Worksheet B Part I

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BRIAN CTR HLTH & REHAB-CHARLOTTE
CHARLOTTE, NC  28212

Medicare Provider Number: 345243
Cost report status: Settled Without Audit
[Record Code 1212480 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 345243
PERIOD:
FROM 04/01/2016
TO 03/31/2017
 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 501,281 ###                                     1
2 Capital-Related Costs - Moveable Equipment 111,440 ###                                   2
3 Employee Benefits 519,733 ### ### ###                               3
4 Administrative and General 1,688,758 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 532,749 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 108,394 ### ### ### ### ### ###                         6
7 Housekeeping 158,561 ### ### ### ### ### ###                       7
8 Dietary 602,175 ### ### ### ### ### ### ###                     8
9 Nursing Administration 375,852 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply 137,608 ### ### ### ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 34,494 ### ### ### ### ### ### ### ###             12
13 Social Service 77,164 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 45,375 ### ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 1,978,226 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care ### ### ### ### ### ### ### ### ### ### ### ### ### 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 10,444 ### ### ### ### 40
41 Laboratory 21,343 ### ### ### ### 41
42 Intravenous Therapy 76,650 ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 147,831 ### ### ### ### ### 43
44 Physical Therapy 190,333 ### ### ### ### ### ### 44
45 Occupational Therapy 173,958 ### ### ### ### ### ### 45
46 Speech Pathology 91,966 ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 99,143 ### ### ### ### 48
49 Drugs Charged to Patients 261,058 ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 2,818 ### ### ### ### 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 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 7,947,354 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen ### ### ### ### ### ### ### ### 90
91 Barber and Beauty Shop 1,422 ### ### ### ### ### ### ### ### 91
92 Physicians' Private Offices 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 7,948,776 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7