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
SMITHS MILL HEALTH CAMPUS
NEW ALBANY, OH  43054-7685

Medicare Provider Number: 366475
Cost report status: Settled Without Audit
[Record Code 1292024 - 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: 366475
PERIOD:
FROM 12/30/2019
TO 12/31/2020
 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 2,043,067 ###                                     1
2 Capital-Related Costs - Moveable Equipment 321,356 ###                                   2
3 Employee Benefits 434,756 ###                               3
4 Administrative and General 745,613 ### ### ###                             4
5 Plant Operation, Maintenance and Repairs 365,460 ### ### ### ###                           5
6 Laundry and Linen Service 19,766 ### ### ###                         6
7 Housekeeping 107,467 ### ### ### ###                       7
8 Dietary 343,547 ### ### ### ###                     8
9 Nursing Administration 244,736 ### ### ### ###                   9
10 Central Services and Supply 43,657 ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library             12
13 Social Service 175,532 ### ### ### ###           13
14 Nursing and Allied Health Education         14
15 Other General Service Cost 103,473 ### ### ### ###       15
INPATIENT ROUTINE SERVICE COST CENTERS                                          
30 Skilled Nursing Facility 844,569 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 30
31 Nursing Facility 31
32 ICF/IID 32
33 Other Long Term Care 236,413 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 33
ANCILLARY SERVICE COST CENTERS                                          
40 Radiology 6,011 ### ### ### 40
41 Laboratory 3,850 ### ### ### 41
42 Intravenous Therapy 42
43 Oxygen (Inhalation) Therapy 6,688 ### ### ### 43
44 Physical Therapy 66,387 ### ### ### ### 44
45 Occupational Therapy 66,885 ### ### ### ### 45
46 Speech Pathology 58,965 ### ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients 216 ### ### ### 48
49 Drugs Charged to Patients 134,347 ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 19,639 ### ### ### 51
52 Other Ancillary Service Cost 5,994 ### ### ### 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 6,398,394 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 89
NON REIMBURSABLE COST CENTERS                                          
90 Gift, Flower, Coffee Shops and Canteen 90
91 Barber and Beauty Shop 2,555 ### ### ### ### 91
92 Physicians' Private Offices 92
93 Nonpaid Workers 93
94 Patients' Laundry 94
95 Other Nonreimbursable Cost 37,313 ### ### ### ### ### ### ### ### 95
98 Cross Foot Adjustments       98
99 Negative Cost Center 99
100 Total 6,438,262 ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120)
08-16   Rev. 7