Worksheet B Part I
- Return to Cost Report Summary
- Form B001
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3524, REV 6
FOX GLOVE CENTER
ATLANTA, GA 30315-7802
ATLANTA, GA 30315-7802
Medicare Provider Number: 115569
Cost report status: Settled Without Audit
[Record Code 1214719 - 2010]
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COST ALLOCATION - GENERAL SERVICE COSTS | Provider CCN: 115569 | 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 | 264,728 | ### | 1 | ||||||||||||||||||
2 | Capital-Related Costs - Moveable Equipment | 2 | ||||||||||||||||||||
3 | Employee Benefits | 489,651 | ### | ### | 3 | |||||||||||||||||
4 | Administrative and General | 1,123,996 | ### | ### | ### | ### | 4 | |||||||||||||||
5 | Plant Operation, Maintenance and Repairs | 334,974 | ### | ### | ### | ### | ### | 5 | ||||||||||||||
6 | Laundry and Linen Service | 131,593 | ### | ### | ### | ### | ### | 6 | ||||||||||||||
7 | Housekeeping | 117,219 | ### | ### | ### | ### | ### | 7 | ||||||||||||||
8 | Dietary | 464,202 | ### | ### | ### | ### | ### | ### | ### | 8 | ||||||||||||
9 | Nursing Administration | 205,460 | ### | ### | ### | ### | ### | ### | ### | 9 | ||||||||||||
10 | Central Services and Supply | 707 | ### | ### | ### | ### | 10 | |||||||||||||||
11 | Pharmacy | 11 | ||||||||||||||||||||
12 | Medical Records and Library | 44,681 | ### | ### | ### | ### | ### | ### | ### | 12 | ||||||||||||
13 | Social Service | 94,145 | ### | ### | ### | ### | ### | ### | ### | 13 | ||||||||||||
14 | Nursing and Allied Health Education | 14 | ||||||||||||||||||||
15 | Other General Service Cost | 61,293 | ### | ### | ### | ### | 15 | |||||||||||||||
INPATIENT ROUTINE SERVICE COST CENTERS | ||||||||||||||||||||||
30 | Skilled Nursing Facility | 2,028,142 | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 30 | ||||
31 | Nursing Facility | 31 | ||||||||||||||||||||
32 | ICF/IID | 32 | ||||||||||||||||||||
33 | Other Long Term Care | 33 | ||||||||||||||||||||
ANCILLARY SERVICE COST CENTERS | ||||||||||||||||||||||
40 | Radiology | 3,871 | ### | ### | ### | ### | 40 | |||||||||||||||
41 | Laboratory | 841 | ### | ### | ### | ### | 41 | |||||||||||||||
42 | Intravenous Therapy | 32,782 | ### | ### | ### | ### | 42 | |||||||||||||||
43 | Oxygen (Inhalation) Therapy | 32,724 | ### | ### | ### | ### | 43 | |||||||||||||||
44 | Physical Therapy | 125,890 | ### | ### | ### | ### | ### | ### | ### | 44 | ||||||||||||
45 | Occupational Therapy | 172,995 | ### | ### | ### | ### | ### | ### | ### | 45 | ||||||||||||
46 | Speech Pathology | 109,398 | ### | ### | ### | ### | ### | ### | ### | 46 | ||||||||||||
47 | Electrocardiology | 47 | ||||||||||||||||||||
48 | Medical Supplies Charged to Patients | 62,792 | ### | ### | ### | ### | ### | 48 | ||||||||||||||
49 | Drugs Charged to Patients | 128,710 | ### | ### | ### | ### | 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 | 6,030,794 | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 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 | 95 | ||||||||||||||||||||
98 | Cross Foot Adjustments | 98 | ||||||||||||||||||||
99 | Negative Cost Center | 99 | ||||||||||||||||||||
100 | Total | 6,030,794 | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | ### | 100 | ||||
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4120) | ||||||||||||||||||||||
08-16 | Rev. 7 |