visibility:hidden'>l

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=
<= span style=3D'font-size:77%'>
ODF Form and Non-ODF Form
Instructions

lSCHEDULE P4, PAGE 2, cont.&#= 13;

l

7.ACTUAL EXPENDITURES-ODF GRP (C): Enter the actual cost of miscella= neous service and supply items listed in column (A) for ODF Group Services.

8.

<= span style=3D'font-size:54%'>8.COUNTY APP= ROVED BUDGET (D): Enter the amount from the latest = County Approved Budget.

9.

9.DEPRECIATI= ON FOR EQUIPMENT/FIXED ASSETS (A): In accordance with the “Fixed Assets Classification Guidelines developed by the Coun= ty Auditor-Controller Accounting Division,” the County of Los Angeles, Alcohol & Drug Progr= am Administration will not pay for the initial outlay of funds for items classified as fixed assets and equipment. However, agencies= may depreciate such f= ixed assets, and equipment over a period of not less than three years from the = date of purchase and c= harge depreciation expense to the contract for the appropriate amount. Depreciat= ion is limited to co= ver those periods the contract is in effect and over the periods benefited.= 3;

10.

10.UNIT COST= (B): En= ter the cost of the items listed in column (A).

11.

<= span style=3D'font-size:54%'>11.NUMBER OF= ITEMS (C): Indicate the actual number of ite= ms identified in column (A).

12.

12.ACTUAL EXPENDITURES-ODF IND (D): Enter the actual depreciation cost charged to ODF Indiv= idual Services.

13.

13.ACTUAL EXPENDITURES-ODF GRP (E): Enter the actual depreciation cost charged to ODF Group Services.

14.

<= span style=3D'font-size:54%'>14. COUNTY APPROVED BUDGET (F): Enter the amount from the latest = County Approved Budget.

15.

15.

15.

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= ODF Form and Non-ODF Form
Instructions

lSCHEDULE P5 – ADMINISTRATIVE OVERHEAD

l

l Administrative Overhead, as defined in the “State Department of Alcohol & Drug Programs Audit Assistance Guide” are indirect costs that were incurr= ed for a common or joint purpose benefiting more than= one cost objective, and not re= adily assignable to a specific cost objective.

l

lThese Costs involve:

l

A.Salaries, wag= es, and employee benefits of administrative personnel = whose effort benefits more than one cost objective= .

<= span style=3D'font-size:69%;visibility:hidden'>B.

B.Operational c= osts and maintenance costs which benefit more than one = cost objective.

<= span style=3D'font-size:60%;visibility:hidden'>A.

lSUGGESTED METHODS TO CALCULATE THE PROGRAM’S

lADMINISTRATIVE OVERHEAD EXPENSE:= 3;

l

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= ODF Form and Non-ODF Form
Instructions

lSCHEDULE P5, cont.

lI.     ADMIN. O.H. EXPENSE AS A PERCENTAGE OF TOTAL AGENCY EXPENSES

<= span style=3D'font-size:47%;color:#7E9CE8;mso-color-index:6;font-weight:bold; visibility:hidden'>1.

<= span style=3D'font-size:47%'>1.TOTAL DIRE= CT AGENCY EXPENSE: Enter the total direct expenses f= or the agency.

<= span style=3D'font-size:47%;visibility:hidden'>2.

2.ADMINISTRA= TIVE OVERHEAD RATE: Divide the total administrative e= xpense by total agency expen= ses.

<= span style=3D'font-size:47%;visibility:hidden'>3.

3.PROGRAM EX= PENSES (A1) and (A2): Transfer amounts from lines 1 thr= ough 4 for ODF Individual and O= DF Group, from the Cost Report Summary Page to Col. (A1) and (A2) respectively.

<= span style=3D'font-size:47%;visibility:hidden'>4.

<= span style=3D'font-size:47%'>4.INDIRECT ADMINISTRATIVE EXPENSE POOL: Enter the administrative expenses= of the agency.

<= span style=3D'font-size:47%;visibility:hidden'>5.

<= span style=3D'font-size:47%'>5.TOTAL DIRE= CT PROGRAM EXPENSES: Add lines 1 through 4.

<= span style=3D'font-size:47%;visibility:hidden'>6.

6.ACTUAL EXPENDITURES-ODF IND (B): Multiply Total Program Expenses c= ol. (A1) by the Administrative Ov= erhead Rate. Post amount to line 5, column (1), on the Summary Page.

<= span style=3D'font-size:47%;visibility:hidden'>7.

7.ACTUAL EXPENDITURES ODF GRP (C): Multiply Total Program Expenses c= ol. (A2) by the Administrative Ov= erhead Rate. Post amount to line 5, column (2), on the Summary Page.

<= span style=3D'font-size:47%;visibility:hidden'>8.

<= span style=3D'font-size:47%'>8.COUNTY APP= ROVED BUDGET (D): Enter the amount from the latest = County Approved Budget.

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ODF Form and Non-ODF Form
Instructions

l

lSCHEDULE P5, cont.

l

lII.     ADMIN. O.H. EXPENSE AS A PERCENTAGE OF TOTAL

lDIRECT AGENCY SALARIES =

l
1.TOTAL PROG= RAM SALARIES: Post Total Salary from col. (G) p= lus col. (H) on Schedule P1, page 1. DO NOT INCLUDE EMPLOYEE BENEFITS.

<= span style=3D'font-size:54%;font-weight:bold;visibility:hidden'>2.

<= span style=3D'font-size:54%'>2.TOTAL AGEN= CY SALARIES: Enter the total salaries paid by = the agency.

<= span style=3D'font-size:54%;visibility:hidden'>3.

3.ADMINISTRA= TIVE OVERHEAD RATE: Total Program Salaries divided by= Total Agency Salaries.

<= span style=3D'font-size:54%;visibility:hidden'>4.

4.ADMINISTRA= TIVE EXPENSE POOL: Enter total administrative expens= es by Individual and Group Counseling Services for the agency.

<= span style=3D'font-size:54%;visibility:hidden'>5.

5.ACTUAL EXPENDITURES-ODF IND (B) AND ODF GRP (C): Administrative Expense= Pool for ODF Individual an= d ODF Group multiplied by Administrative Overhead Rate respectively. =

<= span style=3D'font-size:54%;visibility:hidden'>6.

<= span style=3D'font-size:54%'>6.COUNTY APP= ROVED BUDGET (D): Enter the latest County Approved Budget.

<= span style=3D'font-size:47%;font-weight:bold;visibility:hidden'>1.

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= ODF Form and Non-ODF Form
Instructions

l =

lSCHEDULE P5, cont.

lIII.    <= /span> OTHER METHO= D USED TO CALCULATE THE PROGRAM’S

l ADMIN O.H. EXPENSE

l

l If you use other method, explain the method and attac= h all worksheets

l used to calculate Administrative Overhead Expense.   Please note that:

= l

Ø= ;Actual expenditures must be identified separate= ly between Individual and Group Services.

Ø<= /span>

Ø= ;Manually Post Total to line 5, column (1) and (2),= on the Summary Page.

Ø<= /span>

Ø= Also post the amount from the latest County Approv= ed Budget and the Varianc= e to line 5, columns (3) and (4), respectively.

Ø<= /span>

Ø= ;(Please read detailed instructions attached to Forms).

= l

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<= span style=3D'font-size:77%'>ODF Form and Non-ODF Form
Instructions

lSUMMARY PAGE

l

<= span style=3D'font-size:60%'>1.COMPLETE Agency Contact Information.
<= span style=3D'font-size:60%;visibility:hidden'>2.

2.TOTAL EXPE= NSES from the Schedules are automatically transferred = to the Summary page.

<= span style=3D'font-size:60%;visibility:hidden'>3.

<= span style=3D'font-size:60%'>3.REVENUE SE= CTION:

l

ØParticipant/Client Fees are= fees collected from clients during the Fiscal Year.

<= span style=3D'font-size:78%;visibility:hidden'>Ø = ;

ØExcess Fees Carryover are client fees collected during last Fiscal Year 2007-08 in excess of budgeted projection, but= were not spent during the same Fi= scal Year and therefore, carryover to this Fiscal Year 2008-09.

<= span style=3D'font-size:78%;visibility:hidden'>1.

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<= span style=3D'font-size:77%'>ODF Form and Non-ODF Form
Instructions

lSUMMARY PAGE, <= b>cont.

l<= u>

Ø REVENUE SECT= ION, cont.

Ø

ØExcess Fees Carry Forward are client fees collected during the Fiscal Year 2008-09 in excess of budgeted projection, but not spent during Fis= cal Year 2008-09, therefore are carried forward to the next

Ø Fiscal Year 2009-10.

Ø

ØAny fees carried forward are subject = to the review of the County Program Advisory Board and the approval of both the County Board of = Supervisors and the State Department of Alcohol an= d Drug Program. This amount should= be included in the budget for FY 2009-10 excess fees carryover calculation.

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ODF Form Instructions (ADP)

ØSUMMARY PAGE, cont.

Ø

ØUNITS OF SERVICE :   (MANDATORY, DO NOT LEAVE BLANK)

Ø(See detailed instructions attached to Forms)

Ø

1.Total Staff Hours/Slot Days: = The available staff hours spent providing services.

1.

2.Total Serv= ice Staff Hours (Counseling Hours): The direct treatment service staff hours for Individual Visits and Group Sessions.

2.

3.Total Indi= vidual Face-to-Face Visits: The number of Individual participants.&nbs= p;

2.

<= span style=3D'font-size:69%;font-weight:bold'>4.Total Group Visits: The number of participants in Group Sessions.

2.

<= span style=3D'font-size:69%;font-weight:bold'>5.Total Group Sessions: The Group Sessions provided during year.

1.

ØALWAYS MAKE SURE THAT THE UNITS REPORTED ARE ACCU= RATE

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ODF Form Instructions (Prop 36)

ØSUMMARY PAGE, cont.

Ø

ØUNITS OF SERVICE: (MANDATORY, DO NOT LEAVE BLANK)&#= 13;

Ø(See detailed instructions attached to Forms)

Ø

= 1.Clients Se= rved (# of SACPA Clients): Total of SACPA client served. Do not count the same client more than once.   (Substance Abuse and Crime Prevention Act of 2000 (SACPA)).

2.

= 2.Total Staff Hours: If counseling services were provided and the Contr= act rate is for Staff Hours, enter the number of staff hours and continue filling information on lines 13b-13e.&nb= sp; If no participants and only Outreach Services were provided enter <= /span>staff hours and leave lines 13b-13e blank. (See instructions).

3.

<= span style=3D'font-size:53%;font-weight:bold'>3.Total Serv= ice Staff Hours: The total direct service staff hours (Counseling Hrs).

<= span style=3D'font-size:53%;font-weight:bold'>4.Total Indi= vidual Face-to-Face Visits: The number of Individual participants.

5.Total Group Visits: The number of participants in Group Sessions.

6.Total Group Sessions: The Group Sessions provided.

7.

ØALWAYS MAKE SURE THAT THE UNITS REPORTED ARE ACCU= RATE

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ODF Form Instructions (Cal-Works)

ØSUMMARY PAGE, cont.

Ø

ØUNITS OF SERVICE: (MANDATORY, DO NOT LEAVE BLANK)&#= 13;

Ø(See detailed instructions attached to Forms)

Ø

1.Total Serv= ice Hours Orientation and Outreach: The available hours spent providing services.

2.

2.Total Serv= ice Staff Hours (Counseling Hours): The total direct treatment service staff hours.

3.

<= span style=3D'font-size:53%;font-weight:bold'>3.Total Indi= vidual Face-to-Face Visits: The number of Individual participants.

4.

4.Total Group Visits: The number of participants in Group Sessions.

5.

5.Total Group Sessions: The Group Sessions provided. The number of group sessions reported in line 13e will be the number o= f the cost center’s clients that participated in the group sessions. (Plea= se read the detailed instructions).

6.

ØALWAYS MAKE SURE THAT THE UNITS REPORTED ARE ACCU= RATE

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=
Non-ODF Form Instructions

ØSUMMARY PAGE, cont.

Ø

ØUNITS OF SERVICE: (MANDATORY, DO NOT LEAVE BLANK)&#= 13;

Ø(See detailed instructions attached to Forms)

Ø

Ø 1. Staff Hours: The available staff hours spent providing services.

Ø

Ø 2.     Bed Days: The number of bed days available for services.

Ø

Ø 3. Visit Days: The number of days the clients received Day        Care Habilitative Services.

Ø

Ø ALWAYS MAKE = SURE THAT THE UNITS REPORTED ARE ACCURATE

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<= span style=3D'font-size:77%'>Non-ODF Form Instructions
(Prop 36)

ØSUMMARY PAGE, cont.

Ø

ØUNITS OF SERVICE: (MANDATORY, DO NOT LEAVE BLANK)&#= 13;

Ø(See detailed instructions attached to Forms)

Ø
Ø Substance Abuse and Crime Prevention Act of 2000 (SACPA)

Ø

Ø       1. SACPA Hours <= /div>
Ø 2. Clients Served (# of SACPA Clients)

Ø 3. SACPA Visits

Ø 4. Slots Days

Ø 5. SACPA Bed Days

<= span style=3D'font-size:60%;font-weight:bold;visibility:hidden'>1.

Ø ALWAYS MAKE SURE THAT THE UNITS REPORTED ARE ACCURATE

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Non-ODF Form Instructions
Cal-Works Program

ØSUMMARY PAGE, cont.

Ø

ØUNITS OF SERVICE: (MANDATORY, DO NOT LEAVE BLANK)&#= 13;

Ø(See detailed instructions attached to Forms)

Ø

1.Total Serv= ice Hour: The hour worked where Orientation & Outreach activities were provided directly to Cal-WORKS and= GAIN recipients, or

<= span style=3D'font-size:53%;font-weight:bold;visibility:hidden'>2.

2.Service Day: One “face to face” day of service prov= ided to a client lasting a minimu= m of 3 hours per day.

<= span style=3D'font-size:53%;font-weight:bold;visibility:hidden'>3.

<= span style=3D'font-size:53%;font-weight:bold'>3.Total Unit= s of Services: Staff Hours or Resident Day or Day Care Day. <= /span>

<= span style=3D'font-size:53%;visibility:hidden'>4.

4.Residential Services (RS) or Residential Day:= A 24 hour period during which, a specified licensed bed is assigned and oc= cupied by a registered partic= ipant.

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ØALWAYS MAKE SURE THAT THE UNITS REPORTED ARE ACCU= RATE

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Ø

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Common Errors: <= /div>

<= span style=3D'font-size:77%;font-weight:bold'>1.Summary Page

<= span style=3D'font-size:78%'>Ø= Incorrect contract number.

<= span style=3D'font-size:78%'>Ø= Provider # does not match with facility address= 3;

<= span style=3D'font-size:78%'>Ø= Missing County Approved Budget Information

<= span style=3D'font-size:78%'>Ø= Authorized Signature

Ø= The signature confirms that all information is cor= rect and corresponds to the Agency’s financial records.

Ø= Please make sure that the Summary Page is signed b= y the authorized person and complet= ely filled out with contact person’s name, email address and phone/fax number in case we need to ca= ll for questions concerning your co= st report.

<= span style=3D'font-size:78%;visibility:hidden'>Ø

<= span style=3D'font-size:77%;font-weight:bold'>2.Schedule P2 Facility Rent/Lease

<= span style=3D'font-size:74%'>Ø= Missing Facility Address-

Ø Please fill out the service facility address where the services were provided at. If multiple facilities, then please submit separate <= span style=3D'position:absolute;top:84.75%;left:14.98%;width:79.02%;height:4.0%= '>rent/lease schedules for each facility.

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Common Errors, cont.

Ø3. = Revenue

ØParticipant/Client Fees collected from participants/clients and spent during this 2008-09 Fiscal Year.

ØPlease do not include County Reimbursement as Revenue.

Ø

Ø4. = Private Funding/Public Assist./Other Prov. Revenue

ØIndicate only actual revenue collected during this Fiscal Year.

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Ø5. = Units of Service Information

ØMissing units information

ØUnits do not match with billing.

ØPlease always provide the unit information The unit information on the Summary Pag= e can be obtained from the Performance Data Report.

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