Worksheet S-4
- Return to Cost Report Summary
- Form S400
- INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, , REV
FOUNDATION FOR HEALTH CARE CONTINUUM
SARTELL, MN 56377
SARTELL, MN 56377
Medicare Provider Number: 245330
Cost report status: Settled Without Audit
[Record Code 1329519 - 2010]
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| SNF - BASED HOME HEALTH AGENCY STATISTICAL DATA | Provider CCN: 245330 | PERIOD: FROM 10/01/2020 TO 09/30/2021 |
WORKSHEET S-4 | ||||
| HOME HEALTH AGENCY STATISTICAL DATA | |||||||
| 1 | County | ### | 1 | ||||
| DESCRIPTION | Title V | Title XVIII | Title XIX | Other | Total | ||
| 1 | 2 | 3 | 4 | 5 | |||
| 2 | Home Health Aide Hours | ### | ### | ### | ### | 2 | |
| 3 | Unduplicated Census Count (see instructions) | ### | ### | ### | ### | 3 | |
| HOME HEALTH AGENCY - NUMBER OF EMPLOYEES (FULL TIME EQUIVALENT) | |||||||
| Staff | Contract | Total | |||||
| 1 | 2 | 3 | |||||
| 4 | Enter the number of hours in your normal work week | ### | 4 | ||||
| 5 | Administrator and Assistant Administrator(s) | 5 | |||||
| 6 | Directors and Assistant Director(s) | 6 | |||||
| 7 | Other Administrative Personnel | ### | ### | 7 | |||
| 8 | Direct Nursing Service | ### | ### | 8 | |||
| 9 | Nursing Supervisor | ### | ### | 9 | |||
| 10 | Physical Therapy Service | 10 | |||||
| 11 | Physical Therapy Supervisor | 11 | |||||
| 12 | Occupational Therapy Service | 12 | |||||
| 13 | Occupational Therapy Supervisor | 13 | |||||
| 14 | Speech Pathology Service | 14 | |||||
| 15 | Speech Pathology Supervisor | 15 | |||||
| 16 | Medical Social Service | 16 | |||||
| 17 | Medical Social Service Supervisor | 17 | |||||
| 18 | Home Health Aide | ### | ### | 18 | |||
| 19 | Home Health Aide Supervisor | 19 | |||||
| 20 | Other (specify) HOMEMAKER | ### | ### | 20 | |||
| HOME HEALTH AGENCY CBSA CODES | |||||||
| 21 | Enter in column 1 the number of CBSAs where you provided services during the cost reporting period. | ### | 21 | ||||
| 22 | List those CBSA code(s) in column 1 serviced during this cost reporting period (line 22 contains the first code). | ### | 22 | ||||
| 22.01 | ### | 22.01 | |||||
| PPS ACTIVITY DATA | Full Episodes | LUPA Episodes | PEP only Episodes | Total (cols. 1 through 4) |
|||
| Without Outliers | With Outliers | ||||||
| 1 | 2 | 3 | 4 | 5 | |||
| 23 | Skilled Nursing Visits | ### | ### | ### | ### | ### | 23 |
| 24 | Skilled Nursing Visit Charges | ### | ### | ### | ### | ### | 24 |
| 25 | Physical Therapy Visits | ### | ### | ### | ### | ### | 25 |
| 26 | Physical Therapy Visit Charges | ### | ### | ### | ### | ### | 26 |
| 27 | Occupational Therapy Visits | ### | ### | ### | 27 | ||
| 28 | Occupational Therapy Visit Charges | ### | ### | ### | 28 | ||
| 29 | Speech Pathology Visits | ### | ### | ### | 29 | ||
| 30 | Speech Pathology Visit Charges | ### | ### | ### | 30 | ||
| 31 | Medical Social Service Visits | 31 | |||||
| 32 | Medical Social Service Visit Charges | 32 | |||||
| 33 | Home Health Aide Visits | ### | ### | ### | ### | 33 | |
| 34 | Home Health Aide Visit Charges | ### | ### | ### | ### | 34 | |
| 35 | Total Visits (sum of lines 23, 25, 27, 29, 31, and 33) | ### | ### | ### | ### | ### | 35 |
| 36 | Other Charges | 36 | |||||
| 37 | Total Charges (sum of lines 24, 26, 28, 30, 32, 34 and 36) | ### | ### | ### | ### | ### | 37 |
| 38 | Total Number of Episodes (standard/non outlier) | ### | ### | ### | ### | 38 | |
| 39 | Total Number of Outlier Episodes | ### | ### | 39 | |||
| 40 | Total Non-Routine Medical Supply Charges | ### | ### | ### | 40 | ||
| FORM CMS-2540-10 (11/2012) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4106) | |||||||
| 41-310 | Rev. 4 | ||||||