Worksheet B, Part I
- Return to Cost Report Summary
- Form B001
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3524, REV 6
FAITH HEALTHCARE CENTER
FLORENCE, SC 29501
FLORENCE, SC 29501
Medicare Provider Number: 425009
Cost report status: Settled Without Audit
[Record Code 58080 - 1996]
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COST ALLOCATION - GENERAL SERVICE COSTS | PROVIDER NO: 425009 |
PERIOD: FROM 02/01/1997 TO 12/31/1997 |
WORKSHEET B Part I | |||||||||||||||||||
COST CENTER (Omit Cents) | NET EXPENSES FOR COST ALLOCATION Fr. Wkst A, Col 7 | CAP. REL. BUILDINGS & FIXTURES |
CAP. REL. MOVABLE EQUIPMENT |
EMPLOYEE BENEFITS |
SUBTOTAL (Sum of Columns 0 - 3) |
ADMINIS- TRATIVE & GENERAL |
PLANT OPER. MAINTENANCE & REPAIRS |
LAUNDRY & LINEN SERVICE |
HOUSE KEEPING |
DIETARY | NURSING | CENTRAL SERVICES & SUPPLY |
PHARMACY | MEDICAL RECORDS & LIBRARY |
SOCIAL SERVICE |
INTERNS & RESIDENTS |
OTHER GENERAL SERVICE COST |
SUBTOTAL | POST STEPDOWN ADJUSTMENTS |
TOTAL | ||
0 | 1 | 2 | 3 | 3A | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | |||
GENERAL SERVICE COST CENTERS | ||||||||||||||||||||||
1 | Capital-Related Costs - Building & Fixture | ### | ### | 1 | ||||||||||||||||||
2 | Capital-Related Costs - Movable Equipment | ### | ### | 2 | ||||||||||||||||||
3 | Employee Benefits | ### | ### | ### | ### | 3 | ||||||||||||||||
4 | Administrative and General | ### | ### | ### | ### | ### | ### | 4 | ||||||||||||||
5 | Plant Operation, Maintenance and Repairs | ### | ### | ### | ### | ### | ### | ### | 5 | |||||||||||||
6 | Laundry and Linen Service | ### | ### | ### | ### | ### | ### | ### | 6 | |||||||||||||
7 | Housekeeping | ### | ### | ### | ### | ### | ### | ### | ### | 7 | ||||||||||||
8 | Dietary | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 8 | ||||||||||
9 | Nursing Administration | ### | ### | ### | ### | ### | ### | ### | ### | ### | 9 | |||||||||||
10 | Central Services and Supply | 10 | ||||||||||||||||||||
11 | Pharmacy | 11 | ||||||||||||||||||||
12 | Medical Records and Library | ### | ### | ### | ### | ### | ### | ### | ### | ### | 12 | |||||||||||
13 | Social Service | ### | ### | ### | ### | ### | ### | ### | ### | ### | 13 | |||||||||||
14 | Intern & Residents (Approved Teaching Program) | 14 | ||||||||||||||||||||
15 | Other General Service Cost | ### | ### | ### | ### | ### | ### | ### | ### | ### | 15 | |||||||||||
INPATIENT ROUTINE SERVICE COST CENTERS | ||||||||||||||||||||||
16 | Skilled Nursing Facility | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 16 | ||||
17 | 17 | |||||||||||||||||||||
18 | Nursing Facility | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 18 | ||||
18.1 | Intermediate Care Facility/ Mentally Retarded | 18.1 | ||||||||||||||||||||
19 | Other Long Term Care | 19 | ||||||||||||||||||||
20 | Other Inpatient Routine Services | 20 | ||||||||||||||||||||
ANCILLARY SERVICE COST CENTERS | ||||||||||||||||||||||
21 | Radiology | 21 | ||||||||||||||||||||
22 | Laboratory | ### | ### | ### | 22 | |||||||||||||||||
23 | Intravenous Therapy | ### | ### | ### | ### | ### | ### | ### | 23 | |||||||||||||
24 | Oxygen (Inhalation) Therapy | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 24 | ||||||||
25 | Physical Therapy | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 25 | |||||
26 | Occupational Therapy | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 26 | ||||||||
27 | Speech Pathology | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 27 | |||||||
28 | Electrocardiology | 28 | ||||||||||||||||||||
29 | Medical Supplies Charged to Patients | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 29 | ||||||||||
30 | Drugs Charged to Patients | ### | ### | ### | ### | ### | ### | 30 | ||||||||||||||
31 | Dental Care - Title XIX only | 31 | ||||||||||||||||||||
32 | Support Surfaces | ### | ### | ### | ### | ### | 32 | |||||||||||||||
33 | Other Ancillary Service Cost | 33 | ||||||||||||||||||||
OUTPATIENT SERVICE COST CENTERS | ||||||||||||||||||||||
34 | Clinic | 34 | ||||||||||||||||||||
35 | R H C | 35 | ||||||||||||||||||||
36 | Other Outpatient Service Cost | 36 | ||||||||||||||||||||
OTHER REIMBURSABLE COST CENTERS | ||||||||||||||||||||||
37 | Administrative and General - HHA | 37 | ||||||||||||||||||||
38 | Skilled Nursing Care - HHA | 38 | ||||||||||||||||||||
39 | Physical Therapy - HHA | 39 | ||||||||||||||||||||
40 | Occupational Therapy - HHA | 40 | ||||||||||||||||||||
41 | Speech Pathology - HHA | 41 | ||||||||||||||||||||
42 | Medical Social Services - HHA | 42 | ||||||||||||||||||||
43 | Home Health Aide - HHA | 43 | ||||||||||||||||||||
44 | Durable Medical Equipment - Rented - HHA | 44 | ||||||||||||||||||||
45 | Durable Medical Equipment - Sold - HHA | 45 | ||||||||||||||||||||
46 | Home Delivered Meals - HHA | 46 | ||||||||||||||||||||
47 | Other Home Health Services - HHA | 47 | ||||||||||||||||||||
48 | Ambulance | 48 | ||||||||||||||||||||
49 | Interns and Residents (Not in Approved Teaching Program) | 49 | ||||||||||||||||||||
50 | Outpatient Rehabilitation Provider | 50 | ||||||||||||||||||||
51 | Other Reimbursable Cost | 51 | ||||||||||||||||||||
SPECIAL PURPOSE COST CENTERS | ||||||||||||||||||||||
55 | Hospice | 55 | ||||||||||||||||||||
56 | Other Special Purpose Cost | 56 | ||||||||||||||||||||
57 | Subtotals | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 57 | ||||
NON REIMBURSABLE COST CENTERS | ||||||||||||||||||||||
58 | Gift, Flower, Coffee Shops and Canteen | 58 | ||||||||||||||||||||
59 | Barber and Beauty Shop | ### | ### | ### | ### | ### | ### | ### | ### | ### | 59 | |||||||||||
60 | Physicians' Private Offices | 60 | ||||||||||||||||||||
61 | Nonpaid Workers | 61 | ||||||||||||||||||||
62 | Patients Laundry | 62 | ||||||||||||||||||||
63 | Other Non Reimbursable Cost | 63 | ||||||||||||||||||||
64 | Cross Foot Adjustments | 64 | ||||||||||||||||||||
65 | Negative Cost Center | 65 | ||||||||||||||||||||
75 | TOTAL | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 75 |