Worksheet B Part I

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CHURCH HOME OF HARTFORD INC.
BLOOMFIELD, CT  06002-2650

Medicare Provider Number: 075383
Cost report status: Settled Without Audit
[Record Code 1282794 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 075383
PERIOD:
FROM 10/01/2019
TO 09/30/2020
 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 7,113,389 ###                                     1
2 Capital-Related Costs - Moveable Equipment 1,614,203 ###                                   2
3 Employee Benefits 4,001,430 ###                               3
4 Administrative and General 2,705,979 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 3,218,719 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 75,147 ### ### ### ### ### ### ###                         6
7 Housekeeping 897,703 ### ### ### ### ### ### ### ###                       7
8 Dietary 2,887,260 ### ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 212,129 ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply                 10
11 Pharmacy 97,718 ### ### ###               11
12 Medical Records and Library 59,171 ### ### ### ### ### ### ### ###             12
13 Social Service 60,378 ### ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 3,254,374 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 1,026,193 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 5,980 ### ### ### ### 40
41 Laboratory 27,289 ### ### ### ### 41
42 Intravenous Therapy 639 ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 4,057 ### ### ### ### 43
44 Physical Therapy 618,353 ### ### ### ### ### ### ### ### ### 44
45 Occupational Therapy 475,314 ### ### ### ### ### ### ### ### ### 45
46 Speech Pathology 97,801 ### ### ### ### ### ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 87,112 ### ### ### ### 48
49 Drugs Charged to Patients 114,473 ### ### ### ### 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 805,821 ### ### ### ### ### 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 29,460,632 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen ### ### ### ### ### ### ### ### 90
91 Barber and Beauty Shop 55,081 ### ### ### ### ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 9,299,329 ### ### ### ### ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 38,815,042 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7