Worksheet A
- Return to Cost Report Summary
- Form A000
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3527, REV 11
FRANCISCAN VILLA LLC
BROKEN ARROW, OK 74012
BROKEN ARROW, OK 74012
Medicare Provider Number: 375525
Cost report status: Settled Without Audit
[Record Code 1328935 - 2010]
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RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES- |
Provider CCN: 375525 | PERIOD: FROM 01/01/2021 TO 12/31/2021 |
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 |