Worksheet A-8
- Return to Cost Report Summary
- Form A800
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3519, REV 4
GOOD SAMARITAN SOCIETY - S F VILLAGE
SIOUX FALLS, SD 57106-1799
SIOUX FALLS, SD 57106-1799
Medicare Provider Number: 435045
Cost report status: Settled Without Audit
[Record Code 1118316 - 2010]
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| ADJUSTMENTS TO EXPENSES | Provider CCN: 435045 | PERIOD: FROM 10/01/2014 TO 09/30/2015 |
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 - A8 DUES | ### | ### | ### | ### | 25 |
| 25.01 | PENALTY FEES | ### | ### | ### | ### | 25.01 |
| 25.02 | MARKETING EXP - NON SALARY | ### | ### | ### | ### | 25.02 |
| 25.03 | GIFT SHOP/COMMISSIONARY | ### | ### | ### | ### | 25.03 |
| 25.04 | INTEREST INCOME -ASSISTED LIVING | ### | ### | ### | ### | 25.04 |
| 25.05 | INTEREST INCOME -SENIOR LIVING W/ SE | ### | ### | ### | ### | 25.05 |
| 25.06 | RENT | ### | ### | ### | ### | 25.06 |
| 25.07 | RESIDENT SUPPLIES | ### | ### | ### | ### | 25.07 |
| 25.08 | NON CASH GIFTS - OPERATING | ### | ### | ### | ### | 25.08 |
| 25.09 | ADMINISTRATION | ### | ### | ### | ### | 25.09 |
| 25.10 | POSTAGE | ### | ### | ### | ### | 25.10 |
| 25.11 | GARNISHMENT FEE | ### | ### | ### | ### | 25.11 |
| 25.12 | INTEREST INCOME | ### | ### | ### | ### | 25.12 |
| 25.13 | ADMINISTRATION | ### | ### | ### | ### | 25.13 |
| 25.14 | ADMINISTRATION | ### | ### | ### | ### | 25.14 |
| 25.15 | ADMINISTRATION | ### | ### | ### | ### | 25.15 |
| 25.16 | ADMINISTRATION | ### | ### | ### | ### | 25.16 |
| 25.17 | OPERATIONS/MAINTENANCE | ### | ### | ### | ### | 25.17 |
| 25.18 | OPERATIONS/MAINTENANCE | ### | ### | ### | ### | 25.18 |
| 25.19 | OPERATIONS/MAINTENANCE | ### | ### | ### | ### | 25.19 |
| 25.20 | OPERATIONS/MAINTENANCE | ### | ### | ### | ### | 25.20 |
| 25.21 | CARPORT/GARAGE RENT | ### | ### | ### | ### | 25.21 |
| 25.22 | RENT - EQUIPMENT | ### | ### | ### | ### | 25.22 |
| 25.23 | RENT - BUILDING | ### | ### | ### | ### | 25.23 |
| 25.24 | RENT - BUILDING | ### | ### | ### | ### | 25.24 |
| 25.25 | RENT - BUILDING | ### | ### | ### | ### | 25.25 |
| 25.26 | RENT - BUILDING | ### | ### | ### | ### | 25.26 |
| 25.27 | GUEST ROOM | ### | ### | ### | ### | 25.27 |
| 25.28 | TRANSPORTATION | ### | ### | ### | ### | 25.28 |
| 25.29 | UNIFORM INCOME | ### | ### | ### | ### | 25.29 |
| 25.30 | POP INCOME | ### | ### | ### | ### | 25.30 |
| 25.31 | LAB INCOME | ### | ### | ### | ### | 25.31 |
| 25.32 | VACCINE ADMIN | ### | ### | ### | ### | 25.32 |
| 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 | |||||