Worksheet A-8
- Return to Cost Report Summary
- Form A800
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3519, REV 4
LIFE CARE CENTER OF FLORISSANT
FLORISSANT, MO 63033
FLORISSANT, MO 63033
Medicare Provider Number: 265838
Cost report status: Settled Without Audit
[Record Code 1053261 - 2010]
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ADJUSTMENTS TO EXPENSES | Provider CCN: 265838 | PERIOD: FROM 01/26/2011 TO 12/31/2011 |
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 - NONALLOW. ADVERT - COMMUNICATIONS | ### | ### | ### | ### | 25 |
25.05 | LOBBYING | ### | ### | ### | ### | 25.05 |
25.10 | PHYSICIAN FEES | ### | ### | ### | ### | 25.10 |
25.15 | CONTRACT SERVICE PART B | ### | ### | ### | ### | 25.15 |
25.20 | REFUND DIETARY | ### | ### | ### | ### | 25.20 |
25.25 | REFUND HOUSEKEEPING | ### | ### | ### | ### | 25.25 |
25.30 | REFUND LINEN | ### | ### | ### | ### | 25.30 |
25.35 | REFUND PLANT | ### | ### | ### | ### | 25.35 |
25.40 | REFUND ADMINISTRATIVE | ### | ### | ### | ### | 25.40 |
25.45 | REFUND INCONTINENCE | ### | ### | ### | ### | 25.45 |
25.50 | REFUND ROUTINE / PERSONAL | ### | ### | ### | ### | 25.50 |
25.53 | REMOVE NON-ALLOWABLE CABLE | ### | ### | ### | ### | 25.53 |
25.55 | REMOVE TAIL / RETRO PROF LIAB INS | ### | ### | ### | ### | 25.55 |
25.60 | REMOVE UNIDENTIFIABLE AMBULANCE | ### | ### | ### | ### | 25.60 |
25.65 | REMOVE UNIDENTIFIABLE AMBULANCE | ### | ### | ### | ### | 25.65 |
25.70 | LATE FEES | ### | ### | ### | ### | 25.70 |
25.75 | REMOVE PROVIDER TAX | ### | ### | ### | ### | 25.75 |
26.00 | INTEREST INCOME | ### | ### | ### | ### | 26.00 |
27.00 | START-UP COSTS | ### | ### | ### | ### | 27.00 |
27.05 | START-UP COSTS | ### | ### | ### | ### | 27.05 |
27.10 | START-UP COSTS | ### | ### | ### | ### | 27.10 |
27.15 | START-UP COSTS | ### | ### | ### | ### | 27.15 |
27.20 | START-UP COSTS | ### | ### | ### | ### | 27.20 |
27.25 | START-UP COSTS | ### | ### | ### | ### | 27.25 |
27.30 | START-UP COSTS | ### | ### | ### | ### | 27.30 |
27.35 | START-UP COSTS | ### | ### | ### | ### | 27.35 |
27.40 | START-UP COSTS | ### | ### | ### | ### | 27.40 |
27.45 | START-UP COSTS | ### | ### | ### | ### | 27.45 |
27.50 | START-UP COSTS | ### | ### | ### | ### | 27.50 |
27.55 | START-UP COSTS | ### | ### | ### | ### | 27.55 |
27.60 | START-UP COSTS | ### | ### | ### | ### | 27.60 |
27.65 | START-UP COSTS | ### | ### | ### | ### | 27.65 |
27.70 | START-UP COSTS | ### | ### | ### | ### | 27.70 |
27.75 | START-UP COSTS | ### | ### | ### | ### | 27.75 |
28.00 | PARTIAL-MONTH EXPENSES | ### | ### | ### | ### | 28.00 |
28.05 | PARTIAL-MONTH EXPENSES | ### | ### | ### | ### | 28.05 |
28.10 | PARTIAL-MONTH EXPENSES | ### | ### | ### | ### | 28.10 |
28.15 | PARTIAL-MONTH EXPENSES | ### | ### | ### | ### | 28.15 |
28.20 | PARTIAL-MONTH EXPENSES | ### | ### | ### | ### | 28.20 |
28.25 | PARTIAL-MONTH EXPENSES | ### | ### | ### | ### | 28.25 |
28.30 | PARTIAL-MONTH EXPENSES | ### | ### | ### | ### | 28.30 |
28.35 | PARTIAL-MONTH EXPENSES | ### | ### | ### | ### | 28.35 |
28.40 | PARTIAL-MONTH EXPENSES | ### | ### | ### | ### | 28.40 |
28.45 | PARTIAL-MONTH EXPENSES | ### | ### | ### | ### | 28.45 |
28.50 | PARTIAL-MONTH EXPENSES | ### | ### | ### | ### | 28.50 |
28.55 | PARTIAL-MONTH EXPENSES | ### | ### | ### | ### | 28.55 |
28.60 | PARTIAL-MONTH EXPENSES | ### | ### | ### | ### | 28.60 |
28.65 | PARTIAL-MONTH EXPENSES | ### | ### | ### | ### | 28.65 |
28.70 | PARTIAL-MONTH EXPENSES | ### | ### | ### | ### | 28.70 |
28.75 | PARTIAL-MONTH EXPENSES | ### | ### | ### | ### | 28.75 |
28.80 | PARTIAL-MONTH EXPENSES | ### | ### | ### | ### | 28.80 |
28.90 | PARTIAL-MONTH EXPENSES | ### | ### | ### | ### | 28.90 |
31.00 | RADIOLOGY ADJUSTMENT | ### | ### | ### | ### | 31.00 |
31.02 | MISCELLANEOUS INCOME | ### | ### | ### | ### | 31.02 |
31.05 | CHARITABLE CONTRIBUTIONS | ### | ### | ### | ### | 31.05 |
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 |