Worksheet A-8
- Return to Cost Report Summary
- Form A800
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3519, REV 4
SENTARA NURSING CENTER-NORFOLK
NORFOLK, VA 23502
NORFOLK, VA 23502
Medicare Provider Number: 495173
Cost report status: Settled Without Audit
[Record Code 1080391 - 2010]
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| ADJUSTMENTS TO EXPENSES | Provider CCN: 495173 | PERIOD: FROM 01/01/2012 TO 12/31/2012 |
WORKSHEET A-8 | |||
| Description (1) | Basis for Adjustment (2) | Amount | Expense Classification on Wkst. A to/from which the amount is to be adjusted |
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| Cost Center | Line No. | |||||
| 0 | 1 | 2 | 3 | 4 | ||
| 1 | Investment income on restricted funds (Chapter 2) | 1 | ||||
| 2 | Trade, quantity and time discounts on purchases (Chapter 8) | 2 | ||||
| 3 | Refunds and rebates of expenses Chapter 8) | 3 | ||||
| 4 | Rental of provider space by suppliers Chapter 8) | 4 | ||||
| 5 | Telephone services (pay stations excluded) (Chapter 21) | 5 | ||||
| 6 | Television and radio service (Chapter 21) | 6 | ||||
| 7 | Parking lot (Chapter 21) | 7 | ||||
| 8 | Remuneration applicable to provider-based physician adjustment | Worksheet A-8-2 | 8 | |||
| 9 | Home office costs (Chapter 21) | 9 | ||||
| 10 | Sale of scrap, waste, etc. (Chapter 23) | 10 | ||||
| 11 | Nonallowable costs related to certain Capital expenditures (Chapter 24) | 11 | ||||
| 12 | Adjustment resulting from transactions with related organizations (Chapter 10) | Worksheet A-8-1 | ### | 12 | ||
| 13 | Laundry and Linen service | ### | ### | ### | ### | 13 |
| 14 | Revenue - Employee meals | ### | ### | ### | ### | 14 |
| 15 | Cost of meals - Guests | 15 | ||||
| 16 | Sale of medical supplies to other than patients | 16 | ||||
| 17 | Sale of drugs to other than patients | 17 | ||||
| 18 | Sale of medical records and abstracts | 18 | ||||
| 19 | Vending machines | ### | ### | ### | ### | 19 |
| 20 | Income from imposition of interest, finance or penalty charges (Chapter 21) | 20 | ||||
| 21 | Interest expense on Medicare overpayments and borrowings to repay Medicare overpayments | 21 | ||||
| 22 | Utilization review--physicians' compensation (Chapter 21) | Utilization Review- SNF | 82 | 22 | ||
| 23 | Depreciation--buildings and fixtures | Capital Related Cost- Building | 1 | 23 | ||
| 24 | Depreciation--movable equipment | Capital Related Cost-Movable | 2 | 24 | ||
| 25 | Other Adjustment specify - VENDING MACHINE | ### | ### | ### | ### | 25 |
| 25.01 | CENTRAL SUPPLY PURCHASES | ### | ### | ### | ### | 25.01 |
| 25.02 | CENTRAL SUPPLY PURCHASES | ### | ### | ### | ### | 25.02 |
| 25.03 | BAD DEBT - OTHER | ### | ### | ### | ### | 25.03 |
| 25.04 | BAD DEBT - MEDICARE PART A | ### | ### | ### | ### | 25.04 |
| 25.05 | RECOVERY OF CHARGED OFF ACCT | ### | ### | ### | ### | 25.05 |
| 25.06 | RECOVERY OF COST REPORT BAD DEBT | ### | ### | ### | ### | 25.06 |
| 25.07 | MEALS ON WHEELS REVENUE | ### | ### | ### | ### | 25.07 |
| 25.09 | SHORE DRIVE/RICHARDSON | ### | ### | ### | ### | 25.09 |
| 25.10 | PATIENT VALUABLES REPLACEMENT | ### | ### | ### | ### | 25.10 |
| 25.11 | CASH OVER SHORT | ### | ### | ### | ### | 25.11 |
| 25.12 | PT PART B THERAPY SALARY EXPENSE | ### | ### | ### | ### | 25.12 |
| 25.13 | PUBLIC RELATIONS | ### | ### | ### | ### | 25.13 |
| 25.14 | MISCELLANEOUS INCOME | ### | ### | ### | ### | 25.14 |
| 25.15 | OT PART B THERAPY SAL EXPENSE | ### | ### | ### | ### | 25.15 |
| 25.16 | ST PART B THERAPY SAL EXPENSE | ### | ### | ### | ### | 25.16 |
| 25.17 | PT PART B THERAPY BENEFIT EXPENSE | ### | ### | ### | ### | 25.17 |
| 25.18 | OT PART B THERAPY BENEFIT EXPENSE | ### | ### | ### | ### | 25.18 |
| 25.19 | ST PART B THERAPY BENEFIT EXPENSE | ### | ### | ### | ### | 25.19 |
| 25.20 | MISCODED CONSOL BILLING | ### | ### | ### | ### | 25.20 |
| 25.33 | REVERSE 12/11 PERFORMANCE PLUS | ### | ### | ### | ### | 25.33 |
| 25.34 | PERFORMANCE PLUS 12/2012 | ### | ### | ### | ### | 25.34 |
| 25.62 | OCC THER RESOURCE POOL-PERF PLUS | ### | ### | ### | ### | 25.62 |
| 25.63 | 8801/9901 BALANCE OF PERF PLUS ACCR | ### | ### | ### | ### | 25.63 |
| 25.64 | QUALITY ASSURANCE-QM SALARY | ### | ### | ### | ### | 25.64 |
| 25.65 | QUALITY ASSURANCE-QM BENEFITS | ### | ### | ### | ### | 25.65 |
| 25.66 | NSG RESOURCE POOL-PERF PLUS | ### | ### | ### | ### | 25.66 |
| 25.67 | NSG RESOURCE POOL-FICA PERF PLUS | ### | ### | ### | ### | 25.67 |
| 25.68 | CRIMINAL HISTORY RECORD CHECKS | ### | ### | ### | ### | 25.68 |
| 25.69 | PHYS THER RESOURCE POOL-PERF PLUS | ### | ### | ### | ### | 25.69 |
| 25.71 | REHAB RESOURCE POOL-FICA PERF PLUS | ### | ### | ### | ### | 25.71 |
| 25.74 | ADJ POLLUTION LIAB INSUR (2 TANKS) | ### | ### | ### | ### | 25.74 |
| 100 | TOTAL (sum of lines 1 through 99) (transfer to Wkst. A, col. 6, line 100) |
### | 100 | |||
(1) Description - all chapter references in this column pertain to CMS Pub. 15-1 (2) Basis for adjustment (see instructions) |
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A. Costs - if cost, including applicable overhead, can be determined B. Amount Received - if cost cannot be determined |
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| FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4116) | ||||||
| 41-320 | Rev. 1 | |||||