Worksheet S-3 Parts II and III
- Return to Cost Report Summary
- Form S302
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3509.1, REV 16
SMP HEALTH - AVE MARIA
JAMESTOWN, ND 58401
JAMESTOWN, ND 58401
Medicare Provider Number: 355082
Cost report status: Settled Without Audit
[Record Code 1348541 - 2010]
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| SNF WAGE INDEX INFORMATION PART II - DIRECT SALARIES | Provider CCN: 355082 | PERIOD: FROM 10/01/2021 TO 09/30/2022 |
WORKSHEET S-3 PARTS II & III |
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| Amount Reported | Reclass. of Salaries from Wkst. A-6 |
Adjusted Salaries (col. 1 ± col. 2) |
Paid Hours Related to Salary in col. 3 |
Average Hourly Wage (col. 3 ÷ col. 4) |
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| 1 | 2 | 3 | 4 | 5 | |||
| SALARIES | |||||||
| 1 | Total salary (see instructions) | ### | ### | ### | ### | 1 | |
| 2 | Physician salaries-Part A | 2 | |||||
| 3 | Physician salaries-Part B | 3 | |||||
| 4 | Home office personnel | 4 | |||||
| 5 | Sum of lines 2 through 4 | 5 | |||||
| 6 | Revised wages (line 1 minus line 5) | ### | ### | ### | ### | 6 | |
| 7 | Other Long Term Care | 7 | |||||
| 8 | Home Health Agency | 8 | |||||
| 9 | CMHC | 9 | |||||
| 10 | Hospice | 10 | |||||
| 11 | Other excluded areas | ### | ### | ### | ### | 11 | |
| 12 | Subtotal excluded salary (sum of lines 7 through 11) | ### | ### | ### | ### | 12 | |
| 13 | Total adjusted salaries (line 6 minus line 12) | ### | ### | ### | ### | 13 | |
| OTHER WAGES AND RELATED COSTS | |||||||
| 14 | Contract Labor: Patient Related & Mgmt | 14 | |||||
| 15 | Contract Labor: Physician services-Part A | 15 | |||||
| 16 | Home office salaries & wage related costs | ### | ### | ### | ### | 16 | |
| WAGE RELATED COSTS | |||||||
| 17 | Wage related costs core (see Pt. IV) | ### | ### | 17 | |||
| 18 | Wage related costs other (see Pt. IV) | ### | ### | 18 | |||
| 19 | Wage related costs (excluded units) | ### | ### | 19 | |||
| 20 | Physicians Part A - WRC | 20 | |||||
| 21 | Physicians Part B - WRC | 21 | |||||
| 22 | Total adjusted wage related cost (see instructions) | ### | ### | 22 | |||
| PART III - OVERHEAD COST - DIRECT SALARIES | |||||||
| Amount Reported | Reclass. of Salaries from Wkst. A-6 |
Adjusted Salaries (col. 1 ± col. 2) |
Paid Hours Related to Salary in col. 3 |
Average Hourly Wage (col. 3 ÷ col. 4) |
|||
| 1 | 2 | 3 | 4 | 5 | |||
| 1 | Employee Benefits | 1 | |||||
| 2 | Administrative & General | ### | ### | ### | ### | 2 | |
| 3 | Plant Operation, Maintenance & Repairs | ### | ### | ### | ### | 3 | |
| 4 | Laundry & Linen Service | ### | ### | ### | ### | 4 | |
| 5 | Housekeeping | ### | ### | ### | ### | 5 | |
| 6 | Dietary | ### | ### | ### | ### | 6 | |
| 7 | Nursing Administration | ### | ### | ### | ### | 7 | |
| 8 | Central Services and Supply | 8 | |||||
| 9 | Pharmacy | 9 | |||||
| 10 | Medical Records & Medical Records Library | 10 | |||||
| 11 | Social Service | ### | ### | ### | ### | 11 | |
| 12 | Nursing and Allied Health Ed. Act. | 12 | |||||
| 13 | Other General Service (specify _______________) | 13 | |||||
| 14 | Total (sum lines 1 through 13) | ### | ### | ### | ### | 14 | |
| FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4105.1 - 4105.2) | |||||||
| 41-308 | Rev. 7 | ||||||