Worksheet B Part I

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NHC HEALTHCARE - CHARLESTON
CHARLESTON, SC  29414

Medicare Provider Number: 425381
Cost report status: As Submitted
[Record Code 1358349 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 425381
PERIOD:
FROM 01/01/2022
TO 12/31/2022
 WORKSHEET B PART I
Cost Center Description Net Expenses for Cost Allocation (from Wkst. A, col. 7) Cap. Rel Buildings & Fixtures Cap. Rel Movable Equipment Employee Benefits Subtotal (Sum of cols. 0 - 3) Administrative & General Plant Oper. Maintenance & Repairs Laundry & Linen Service House Keeping Dietary Nursing Administration Central Services & Supply Pharmacy Medical Records & Library Social Service Nursing & Allied Health Education Other General Service Cost Subtotal Post Step-down Adjustments Total  
0 1 2 3 3 A 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
GENERAL SERVICE COST CENTERS                                          
1 Capital-Related Costs - Buildings & Fixtures 709,695 ###                                     1
2 Capital-Related Costs - Moveable Equipment                                   2
3 Employee Benefits 1,148,847 ###                               3
4 Administrative and General 1,392,365 ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 393,088 ### ### ### ### ###                           5
6 Laundry and Linen Service 143,319 ### ### ### ### ### ###                         6
7 Housekeeping 424,154 ### ### ### ### ### ###                       7
8 Dietary 845,867 ### ### ### ### ### ### ###                     8
9 Nursing Administration 980,731 ### ### ### ###                   9
10 Central Services and Supply 362,018 ### ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 131,519 ### ### ### ### ### ### ###             12
13 Social Service 459,006 ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 4,645,134 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 1,466,069 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 29,540 ### ### ### ### ### 40
41 Laboratory 40,150 ### ### ### ### ### 41
42 Intravenous Therapy 195,826 ### ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy 745,021 ### ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 590,131 ### ### ### ### ### ### ### ### ### 45
46 Speech Pathology 88,801 ### ### ### ### ### ### ### ### ### 46
47 Electrocardiology 1,256 ### ### ### ### ### 47
48 Medical Supplies Charged to Patients 48
49 Drugs Charged to Patients 1,743,286 ### ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 52
OUTPATIENT SERVICE COST CENTERS                                          
60 Clinic 60
61 Rural Health Clinic (RHC) 61
62 FQHC 62
63 Other Outpatient Service Cost 63
OTHER REIMBURSABLE COST CENTERS                                          
70 Home Health Agency Cost 70
71 Ambulance 71
72 Outpatient Rehabilitation (specify) 72
73 CMHC 73
74 Other Reimbursable Cost 74
SPECIAL PURPOSE COST CENTERS                                          
83 Hospice 83
84 Other Special Purpose Cost 84
89 Subtotals 16,535,823 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop ### ### ### ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 16,535,823 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7