SNFData - 335174 - 12/2013

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Form S400
INSTRUCTIONS AS PUBLISHED IN CMS PUB. 15-II, , REV

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COBBLE HILL HEALTH CENTER
BROOKLYN, NY 11201

Medicare Provider Number: 335174

Cost report status: Settled Without Audit

[Record Code 1083447 - 2010]

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SNF - BASED HOME HEALTH AGENCY STATISTICAL DATA			Provider CCN: 335174	PERIOD: FROM 01/01/2013 TO 12/31/2013		WORKSHEET S-4
HOME HEALTH AGENCY STATISTICAL DATA
1	County					###	1

DESCRIPTION		Title V	Title XVIII	Title XIX	Other	Total
DESCRIPTION		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)			###		###	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
PPS ACTIVITY DATA		Full Episodes		LUPA Episodes	PEP only Episodes	Total (cols. 1 through 4)
		Without Outliers	With Outliers	LUPA Episodes	PEP only Episodes	Total (cols. 1 through 4)
		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

Worksheet S-4