Worksheet A

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GOOD SAMARITAN SOCIETY-TYNDALL
TYNDALL, SD  57066-2214

Medicare Provider Number: 435098
Cost report status: Settled Without Audit
[Record Code 1313845 - 2010]
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RECLASSIFICATION AND ADJUSTMENT
OF TRIAL BALANCE OF EXPENSES-
 Provider CCN: 435098
PERIOD:
FROM 10/01/2020
TO 09/30/2021
 WORKSHEET A
Cost Center Description SALARIES OTHER TOTAL (col. 1 + col. 2) RECLASSIFICATIONS Increase/Decrease (from Wkst. A-6) RECLASSIFIED TRIAL BALANCE (col. 3 +/- col. 4) ADJUSTMENTS TO EXPENSES Increase/Decrease (from Wkst. A-8) NET EXPENSES FOR COST ALLOCATION (col. 5 +/- col. 6)  
A B C 1 2 3 4 5 6 7 A
GENERAL SERVICE COST CENTERS                
1 0100 Capital-Related Costs - Buildings & Fixtures   ### ### ### ### ### ### 1
2 0200 Capital-Related Costs - Moveable Equipment   ### ### ### ### ### ### 2
3 0300 Employee Benefits ### ### ### ### ### 3
4 0400 Administrative and General ### ### ### ### ### ### ### 4
5 0500 Plant Operation, Maintenance and Repairs ### ### ### ### ### ### ### 5
6 0600 Laundry and Linen Service ### ### ### ### ### 6
7 0700 Housekeeping ### ### ### ### ### ### 7
8 0800 Dietary ### ### ### ### ### ### 8
9 0900 Nursing Administration ### ### ### 9
10 1000 Central Services and Supply ### ### ### ### 10
11 1100 Pharmacy 11
12 1200 Medical Records and Library ### ### ### ### ### ### 12
13 1300 Social Service ### ### ### ### ### ### 13
14 1400 Nursing and Allied Health Education 14
15   Other General Service Cost 15
INPATIENT ROUTINE SERVICE COST CENTERS                
30 3000 Skilled Nursing Facility ### ### ### ### ### ### ### 30
31 3100 Nursing Facility 31
32 3200 ICF/IID 32
33 3300 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                
40 4000 Radiology 40
41 4100 Laboratory 41
42 4200 Intravenous Therapy 42
43 4300 Oxygen (Inhalation) Therapy 43
44 4400 Physical Therapy ### ### ### ### ### 44
45 4500 Occupational Therapy ### ### ### ### ### 45
46 4600 Speech Pathology ### ### ### ### ### 46
47 4700 Electrocardiology 47
48 4800 Medical Supplies Charged to Patients 48
49 4900 Drugs Charged to Patients ### ### ### ### 49
50 5000 Dental Care - Title XIX only 50
51 5100 Support Surfaces 51
52   Other Ancillary Service Cost 52
OUTPATIENT SERVICE COST CENTERS                
60 6000 Clinic 60
61 6100 Rural Health Clinic (RHC) 61
62 6200 FQHC 62
63   Other Outpatient Service Cost 63
OTHER REIMBURSABLE COST CENTERS                
70 7000 Home Health Agency Cost 70
71 7100 Ambulance 71
72   Outpatient Rehabilitation (specify) 72
73 7300 CMHC 73
74   Other Reimbursable Cost 74
SPECIAL PURPOSE COST CENTERS                
80 8000 Malpractice Premiums & Paid Losses   - 0 - 80
81 8100 Interest Expense   - 0 - 81
82 8200 Utilization Review - 0 - 82
83 8300 Hospice 83
84   Other Special Purpose Cost 84
89   SUBTOTALS (sum of lines 1 through 84) ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                
90 9000 Gift, Flower, Coffee Shops and Canteen 90
91 9100 Barber and Beauty Shop 91
92 9200 Physicians' Private Offices 92
93 9300 Nonpaid Workers 93
94 9400 Patients' Laundry 94
95   Other Nonreimbursable Cost ### ### ### ### ### ### 95
100   TOTAL ### ### ### ### ### ### 100
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4113)
Rev. 7   41-317