Worksheet B Part I

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RIVER VALLEY HEALTH & REHAB
GAINESVILLE, TX  76240

Medicare Provider Number: 455970
Cost report status: Settled Without Audit
[Record Code 1104895 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 455970
PERIOD:
FROM 01/01/2014
TO 12/31/2014
 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 142,397 ###                                     1
2 Capital-Related Costs - Moveable Equipment                                   2
3 Employee Benefits 168,710 ### ###                               3
4 Administrative and General 546,884 ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 216,948 ### ### ### ### ###                           5
6 Laundry and Linen Service 30,697 ### ### ### ### ### ###                         6
7 Housekeeping 70,851 ### ### ### ### ### ###                       7
8 Dietary 267,510 ### ### ### ### ### ### ###                     8
9 Nursing Administration 131,445 ### ### ### ### ### ### ###                   9
10 Central Services and Supply ### ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library 18,770 ### ### ### ### ### ### ###             12
13 Social Service 37,887 ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 41,374 ### ### ### ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 925,636 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 3,809 ### ### ### ### 40
41 Laboratory 4,093 ### ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 104 ### ### ### ### ### ### ### 43
44 Physical Therapy 158,272 ### ### ### ### ### ### ### 44
45 Occupational Therapy 158,975 ### ### ### ### ### ### ### 45
46 Speech Pathology 504 ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 12,505 ### ### ### ### ### ### ### ### 48
49 Drugs Charged to Patients 63,217 ### ### ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 9 ### ### ### ### 51
52 Other Ancillary Service Cost 2,180 ### ### ### ### 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 3,002,777 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 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 80,760 ### ### ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 3,083,537 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7