Worksheet B, Part I

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IDAHO FALLS GOOD SAMARITAN CENTER
IDAHO FALLS, ID  83401-

Medicare Provider Number: 135092
Cost report status: Settled Without Audit
[Record Code 519 - 1996]
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COST ALLOCATION - GENERAL SERVICE COSTS
PROVIDER NO:
135092
PERIOD:
FROM 01/01/1999
TO 12/31/1999
 WORKSHEET B Part I  
COST CENTER (Omit Cents) NET EXPENSES FOR COST ALLOCATION Fr. Wkst A, Col 7
CAP. REL.
BUILDINGS
& FIXTURES
CAP. REL.
MOVABLE
EQUIPMENT
EMPLOYEE
BENEFITS
SUBTOTAL
(Sum of
Columns 0 - 3)
ADMINIS-
TRATIVE
& GENERAL
PLANT OPER.
MAINTENANCE
& REPAIRS
LAUNDRY
& LINEN
SERVICE
HOUSE
KEEPING
 DIETARY NURSING
CENTRAL
SERVICES
& SUPPLY
 PHARMACY
MEDICAL
RECORDS
& LIBRARY
SOCIAL
SERVICE
INTERNS &
RESIDENTS
OTHER
GENERAL
SERVICE
COST
 SUBTOTAL
POST
STEPDOWN
ADJUSTMENTS
 TOTAL  
    0 1 2 3 3A 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
  GENERAL SERVICE COST CENTERS    
1 Capital-Related Costs - Building & Fixture ### ###                                     1
2 Capital-Related Costs - Movable Equipment ### ###                                   2
3 Employee Benefits ### ### ### ###                                 3
4 Administrative and General ### ### ### ### ### ###                             4
5 Plant Operation, Maintenance and Repairs ### ### ### ### ### ### ###                           5
6 Laundry and Linen Service ### ### ### ### ### ### ### ###                         6
7 Housekeeping ### ### ### ### ### ### ### ###                       7
8 Dietary ### ### ### ### ### ### ### ### ###                     8
9 Nursing Administration ### ### ### ### ### ### ### ### ###                   9
10 Central Services and Supply ### ### ### ### ### ### ### ###                 10
11 Pharmacy               11
12 Medical Records and Library ### ### ### ### ### ### ### ### ###             12
13 Social Service ### ### ### ### ### ### ### ### ###           13
14 Intern & Residents (Approved Teaching Program)         14
15 Other General Service Cost       15
  INPATIENT ROUTINE SERVICE COST CENTERS
16 Skilled Nursing Facility ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 16
17                                           17
18 Nursing Facility 18
18.1 Intermediate Care Facility/ Mentally Retarded 18.1
19 Other Long Term Care 19
20 Other Inpatient Routine Services                           20
  ANCILLARY SERVICE COST CENTERS
21 Radiology 21
22 Laboratory ### ### ### ### ### ### ### 22
23 Intravenous Therapy 23
24 Oxygen (Inhalation) Therapy 24
25 Physical Therapy ### ### ### ### ### ### ### ### ### ### ### 25
26 Occupational Therapy ### ### ### ### ### ### ### ### ### ### ### 26
27 Speech Pathology ### ### ### ### ### ### ### 27
28 Electrocardiology 28
29 Medical Supplies Charged to Patients ### ### ### ### ### ### ### ### ### ### 29
30 Drugs Charged to Patients ### ### ### ### 30
31 Dental Care - Title XIX only 31
32 Support Surfaces 32
33 Other Ancillary Service Cost 33
  OUTPATIENT SERVICE COST CENTERS
34 Clinic 34
35 R H C 35
36 Other Outpatient Service Cost 36
  OTHER REIMBURSABLE COST CENTERS
37 Administrative and General - HHA ### ### ### ### ### ### ### ### ### ### 37
38 Skilled Nursing Care - HHA ### ### ### ### ### ### ### ### 38
39 Physical Therapy - HHA ### ### ### ### ### ### ### 39
40 Occupational Therapy - HHA ### ### ### ### ### ### ### 40
41 Speech Pathology - HHA 41
42 Medical Social Services - HHA 42
43 Home Health Aide - HHA ### ### ### ### ### ### ### ### 43
44 Durable Medical Equipment - Rented - HHA 44
45 Durable Medical Equipment - Sold - HHA 45
46 Home Delivered Meals - HHA 46
47 Other Home Health Services - HHA ### ### ### ### ### ### ### 47
48 Ambulance 48
49 Interns and Residents (Not in Approved Teaching Program) 49
50 Outpatient Rehabilitation Provider 50
51 Other Reimbursable Cost 51
  SPECIAL PURPOSE COST CENTERS
55 Hospice ### ### ### ### ### ### ### ### ### ### 55
56 Other Special Purpose Cost 56
57 Subtotals ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 57
  NON REIMBURSABLE COST CENTERS
58 Gift, Flower, Coffee Shops and Canteen 58
59 Barber and Beauty Shop ### ### ### ### ### ### ### ### 59
60 Physicians' Private Offices 60
61 Nonpaid Workers 61
62 Patients Laundry 62
63 Other Non Reimbursable Cost ### ### ### ### ### ### ### ### ### ### ### ### ### 63
64 Cross Foot Adjustments       64
65 Negative Cost Center 65
75 TOTAL ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### ### 75