Worksheet B Part I

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GOOD SAMARITAN SOCIETY - HAYS
HAYS, KS  67601-1798

Medicare Provider Number: 175322
Cost report status: Settled Without Audit
[Record Code 1262316 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 175322
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 182,855 ###                                     1
2 Capital-Related Costs - Moveable Equipment 93,928 ###                                   2
3 Employee Benefits 462,422 ### ### ###                               3
4 Administrative and General 1,107,624 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 241,440 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 50,294 ### ### ### ### ### ### ###                         6
7 Housekeeping 70,003 ### ### ### ### ### ### ###                       7
8 Dietary 499,018 ### ### ### ### ### ### ###                     8
9 Nursing Administration 179,708 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply 59,453 ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 117,342 ### ### ### ### ### ### ### ###             12
13 Social Service 46,021 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 1,684,063 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 40
41 Laboratory 7,818 ### ### ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy ### ### ### 43
44 Physical Therapy 113,287 ### ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 119,165 ### ### ### ### ### ### ### ### ### 45
46 Speech Pathology 46,079 ### ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients ### ### ### ### 48
49 Drugs Charged to Patients 88,209 ### ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 52
OUTPATIENT SERVICE COST CENTERS                                          
60 Clinic 2,415 ### ### ### ### ### 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 5,171,144 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop 10,196 ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 113,437 ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 5,294,777 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7