Worksheet B-1
- Return to Cost Report Summary
- Form B100
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3524, REV 5
VILLA GEORGETOWN NURSING
GEORGETOWN, OH 45121-
GEORGETOWN, OH 45121-
Medicare Provider Number: 365786
Cost report status: Settled Without Audit
[Record Code 274494 - 1996]
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COST ALLOCATION - GENERAL SERVICE COSTS | PROVIDER NO: 365786 |
PERIOD: FROM 01/01/2005 TO 12/31/2005 |
WORKSHEET B - I | |||||||||||||||||||
COST CENTER (Omit Cents) |
CAP. REL. BUILDINGS & FIXTURES (Square Feet) |
CAP. REL. MOVABLE EQUIPMENT (Square Feet) |
EMPLOYEE BENEFITS (Gross Salaries) |
RECONCIL- IATION |
ADMINIS- TRATIVE & GENERAL (Accumulated Cost) |
PLANT OPER. MAINTENANCE & REPAIRS (Square Feet) |
LAUNDRY & LINEN SERVICE (Pounds of Laundry) |
HOUSE KEEPING (Hours of Service) |
DIETARY (Meals Served) |
NURSING ADMINIS- TRATION (Direct Nursing Hrs.) |
CENTRAL SERVICES & SUPPLY (Costed Requisitions) |
PHARMACY (Costed Requisitions) |
MEDICAL RECORDS & LIBRARY (Time Spent) |
SOCIAL SERVICE (Time Spent) |
INTERNS & RESIDENTS (Assigned Time) |
OTHER GENERAL SERVICE COST |
SUBTOTAL |
POST STEPDOWN ADJUSTMENTS |
TOTAL |
|||
0 | 1 | 2 | 3 | 4A | 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 Services | 20 | ||||||||||||||||||||
ANCILLARY SERVICE COST CENTERS | ||||||||||||||||||||||
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 in 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 left | 65 | ||||||||||||||||||||
66 | Cost to be Allocated (Per Wkst. B, Part I) | 66 | ||||||||||||||||||||
67 | Unit Cost Multiplier (Wkst. B, Part I) | 67 | ||||||||||||||||||||
68 | Cost to be Allocated (Per Wkst. B, Part II) | 68 | ||||||||||||||||||||
69 | Unit Cost Multiplier (Wkst. B, Part II) | 69 |