Worksheet B Part I

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ALEXIAN VILLAGE OF TENNESSEE
SIGNAL MOUNTAIN, TN  37377

Medicare Provider Number: 445123
Cost report status: Settled Without Audit
[Record Code 1278978 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 445123
PERIOD:
FROM 07/01/2018
TO 06/30/2019
 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 4,745,241 ###                                     1
2 Capital-Related Costs - Moveable Equipment                                   2
3 Employee Benefits 2,304,968 ### ###                               3
4 Administrative and General 3,299,277 ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 2,338,523 ### ### ### ### ###                           5
6 Laundry and Linen Service -1,300 ### ###                         6
7 Housekeeping 842,791 ### ### ### ### ###                       7
8 Dietary 2,569,279 ### ### ### ### ### ### ###                     8
9 Nursing Administration 460,243 ### ### ### ### ### ### ###                   9
10 Central Services and Supply                 10
11 Pharmacy               11
12 Medical Records and Library             12
13 Social Service 253,679 ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 260,160 ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 2,985,365 ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 893,117 ### ### ### ### ### ### ### ### ### ### 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 27,037 ### ### ### ### 40
41 Laboratory 26,183 ### ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy 402,982 ### ### ### ### ### ### ### 44
45 Occupational Therapy 251,304 ### ### ### ### ### ### ### 45
46 Speech Pathology 73,782 ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 48,876 ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 183,454 ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 13,531 ### ### ### ### 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 1,590 ### ### ### ### 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 21,980,082 ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop 91,306 ### ### ### ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 1,532,823 ### ### ### ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center ### ### ### 99
100 Total 23,604,211 ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7