Worksheet B Part I

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ST. MARY HOME
WEST HARTFORD, CT  06117

Medicare Provider Number: 075085
Cost report status: Settled Without Audit
[Record Code 1181910 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 075085
PERIOD:
FROM 07/01/2016
TO 06/30/2017
 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 777,930 ###                                     1
2 Capital-Related Costs - Moveable Equipment 426,731 ###                                   2
3 Employee Benefits 4,643,948 ###                               3
4 Administrative and General 4,757,570 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 2,416,930 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 186,705 ### ### ### ### ### ### ###                         6
7 Housekeeping 1,386,031 ### ### ### ### ### ### ###                       7
8 Dietary 2,914,505 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 186,387 ### ### ### ###                   9
10 Central Services and Supply                 10
11 Pharmacy               11
12 Medical Records and Library             12
13 Social Service 308,203 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 273,668 ### ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 10,327,755 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 1,372,965 ### ### ### ### ### ### ### ### ### ### ### ### ### 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 26,725 ### ### ### 40
41 Laboratory 67,449 ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 102,837 ### ### ### ### 43
44 Physical Therapy 893,306 ### ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 772,891 ### ### ### ### 45
46 Speech Pathology 189,848 ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 48
49 Drugs Charged to Patients 513,509 ### ### ### 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 32,545,893 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 23,096 ### ### ### ### ### ### ### ### ### 90
91 Barber and Beauty Shop ### ### ### ### ### ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 165,579 ### ### ### ### ### ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 32,734,568 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7