Worksheet B Part I

Add to Cart
Add to Cart
back to list
back to list
free profile
free profile
profile
profile
financial & statistical
financial & statistical
financial indicators
financial indicators
RUGs statistics
RUGs statistics
cost reports
cost reports
GOODWIN HOUSE BAILEYS CROSSROADS
FALLS CHURCH, VA  22041

Medicare Provider Number: 495171
Cost report status: Settled Without Audit
[Record Code 1282701 - 2010]
Print
Print
Excel
Excel
PDF
PDF

You are not logged in or you have not purchased this report. This report has had its actual values replaced with dummy text ('###').

If you would like to become a subscriber, please look at our subscription details.

If you are already a subscriber, please login.

COST ALLOCATION - GENERAL SERVICE COSTS Provider CCN: 495171
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 7,249,556 ###                                     1
2 Capital-Related Costs - Moveable Equipment 1,171,865 ###                                   2
3 Employee Benefits ### ### ###                               3
4 Administrative and General 5,262,579 ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 3,387,416 ### ### ### ### ### ###                           5
6 Laundry and Linen Service 326,802 ### ### ### ### ### ### ###                         6
7 Housekeeping 1,610,392 ### ### ### ### ### ### ### ###                       7
8 Dietary 7,296,933 ### ### ### ### ### ### ### ###                     8
9 Nursing Administration 960,176 ### ### ### ### ### ### ###                   9
10 Central Services and Supply                 10
11 Pharmacy               11
12 Medical Records and Library ### ### ### ### ### ###             12
13 Social Service 1,089,401 ### ### ### ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 4,771,209 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 2,147,942 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 9,361 ### ### ### ### 40
41 Laboratory 20,542 ### ### ### ### 41
42 Intravenous Therapy 3,609 ### ### ### ### 42
43 Oxygen (Inhalation) Therapy 18,345 ### ### ### ### 43
44 Physical Therapy 439,462 ### ### ### ### ### ### ### 44
45 Occupational Therapy 252,357 ### ### ### ### 45
46 Speech Pathology 66,859 ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 88,167 ### ### ### ### 48
49 Drugs Charged to Patients 460,366 ### ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 99,550 ### ### ### ### 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 4,336,853 ### ### ### ### ### 83
84 Other Special Purpose Cost 84
89 Subtotals 41,069,742 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop 222,168 ### ### ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 7,151,061 ### ### ### ### ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 48,442,971 ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7