Sunnycrest Manor FY18 Budget Presentation

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1 Sunnycrest Manor FY18 Budget Presentation

2 SUCCESSES Stable NF occupancy at 98% (Iowa average=80%), 100% occupancy in Sunrise NF Case mix above state average at (compared to average of ) Medicaid Privatization CPR instructor certification Positive annual and self-report surveys Expansion of therapy programs with Aegis Recipient of numerous grants through the Auxiliary

3 SUCCESSES CONT D Continued relationship with NICC and Loras College Alarm reduction Continued commitment of integrating Sunrise residents into the community by developing independent work skills. Gemini Program has built alliances with the Courthouse, Hospice, Medical Associates and Compass to Care. Aegis Therapy Group assisting in treating residents with Autism.

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6 LOOKING FORWARD Celebrating 100 years of caring at Sunnycrest Manor Full implementation of Electronic Health Record Licensed Nurse skills education Mentor program to enhance retention Expand on Gemini opportunities Develop and maintain collaborative relationships with other LTC facilities, regulatory agencies, and our contracting services.

7 LOOKING FORWARD CONT D Evaluate current products for quality and cost-effectiveness Educate all employees on upcoming CMS guidelines Utilize QAPI tools to enhance the environment at Sunnycrest Manor

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9 Issues Impacting Sunnycrest All nursing homes in Iowa governed by Iowa Administrative Code Does not differentiate between public/private/rural/urban/large/small facilities The nursing home administrator is employed by Dubuque County and must follow Iowa Code Chapter 331-Local Government for Counties The nursing home license belongs to the individual, not the facility License holder working in a public facility is restricted by Iowa Code If there is an issue, it is still the license holder who is impacted

10 Issues Impacting Sunnycrest Hiring and Personnel The administrator of a government run facility does not have control of the operations as required per the Iowa Administrative Rules County Personnel Director, as an appointed official, has overall responsibility for all county personnel, including all unions and nonunion positions. County Job Postings - must be posted internally to all county departments for a minimum of 5 days. Applicants cannot be interviewed until the posting period is closed and all applications have been recorded as received within the timeframe. Hiring a new county employee requires a resolution instructing the auditor to take the appropriate steps to place the employee on payroll and be approved by the board of supervisors as an agenda item at a public meeting.

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12 Issues Impacting Sunnycrest Hiring and Personnel Iowa code and public sector policies prevent attracting staffing It is cumbersome, moves extremely slowly, and is extremely limited in any flexibility or outside the box thinking. It prevents quick reaction or being proactive to the constant changes in the modern long term healthcare industry. It is very difficult to find healthcare professionals and the current trend is that it is going to only become more difficult. It prevents attracting staff who could choose to work for other more cutting edge facilities who offer: Fast hiring process Other facilities can offer more flexible scheduling 12-hour days and weekend packages Signing bonuses Thank-you and morale-boosting incentives or perks. A competitive wage and excellent health care benefits are just not enough anymore.

13 Issues Impacting Sunnycrest Fiscal Authority for the Facility The administrator of a government run facility does not have control of the operations as required per the Iowa Administrative Rules The board of supervisors appoint officials and boards and commissions. Only elected officers and appointed officials have expense appropriation authority. It is unlawful for a county official, the expenditures of whose office come under this part, to authorize the expenditure of a sum for the offi ial s depart e t larger tha the a ou t whi h has ee appropriated for that depart e t y the oard.

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15 Issues Impacting Sunnycrest Accounts Payable/Payroll The administrator has no authority to issue payables checks or payroll checks Process is bulky at best with no way to take care of payment issues quickly. All warrants are issued by the Auditor s office only. All claims for payment must be approved by the department, two board of supervisors, and the Auditor. Payables checks are issued weekly approved claims for payments are due the week before in order to go through the process flow of approvals. Payroll is only generated by the Auditor s office for all county personnel.

16 Issues Impacting Sunnycrest Additional Constraints The account numbering structure and use is defined by the Iowa State uniform chart of accounts for county governments Structure does not work for the nursing home to produce required reporting The county software is for county services and property valuations, tax bills, etc. Does not work well for the needs of the long term care facility The County is on a cash basis Long term care facilities are on an accrual basis and comparisons between facilities is done on accrual basis More manual work is needed to convert the facility from cash to accrual. However, from the county view, expenditures are still on cash basis and cash balance should not be a negative at year end a negative cash balance indicates expenditures exceeding appropriation - refer to Iowa code Expenditures exceeding appropriations. The county model of centralized services Does not fit the requirements of the administrative rules that govern the nursing home administrator to be in charge of all aspects of the day to day operations of the facility

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18 Sunnycrest Staffing Budget Methodology Nursing Scheduled ideal staffing Per Payperiod (14 days/24 hrs per day) 1st 2nd 3rd Total NF Hours Headcount Hours Headcount Hours Headcount Hours Headcount RN/LPN's CNA's Rehab RCNA's CMA's ICF/ID RN/LPN's CNA's Total

19 Sunnycrest Staffing Budget Methodology

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21 Sunnycrest Staffing Budget Methodology

22 Sunnycrest Staffing Budget Methodology Ideal Headcount needed to meet staffing (14 days/24 hrs per day) PP Hours FT PT FTEs Ave Rate/Hr per FY16 Cost Report Nurses CNAs-NF/CMAs/Rehab CNAs-ID

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24 Sunnycrest Staffing Budget Methodology

25 Sunnycrest Staffing Budget Methodology

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27 Sunnycrest Staffing Budget Methodology FY16 Total Actual Hours Regular % OT % PTO % Payouts % Budget Actual Wages/OT/Shift $ 4,302,621 $ 4,309,995 $ 7, % Over Budget

28 Sunnycrest Staffing Budget Methodology

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30 Sunnycrest Staffing Budget Methodology

31 Sunnycrest Staffing Budget Methodology Ideal Headcount needed to meet staffing (14 days/24 hrs per day) PP Hours FT PT FTEs Ave Rate/Hr per FY16 Cost Report Nurses CNAs-NF/CMAs/Rehab CNAs-ID

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33 Sunnycrest Staffing Budget Methodology

34 Sunnycrest Staffing Budget Methodology

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36 Sunnycrest Staffing Budget Methodology

37 Medicaid Reimbursement Rates 07/01/15 Rate 07/01/16 Rate 10/01/16 Rate 01/01/17 Rate ICF $ $ SNF $ $ $ $ Highlighted Rates are what MCOs are reimbursing Sunnycrest

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39 FY17 Revenue Projection Max Bed Days Occupancy Rate Per Day Per Year SNF % $ $ 5,425, Mcaid(not including QAAF reimbursement) % $ $ 74, Private % $ $ 275, QAAF Reimbursement $ 5,775, ICF % $ $ 3,597, Mcaid includes QAAF fee % $ (10.00) $ (98,521.00) QAAF Takeback $ 3,498, RCF % $ $ 34, Waiver/Hab/ + county RCF % $ $ 11, $ $ 45, Billing Revenue $ 9,319, Miscellaneous Revenue $ 15, Employee Meals $ 6, $ 21, Grand Total Revenue $ 9,340,391.00

40 FY17 Revenue Projection MCO Adjustments FY17 NF Rate $ (6.73) $ (185,364) ICF Rate $ (1.07) $ (10,542) ICF On Hold $ 56,000 $ (56,000) QAAF Fees owed $10 * ICF Bed Days 9,852 $ (98,521) FY16 NF Rate $ (6.73) $ (62,340) ICF Rate $ (1.07) $ (3,525) QAAF Fees owed $10 * ICF Bed Days 3,294 $ (32,940) $ (449,231) $ 8,891,160

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42 FY17 Re-Estimate Re-Estimated Payroll Calculated each individual staff and open position to determine remainder of wages, OT, FICA, IPERS, Insurance Premiums Used OT Rates as of 12/31/16: Activities 0.50% Nursing 9.05% Dietary 10.79% EvSvs 1.69% Maint 5.21% BusOffc 0.10% ICF 11.34% Moved HRA actual Usage from each department line to Business office Reduced projection $100,000 Difference in Projections: Individual Methodology: $8,777,892 Ideal Staffing Methodology: $9,989,907 Results in $1,212,015 reduction in FY17 projection Re-Estimated non-payroll lines Increasing $749,559 Original Expenditure Budget: $10,566,054 Re-Estimate: $11,316,141 8,891,160 Cash Receipts (11,316,141) Expenditures (2,424,981) Total Operations Supplement 1,468,000 County Supplement Budgeted (956,981) Additional Supplement needed 8,777,892 Payroll + Benefits (Wages+ER taxes+ins prem) 2,538,249 Non-Payroll expenses + HRA Usage

43 FY18 Revenue Max Bed Days Occupancy Rate Per Day Per Year SNF % $ $ 5,240, Mcaid(not including QAAF reimbursement) % $ $ 74, Private % $ $ 275, QAAF Reimbursement $ 5,590, ICF % $ $ 3,586, Mcaid includes QAAF fee % $ (10.00) $ (98,521.00) QAAF Takeback $ 3,488, RCF % $ $ 34, Waiver/Hab/ + county RCF % $ $ 11, $ $ 45, Billing Revenue $ 9,123, Miscellaneous Revenue $ 15, Employee Meals $ 2, $ 17, Grand Total Revenue $ 9,140,487.00

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45 FY18 Expenditures $ 9,140,487 Cash Receipts ($12,019,283) Expenditures ($ 2,878,796) Total Operations Supplement $ 8,415,120 Payroll + Benefits (Wages+ER taxes+ins prem) (26 payrolls) $ 3,604,163 Non-Payroll expenses + HRA Usage

46 Budget vs. Actual Trend FY18 % of Revenue FY17 Budget % of Revenue FY17 February % of Revenue Billing Cash Receipts $ 9,140,487 $ 9,183,910 $ 6,939,274 FY16 Billing received in FY17 $ 1,951,886 In-Kind Contribution Expenses PERSONNEL COSTS/benefits $ 8,995, % $ 7,956, % $ 8,292, % COMMODITIES (Supplies) $ 758, % $ 704, % $ 758, % HUMAN SERVICES PROVIDER $ 387,319 $ 387,319 CHARGES 4.2% 4.2% $ 387, % (Oustide Services) OTHER SERVICES & CHARGES $ 1,875, % $ 1,515, % $ 1,875, % (risk management, repairs/maint) CAPITAL OUTLAY $ 2, % $ 2, % $ 2, % (technology costs) Total Expenses $ 12,019, % $ 10,566, % $ 11,316, % County Supplement $ - $ 1,468,000 1,468,000 $ Ending Enterprise Surplus/(Deficit) $ (2,878,796) $ 85,328 $ (956,981)

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48 Budget vs. Actual Trend General Fund FY16 Budget % of Revenue FY16 Actual (Unaudited) % of Revenue FY15 Budget % of Revenue FY15 Actual % of Revenue FY14 Budget % of Revenue FY14 Actual % of Revenue Billing Cash Receipts $ 10,021,366 $ 7,709,900 $ 8,939,263 $ 8,212,063 $ 8,850,500 $ 7,753,762 FY16 Billing received in FY17 In-Kind Contribution $ 648,244 $ 327,870 $ 143,875 Expenses PERSONNEL COSTS/benefits $ 7,976, % $ 8,013, % $ 8,079, % 7,858, % $ 8,593, % 9,303, % COMMODITIES (Supplies) $ 647, % $ 669, % $ 714, % 700, % $ 747, % 683, % HUMAN SERVICES PROVIDER CHARGES $ 353, % $ 396, % $ 482, % 454, % $ 628, % 624, % (Oustide Services) OTHER SERVICES & CHARGES $ 2,112, % $ 1,528, % $ 1,073, % 2,358, % $ 732, % 1,265, % (risk management, repairs/maint) CAPITAL OUTLAY $ 210, % $ 22, % $ - 0.0% 1, % $ - 0.0% - 0.0% (technology costs) Total Expenses $ 11,300, % $ 10,631, % $ 10,349, % 11,372, % $ 10,701, % 11,876, % County Supplement $ 1,300,000 $ 1,300,000 $ 1,410,078 $ 2,832,692 $ 1,851,259 $ 3,979,035 Ending Enterprise Surplus/(Deficit) $ 21,227 $ (973,419)

49 Budget vs. Actual Trend FY13 Budget % of Revenue FY13 Actual % of Revenue FY12 Budget % of Revenue FY12 Actual % of Revenue FY11 Budget % of Revenue FY11 Actual % of Revenue Billing Cash Receipts $ 8,717,138 $ 8,840,480 $ 8,850,410 $ 8,450,184 $ 8,811,550 $ 8,381,754 FY16 Billing received in FY17 In-Kind Contribution Expenses PERSONNEL COSTS/benefits $ 8,514, % 8,879, % $ 8,872, % 8,944, % $ 8,924, % 8,589, % COMMODITIES (Supplies) $ 766, % 770, % $ 786, % 777, % $ 728, % 730, % HUMAN SERVICES PROVIDER CHARGES $ 674, % 671, % $ 642, % 647, % $ 631, % 663, % (Oustide Services) OTHER SERVICES & CHARGES $ 569, % 1,115, % $ 593, % 1,118, % $ 573, % 926, % (risk management, repairs/maint) CAPITAL OUTLAY $ - 0.0% - 0.0% $ 40, % - 0.0% $ - 0.0% - 0.0% (technology costs) Total Expenses $ 10,525, % 11,436, % $ 10,934, % 11,487, % $ 10,857, % 10,909, % County Supplement $ 1,807,954 $ 2,596,038 $ 2,084,185 $ 3,037,499 $ 2,046,334 $ 2,527,850

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51 Budget vs. Actual Trend FY17 Total Cost Share from County and County Hospital Board for expenses in excess of Revenues $ 3,570,617 Per Day $ 9,783 Per Bed Analysis Revenue per Bed (115 Beds/108 in FY15) $ 64,253 Operating Cost per Bed (115 beds/108 in FY15) $ 104,779 Facility Cost Per Bed (115 beds/ 108 in FY15) $ 10,608 Total Cost Per Bed (115 beds/108 in FY15) $ 179,640 Daily Cost $ Cost not covered by Revenue- Taxpayers pay per bed per year (115 beds/108 in FY15) $ 33,061.27

52 Property Tax Calculation Sunnycrest cost to taxpayers to cover expenses in excess of revenue+ levy for facility/grounds Current year proposed funding to cover excess operations costs MCO Credit ine for Cash Flow Current year taxable value Levy per thousand for general operations (A/B) Separate Levy for Buildings and Grounds 2,424, ,356,057, Total Paid Per Taxpayer Taxable value Tax dollars paid Tax dollars paid $154,200 Home 85,755 $47.74 $23.13 $ 71 just homeowner $1,000,000 Business Property 675,000 $ $ $ 558 just business owner $ 629 If both business/homeowner

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