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
HIBBARD NURSING HOME
DOVER-FOXCROFT, ME 04426-
DOVER-FOXCROFT, ME 04426-
Medicare Provider Number: 205004
Cost report status: Settled Without Audit
[Record Code 22039 - 1996]
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| SNF WAGE INDEX INFORMATION | PROVIDER NO: 205004 |
PERIOD: FROM 10/01/1996 TO 09/30/1997 |
WORKSHEET S-3, Part II | |||||
| PART II 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) |
Data Source |
||
| 1 | 2 | 3 | 4 | 5 | 6 | |||
| 1 | Total salary (See Instructions) | ### | ### | ### | ### | 1 | ||
| 2 | Physician salaries-Part A | 2 | ||||||
| 3 | Physician salaries-Part B | 3 | ||||||
| 4 | Interns & Residents (approved) | 4 | ||||||
| 5 | Home office personnel | 5 | ||||||
| 6 | Sum of lines 2 thru 5 | 6 | ||||||
| 7 | Revised wages (line 1 minus line 6) | ### | ### | ### | ### | 7 | ||
| 8 | Other Long Term Care | 8 | ||||||
| 9 | Other Inpatient Routine Service | 9 | ||||||
| 10 | Interns & Residents (Not In Approved Program) | 10 | ||||||
| 11 | HHA | 11 | ||||||
| 12 | Outpatient Rehabilitation Providers | 12 | ||||||
| 13 | Hospice | 13 | ||||||
| 14 | Non-reimbursable | 14 | ||||||
| 15 | Total Excluded salary (Sum of lines 8 through 14) | 15 | ||||||
| 16 | Subtotal (line 7 minus line 15) | ### | ### | ### | ### | 16 | ||
| 17 | Contract Labor: Patient Related & Mgmt | ### | ### | ### | ### | CMS 339 | 17 | |
| 18 | Home office salaries & wage related costs | 18 | ||||||
| 19 | Wage related costs (core) | CMS 339 | 19 | |||||
| 20 | Wage related costs (other) | CMS 339 | 20 | |||||
| 21 | Wage related costs (excluded units) | CMS 339 | 21 | |||||
| 22 | Subtotal (see instructions) | 22 | ||||||
| 23 | Total (see instructions) | ### | ### | ### | ### | 23 | ||
| 24 | Contract Labor: Physician services-Part A | 24 | ||||||
| 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 | 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 & Library | 10 | ||||||
| 11 | Social Service | ### | ### | ### | ### | 11 | ||
| 12 | Interns & Residents (Apprvd Teaching Prog) | 12 | ||||||
| 13 | Other General Service (specify) | ### | ### | ### | ### | 13 | ||
| 14 | Total (sum lines 1 thru 13) | ### | ### | ### | ### | 14 | ||