Worksheet B Part I

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CHARLOTTE HALL VETERANS HOME
CHARLOTTE HALL, MD  20622

Medicare Provider Number: 215161
Cost report status: Settled Without Audit
[Record Code 1049051 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 215161
PERIOD:
FROM 10/01/2011
TO 09/30/2012
 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 817,390 ###                                     1
2 Capital-Related Costs - Moveable Equipment 143,388 ###                                   2
3 Employee Benefits 3,765,210 ###                               3
4 Administrative and General 5,713,489 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 3,052,904 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 783,641 ### ### ### ### ### ###                         6
7 Housekeeping 1,120,083 ### ### ### ### ### ###                       7
8 Dietary 2,988,919 ### ### ### ### ### ### ###                     8
9 Nursing Administration 1,017,329 ### ### ### ###                   9
10 Central Services and Supply 55,604 ### ### ### ###                 10
11 Pharmacy 23,760 ### ### ###               11
12 Medical Records and Library 117,815 ### ### ### ###             12
13 Social Service 491,553 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 623,872 ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 7,854,016 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 2,840,652 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 21,113 ### ### ### ### 40
41 Laboratory 24,165 ### ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy 746,628 ### ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 447,427 ### ### ### ### ### ### ### ### 45
46 Speech Pathology 164,451 ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 162,620 ### ### ### ### 48
49 Drugs Charged to Patients 1,240,645 ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 1,161 ### ### ### ### 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 1,469 ### ### ### ### 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 34,219,304 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop 10,939 ### ### ### ### ### ### ### ### 91
92 Physicians' Private Offices 179,954 ### ### ### ### 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 34,410,197 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7