Worksheet B Part I

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UNIVERSAL HEALTHCARE/BRUNSWICK
BOLIVIA, NC  28422

Medicare Provider Number: 345549
Cost report status: Settled Without Audit
[Record Code 1276629 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 345549
PERIOD:
FROM 01/01/2018
TO 12/31/2018
 WORKSHEET B PART I
Cost Center Description Net Expenses for Cost Allocation (from Wkst. A, col. 7) Cap. Rel Buildings & Fixtures Cap. Rel Movable Equipment Employee Benefits Subtotal (Sum of cols. 0 - 3) Administrative & General Plant Oper. Maintenance & Repairs Laundry & Linen Service House Keeping Dietary Nursing Administration Central Services & Supply Pharmacy Medical Records & Library Social Service Nursing & Allied Health Education Other General Service Cost Subtotal Post Step-down Adjustments Total  
0 1 2 3 3 A 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
GENERAL SERVICE COST CENTERS                                          
1 Capital-Related Costs - Buildings & Fixtures 450,992 ###                                     1
2 Capital-Related Costs - Moveable Equipment                                   2
3 Employee Benefits 886,146 ###                               3
4 Administrative and General 705,445 ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 290,910 ### ### ### ###                           5
6 Laundry and Linen Service 43,285 ### ### ###                         6
7 Housekeeping 182,158 ### ### ###                       7
8 Dietary 541,370 ### ### ### ###                     8
9 Nursing Administration 255,709 ### ### ### ###                   9
10 Central Services and Supply 51,565 ### ### ###                 10
11 Pharmacy 59,414 ### ### ###               11
12 Medical Records and Library 146,384 ### ### ### ###             12
13 Social Service 41,143 ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 52,843 ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 1,921,190 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 16,517 ### ### ### ### 40
41 Laboratory 14,347 ### ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 5,763 ### ### ### ### 43
44 Physical Therapy 444,696 ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 274,677 ### ### ### ### ### ### ### ### 45
46 Speech Pathology 68,936 ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 25,033 ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 508,526 ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 23,718 ### ### ### ### 52
OUTPATIENT SERVICE COST CENTERS                                          
60 Clinic 60
61 Rural Health Clinic (RHC) 61
62 FQHC 62
63 Other Outpatient Service Cost 63
OTHER REIMBURSABLE COST CENTERS                                          
70 Home Health Agency Cost 70
71 Ambulance 13,324 ### ### ### ### 71
72 Outpatient Rehabilitation (specify) 72
73 CMHC 73
74 Other Reimbursable Cost 74
SPECIAL PURPOSE COST CENTERS                                          
83 Hospice 83
84 Other Special Purpose Cost 84
89 Subtotals 7,024,091 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop 11,281 ### ### ### ### ### ### ### 91
92 Physicians' Private Offices -35 ### ### ### 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 7,035,337 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7