Worksheet B, Part II
- Return to Cost Report Summary
- Form B002
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3525, REV 6
THE JEFFERSON
ARLINGTON, VA 22203-
ARLINGTON, VA 22203-
Medicare Provider Number: 495269
Cost report status: Reopened
[Record Code 158251 - 1996]
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ALLOCATION OF CAPITAL - RELATED COSTS | PROVIDER NO: 495269 |
PERIOD: FROM 01/01/1998 TO 12/31/1998 |
WORKSHEET B Part II |
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COST CENTER | DIRECTLY ASSIGNED CAPITAL RELATED COSTS |
CAP. REL. BUILDINGS & FIXTURES |
CAP. REL. MOVABLE EQUIPMENT |
SUBTOTAL | EMPLOYEE BENEFITS |
ADMINIS- TRATIVE & GENERAL |
PLANT OPER. MAINTENANCE & REPAIRS |
LAUNDRY & LINEN SERVICE |
HOUSE KEEPING |
DIETARY | NURSING ADMINIS- TRATION |
CENTRAL SERVICES & SUPPLY |
PHARMACY | MEDICAL RECORDS AND LIBRARY | SOCIAL SERVICE | INTERNS & RESIDENTS | OTHER GENERAL SERVICE COST | SUBTOTAL | POST STEPDOWN ADJUSTMENTS | TOTAL | ||
0 | 1 | 2 | 2A | 3 | 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 Service Cost | 20 | ||||||||||||||||||||
ANCILLARY SERVICE COST CENTER | ||||||||||||||||||||||
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 An 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 |