Worksheet B Part I

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SAINT MARYS EAST
ERIE, PA  16504

Medicare Provider Number: 395042
Cost report status: Settled Without Audit
[Record Code 1079961 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 395042
PERIOD:
FROM 01/01/2013
TO 12/31/2013
 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 1,794,987 ###                                     1
2 Capital-Related Costs - Moveable Equipment                                   2
3 Employee Benefits 1,958,706 ### ###                               3
4 Administrative and General 1,586,495 ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 1,190,524 ### ### ### ### ###                           5
6 Laundry and Linen Service 397,399 ### ### ### ### ### ###                         6
7 Housekeeping 475,302 ### ### ### ### ### ### ###                       7
8 Dietary 1,905,514 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 445,830 ### ### ### ### ### ### ###                   9
10 Central Services and Supply 29,100 ### ### ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 35,093 ### ### ### ### ### ### ###             12
13 Social Service 111,548 ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 206,863 ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 2,852,861 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 882,757 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 31
32 ICF/IID 32
33 Other Long Term Care 815,358 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 10,854 ### ### ### ### 40
41 Laboratory 26,523 ### ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 31,046 ### ### ### ### ### ### ### ### 43
44 Physical Therapy 445,857 ### ### ### ### ### ### ### 44
45 Occupational Therapy 420,798 ### ### ### ### ### ### ### 45
46 Speech Pathology 112,974 ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 1,141 ### ### ### ### ### 48
49 Drugs Charged to Patients 152,822 ### ### ### ### ### ### ### 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 15,890,352 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen ### ### ### ### ### ### ### 90
91 Barber and Beauty Shop 8,480 ### ### ### ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 157,917 ### ### ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 16,056,749 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7