Worksheet A-8
- Return to Cost Report Summary
- Form A800
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3519, REV 4
GSS-POHAI NANI
KANEOHE, HI 96744-5305
KANEOHE, HI 96744-5305
Medicare Provider Number: 125033
Cost report status: As Submitted
[Record Code 1377482 - 2010]
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ADJUSTMENTS TO EXPENSES | Provider CCN: 125033 | PERIOD: FROM 01/01/2023 TO 12/31/2023 |
WORKSHEET A-8 | |||
Description (1) | Basis for Adjustment (2) | Amount | Expense Classification on Wkst. A to/from which the amount is to be adjusted |
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Cost Center | Line No. | |||||
0 | 1 | 2 | 3 | 4 | ||
1 | Investment income on restricted funds (Chapter 2) | 1 | ||||
2 | Trade, quantity and time discounts on purchases (Chapter 8) | 2 | ||||
3 | Refunds and rebates of expenses Chapter 8) | 3 | ||||
4 | Rental of provider space by suppliers Chapter 8) | 4 | ||||
5 | Telephone services (pay stations excluded) (Chapter 21) | 5 | ||||
6 | Television and radio service (Chapter 21) | ### | ### | ### | ### | 6 |
7 | Parking lot (Chapter 21) | 7 | ||||
8 | Remuneration applicable to provider-based physician adjustment | Worksheet A-8-2 | 8 | |||
9 | Home office costs (Chapter 21) | 9 | ||||
10 | Sale of scrap, waste, etc. (Chapter 23) | 10 | ||||
11 | Nonallowable costs related to certain Capital expenditures (Chapter 24) | 11 | ||||
12 | Adjustment resulting from transactions with related organizations (Chapter 10) | Worksheet A-8-1 | ### | 12 | ||
13 | Laundry and Linen service | 13 | ||||
14 | Revenue - Employee meals | ### | ### | ### | ### | 14 |
15 | Cost of meals - Guests | ### | ### | ### | ### | 15 |
16 | Sale of medical supplies to other than patients | 16 | ||||
17 | Sale of drugs to other than patients | 17 | ||||
18 | Sale of medical records and abstracts | 18 | ||||
19 | Vending machines | 19 | ||||
20 | Income from imposition of interest, finance or penalty charges (Chapter 21) | 20 | ||||
21 | Interest expense on Medicare overpayments and borrowings to repay Medicare overpayments | 21 | ||||
22 | Utilization review--physicians' compensation (Chapter 21) | Utilization Review- SNF | 82 | 22 | ||
23 | Depreciation--buildings and fixtures | Capital Related Cost- Building | 1 | 23 | ||
24 | Depreciation--movable equipment | Capital Related Cost-Movable | 2 | 24 | ||
25 | Other Adjustment specify - MEAL REVENUE | ### | ### | ### | ### | 25 |
25.01 | MEAL REVENUE | ### | ### | ### | ### | 25.01 |
25.02 | PS&R ADMIN VACCINE OFFSET | ### | ### | ### | ### | 25.02 |
25.03 | LOBBYING DUES | ### | ### | ### | ### | 25.03 |
25.04 | REAL ESTATE TAX | ### | ### | ### | ### | 25.04 |
25.05 | ADVERTISING-PROMOTIONAL ITEMS | ### | ### | ### | ### | 25.05 |
25.06 | ADMINISTRATION | ### | ### | ### | ### | 25.06 |
25.07 | RSDT SPLY | ### | ### | ### | ### | 25.07 |
25.08 | ADMINISTRATION | ### | ### | ### | ### | 25.08 |
25.09 | INTEREST INCOME PAST DUE RESIDENT | ### | ### | ### | ### | 25.09 |
25.10 | ADMINISTRATION APARTMENT PROCESSIN | ### | ### | ### | ### | 25.10 |
25.11 | ADMINISTRATION APARTMENT PROCESSIN | ### | ### | ### | ### | 25.11 |
25.12 | LAUNDRY | ### | ### | ### | ### | 25.12 |
25.13 | HOUSEKEEPING/MAID SERVICE | ### | ### | ### | ### | 25.13 |
25.14 | OPERATIONS/MAINTENANCE | ### | ### | ### | ### | 25.14 |
25.15 | OPERATIONS/MAINTENANCE | ### | ### | ### | ### | 25.15 |
25.16 | CARPORT/GARAGE RENT | ### | ### | ### | ### | 25.16 |
25.17 | RENT - BUILDING | ### | ### | ### | ### | 25.17 |
25.18 | GUEST ROOM | ### | ### | ### | ### | 25.18 |
25.19 | GUEST ROOM | ### | ### | ### | ### | 25.19 |
25.20 | POSTAGE | ### | ### | ### | ### | 25.20 |
25.21 | POSTAGE | ### | ### | ### | ### | 25.21 |
25.22 | POSTAGE | ### | ### | ### | ### | 25.22 |
25.23 | EMPLOYEE RELATIONS INCOME | ### | ### | ### | ### | 25.23 |
25.24 | TRANSPORTATION | ### | ### | ### | ### | 25.24 |
25.25 | TRANSPORTATION | ### | ### | ### | ### | 25.25 |
25.26 | TRANSPORTATION | ### | ### | ### | ### | 25.26 |
25.27 | COMPANION SERVICES | ### | ### | ### | ### | 25.27 |
25.28 | MOVING FEE | ### | ### | ### | ### | 25.28 |
100 | TOTAL (sum of lines 1 through 99) (transfer to Wkst. A, col. 6, line 100) |
### | 100 | |||
(1) Description - all chapter references in this column pertain to CMS Pub. 15-1 (2) Basis for adjustment (see instructions) |
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A. Costs - if cost, including applicable overhead, can be determined B. Amount Received - if cost cannot be determined |
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FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4116) | ||||||
41-320 | Rev. 1 |