Worksheet A
- Return to Cost Report Summary
- Form A000
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3527, REV 11
MCHS WILMINGTON
WILMINGTON, DE 19803-
WILMINGTON, DE 19803-
Medicare Provider Number: 085028
Cost report status: Settled Without Audit
[Record Code 214215 - 1996]
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RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES | PROVIDER NO: 085028 |
PERIOD: FROM 06/01/2003 TO 05/31/2004 |
WORKSHEET A | ||||||||
COST CENTER (Omit Cents) | SALARIES | OTHER | TOTAL (Col 1 + Col 2) |
RECLASSI- FICATIONS Increase / Decrease (Fr Wkst A-6) |
RECLASSIFIED TRIAL BALANCE (Col 3 +/- Col 4) | ADJUSTMENTS TO EXPENSES Increase/Decrease (Fr Wkst A-8) | NET EXPENSES FOR COST ALLOC (Col 5 +/- Col 6) | ||||
A | B | C | D | 1 | 2 | 3 | 4 | 5 | 6 | 7 | |
GENERAL SERVICE COST CENTERS | |||||||||||
1 | 0100 | x | Capital-Related Costs - Building & Fixture | ### | ### | ### | ### | ### | ### | 1 | |
2 | 0200 | x | Capital-Related Costs - Movable Equipment | ### | ### | ### | ### | ### | 2 | ||
3 | 0300 | x | Employee Benefits | ### | ### | ### | ### | ### | 3 | ||
4 | 0400 | x | Administrative and General | ### | ### | ### | ### | ### | ### | ### | 4 |
5 | 0500 | x | Plant Operation, Maintenance and Repairs | ### | ### | ### | ### | ### | 5 | ||
6 | 0600 | x | Laundry and Linen Service | ### | ### | ### | ### | ### | 6 | ||
7 | 0700 | x | Housekeeping | ### | ### | ### | ### | ### | 7 | ||
8 | 0800 | x | Dietary | ### | ### | ### | ### | ### | 8 | ||
9 | 0900 | x | 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 | Intern & Residents (Apprvd Teaching Prog.) | 14 | ||||||||
15 | Other General Service Cost | ### | ### | ### | ### | ### | ### | 15 | |||
INPATIENT ROUTINE SERVICE COST CENTERS | |||||||||||
16 | 1600 | x | Skilled Nursing Facility | ### | ### | ### | ### | ### | ### | 16 | |
17 | 17 | ||||||||||
18 | 1800 | x | Nursing Facility | ### | ### | ### | 18 | ||||
18.01 | 1810 | Intermediate Care Facility - Mentally Retarded | 18.01 | ||||||||
19 | 1900 | x | Other Long Term Care | 19 | |||||||
20 | Other Inpatient Routine Cost | 20 | |||||||||
ANCILLARY SERVICE COST CENTERS | |||||||||||
21 | 2100 | x | Radiology | ### | ### | ### | ### | 21 | |||
22 | 2200 | x | Laboratory | ### | ### | ### | ### | 22 | |||
23 | 2300 | x | Intravenous Therapy | ### | ### | ### | ### | 23 | |||
24 | 2400 | x | Oxygen (Inhalation) Therapy | ### | ### | ### | ### | 24 | |||
25 | 2500 | x | Physical Therapy | ### | ### | ### | ### | ### | 25 | ||
26 | 2600 | x | Occupational Therapy | ### | ### | ### | ### | ### | 26 | ||
27 | 2700 | x | Speech Pathology | ### | ### | ### | ### | ### | 27 | ||
28 | 2800 | x | Electrocardiology | 28 | |||||||
29 | 2900 | x | Medical Supplies Charged to Patients | ### | ### | ### | ### | 29 | |||
30 | 3000 | x | Drugs Charged to Patients | ### | ### | ### | ### | 30 | |||
31 | 3100 | x | Dental Care - Title XIX only | 31 | |||||||
32 | 3200 | x | Support Surfaces | ### | ### | ### | ### | 32 | |||
33 | x | Other Ancillary Service Cost Center | 33 | ||||||||
OUTPATIENT SERVICE COST CENTERS | |||||||||||
34 | 3400 | Clinic | 34 | ||||||||
35 | 3500 | Rural Health Clinic (RHC) | 35 | ||||||||
36 | Other Outpatient Service Cost | 36 | |||||||||
OTHER REIMBURSABLE COST CENTERS | |||||||||||
37 | 3700 | Administrative and General - HHA | 37 | ||||||||
38 | 3800 | Skilled Nursing Care - HHA | 38 | ||||||||
39 | 3900 | Physical Therapy - HHA | 39 | ||||||||
40 | 4000 | Occupational Therapy - HHA | 40 | ||||||||
41 | 4100 | Speech Pathology - HHA | 41 | ||||||||
42 | 4200 | Medical Social Services - HHA | 42 | ||||||||
43 | 4300 | Home Health Aide - HHA | 43 | ||||||||
44 | 4400 | Durable Medical Equipment - Rented - HHA | 44 | ||||||||
45 | 4500 | Durable Medical Equipment - Sold - HHA | 45 | ||||||||
46 | 4600 | Home Delivered Meals - HHA | 46 | ||||||||
47 | 4700 | Other Home Health Services - HHA | 47 | ||||||||
48 | 4800 | Ambulance | 48 | ||||||||
49 | 4900 | Intern and Resident (Not Apprvd Teaching Prog) | 49 | ||||||||
50 | 5000 | Outpatient Rehabilitation Provider | 50} | ||||||||
51 | Other Reimbursable Cost | 51 | |||||||||
SPECIAL PURPOSE COST CENTERS | |||||||||||
52 | 5200 | Malpractice Premiums & Paid Losses | 52 | ||||||||
53 | 5300 | Interest Expense | ### | ### | ### | ### | 53 | ||||
54 | 5400 | x | Utilization Review -- SNF | 54 | |||||||
55 | 5500 | Hospice | 55 | ||||||||
56 | x | Other Special Purpose Cost | 56 | ||||||||
57 | 5700 | Subtotals | ### | ### | ### | ### | ### | ### | 57 | ||
NON REIMBURSABLE COST CENTERS | |||||||||||
58 | 5800 | Gift, Flower, Coffee Shops and Canteen | 58 | ||||||||
59 | 5900 | x | Barber and Beauty Shop | ### | ### | ### | ### | 59 | |||
60 | 6000 | Physicians' Private Offices | 60 | ||||||||
61 | 6100 | Nonpaid Workers | 61 | ||||||||
62 | 6200 | Patients Laundry | 62 | ||||||||
63 | x | Other Non Reimbursable Cost | 63 | ||||||||
75 | x | TOTAL | ### | ### | ### | ### | ### | ### | 75 |