SNFData - - 12/1969 - Worksheet S-3 Parts II and III

Return to Cost Report Summary
Form S302
INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, 3509.1, REV 16

Add to Cart

back to list

free profile

profile

financial & statistical

financial indicators

RUGs statistics

cost reports

Medicare Provider Number: -E

[Record Code 1322370 - 2010]

Excel

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.

SNF WAGE INDEX INFORMATION PART II - DIRECT SALARIES			Provider CCN:	PERIOD: FROM 12/31/1969 TO 12/31/1969		WORKSHEET S-3 PARTS II & III
		Amount Reported	Reclass. of Salaries from Wkst. A-6	Adjusted Salaries (col. 1 ± col. 2)	Paid Hours Related to Salary in col. 3	Average Hourly Wage (col. 3 ÷ col. 4)
		1	2	3	4	5
SALARIES
1	Total salary (see instructions)						1
2	Physician salaries-Part A						2
3	Physician salaries-Part B						3
4	Home office personnel						4
5	Sum of lines 2 through 4						5
6	Revised wages (line 1 minus line 5)						6
7	Other Long Term Care						7
8	Home Health Agency						8
9	CMHC						9
10	Hospice						10
11	Other excluded areas						11
12	Subtotal excluded salary (sum of lines 7 through 11)						12
13	Total adjusted salaries (line 6 minus line 12)						13
OTHER WAGES AND RELATED COSTS
14	Contract Labor: Patient Related & Mgmt						14
15	Contract Labor: Physician services-Part A						15
16	Home office salaries & wage related costs						16
WAGE RELATED COSTS
17	Wage related costs core (see Pt. IV)						17
18	Wage related costs other (see Pt. IV)						18
19	Wage related costs (excluded units)						19
20	Physicians Part A - WRC						20
21	Physicians Part B - WRC						21
22	Total adjusted wage related cost (see instructions)						22

PART III - OVERHEAD COST - DIRECT SALARIES
		Amount Reported	Reclass. of Salaries from Wkst. A-6	Adjusted Salaries (col. 1 ± col. 2)	Paid Hours Related to Salary in col. 3	Average Hourly Wage (col. 3 ÷ col. 4)
		1	2	3	4	5
1	Employee Benefits						1
2	Administrative & General						2
3	Plant Operation, Maintenance & Repairs						3
4	Laundry & Linen Service						4
5	Housekeeping						5
6	Dietary						6
7	Nursing Administration						7
8	Central Services and Supply						8
9	Pharmacy						9
10	Medical Records & Medical Records Library						10
11	Social Service						11
12	Nursing and Allied Health Ed. Act.						12
13	Other General Service (specify _______________)						13
14	Total (sum lines 1 through 13)						14
FORM CMS-2540-10 (08/2016) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTIONS 4105.1 - 4105.2)
41-308						Rev. 7