Worksheet B-1
- Return to Cost Report Summary
- Form B100
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3524, REV 5
THE JEFFERSON
ARLINGTON, VA 22203
ARLINGTON, VA 22203
Medicare Provider Number: 495269
Cost report status: Settled Without Audit
[Record Code 1071868 - 2010]
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COST ALLOCATION - STATISTICAL BASIS | Provider CCN: 495269 | PERIOD: FROM 01/01/2013 TO 12/31/2013 |
WORKSHEET B - 1 | |||||||||||||||||||
Cost Center Description | Cap. Rel. Buildings & Fixtures (Sq. Feet) | Cap. Rel. Movable Equipment (Dollar Value or Sq. Feet) | Employee Benefits (Gross Salaries) | Reconciliation | Administrative & General (Accumulated Cost) | Plant Oper. Maintenance & Repairs (Sq. Feet) | Laundry & Linen Service (Pounds of Laundry) | House Keeping (Hours of Service) | Dietary (Meals Served) | Nursing Administration (Direct Nursing Hrs.) | Central Services & Supply (Costed Requisitions) | Pharmacy (Costed Requisitions) | Medical Records & Library (Time Spent) | Social Service (Time Spent) | Nursing & Allied Health Education (Assigned Time) | Other General Service Cost | Subtotal | Post Step-down Adjustments | Total | |||
0 | 1 | 2 | 3 | 4 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 | ### | 1 | |||||||||||||||||||
2 | Capital-Related Costs - Moveable 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 | Nursing and Allied Health Education | 14 | ||||||||||||||||||||
15 | Other General Service Cost | ### | ### | ### | 15 | |||||||||||||||||
INPATIENT ROUTINE SERVICE COST CENTERS | ||||||||||||||||||||||
30 | Skilled Nursing Facility | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 30 | |||||||||
31 | Nursing Facility | 31 | ||||||||||||||||||||
32 | ICF/IID | 32 | ||||||||||||||||||||
33 | Other Long Term Care | ### | ### | ### | ### | ### | ### | ### | ### | ### | 33 | |||||||||||
ANCILLARY SERVICE COST CENTERS | ||||||||||||||||||||||
40 | Radiology | ### | 40 | |||||||||||||||||||
41 | Laboratory | ### | 41 | |||||||||||||||||||
42 | Intravenous Therapy | 42 | ||||||||||||||||||||
43 | Oxygen (Inhalation) Therapy | 43 | ||||||||||||||||||||
44 | Physical Therapy | ### | ### | ### | ### | ### | ### | 44 | ||||||||||||||
45 | Occupational Therapy | ### | ### | ### | ### | ### | 45 | |||||||||||||||
46 | Speech Pathology | ### | ### | ### | ### | ### | 46 | |||||||||||||||
47 | Electrocardiology | 47 | ||||||||||||||||||||
48 | Medical Supplies Charged to Patients | ### | ### | ### | ### | ### | 48 | |||||||||||||||
49 | Drugs Charged to Patients | ### | 49 | |||||||||||||||||||
50 | Dental Care - Title XIX only | 50 | ||||||||||||||||||||
51 | Support Surfaces | 51 | ||||||||||||||||||||
52 | Other Ancillary Service Cost | 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 | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 89 | ||||||||
NON REIMBURSABLE COST CENTERS | ||||||||||||||||||||||
90 | Gift, Flower, Coffee Shops and Canteen | ### | ### | ### | ### | ### | 90 | |||||||||||||||
91 | Barber and Beauty Shop | ### | ### | 91 | ||||||||||||||||||
92 | Physicians' Private Offices | 92 | ||||||||||||||||||||
93 | Nonpaid Workers | 93 | ||||||||||||||||||||
94 | Patients' Laundry | 94 | ||||||||||||||||||||
95 | Other Nonreimbursable Cost | ### | ### | ### | 95 | |||||||||||||||||
98 | Cross Foot Adjustment | 98 | ||||||||||||||||||||
99 | Negative Cost Center | 99 | ||||||||||||||||||||
102 | Cost to be allocated (Per Wkst. B, Pt I.) | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 102 | |||||||||
103 | Unit Cost Multiplier (Wkst. B, Pt I.) | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 103 | |||||||||
104 | Cost to be allocated (Per Wkst. B, Pt. II) | ### | ### | ### | ### | ### | ### | ### | ### | 104 | ||||||||||||
105 | Unit Cost Multiplier (Wkst B, Pt. II) | ### | ### | ### | ### | ### | ### | ### | ### | 105 | ||||||||||||
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120) | ||||||||||||||||||||||
08-16 | Rev 7 |