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					WAGE DATA - PREPARATORY WORKSHEET Calendar Year 2004

INSTRUCTIONS FOR REPORTING COST DATA 1 The five categories of salary data requested below are mutually exclusive. If a nurse spends hours working in a non-nursing function, (e.g. in dietary), report the related costs, hours worked and paid leave hours as non-nursing data (Part IV). 2 All salary costs related to nursing home services should be reported. Report salaries, hours and paid leave hours for all nursing staff, including direct care and nursing administration, (e.g. Directors of Nursing, Assistant Directors of Nursing, nursing unit supervisors, patient care coordinators, Minimum Data Set coordinators, and quality assurance nurses). Reference line 4 of Schedule A-4 or line 29 of Schedule B-5, Part 1 and Schedule N of the PIRS 1090 Series cost reporting forms, as a basis for nurse salaries, hours and paid leave hour allocations. Although not separately identified on the PIRS 1090 forms, quality assurance nurses and home office quality assurance coordinator salaries, hours and paid leave hours are included in direct care costs and should be reported in this survey in Parts I through III, Nursing Data. No other home office staff should be included. In cases where the facility administrator is a nurse, report associated salaries, hours and paid leave in Part IV, NonNursing Data. Reference line 7 of Schedule A-3 or line 55 of B-5, Part 1 of the PIRS 1090 for non-nursing allocations. Reference Schedule C of the PIRS 1090 cost reporting forms as a basis for Therapist data (Part V of this survey). Employee salary and hours data should be reported for the stated time period of the survey. If pay periods do not begin and end with calendar months, it may be necessary to adjust salaries and hours of the beginning and/or ending pay period, in order to reflect the number of calendar days in the survey period. For example, if pay periods begin on the 5th day of the month and end on the 25th day of the month, it will be necessary to adjust amounts to include hours and salaries from January 1 through 4 and for December 26 through 31. Do not include salaries or hours from any time period other than the specified survey time period (calendar year 2004). Definitions: For purposes of this survey the following terms have the following meaning.
SALARY COST = Any compensation paid/accrued to the employee, including bonuses and paid leave. HOURS WORKED = Total hours providing patien+B49t related care or supervision, or performing other duties necessary to the
operation of a nursing home.A78

3

4

PAID LEAVE HOURS = Non-work hours including sick, vacation and holiday. EMPLOYEE BENEFIT COSTS = Costs incurred for employee health insurance, FICA, unemployment insurance, workers'
compensation insurance, group life, pension plan, and other benefits costs incurred.

PROVIDER NUMBER: FACILITY NAME: FACILITY ADDRESS: NAME OF CONTACT: PHONE NUMBER: (area code) number E-MAIL ADDRESS (if available):
PART I: CNA DATA 1 2 3 4 5 6 7 PART II: LPN DATA 8 9 10 11 12 13 14 PART III: RN DATA 15 16 17 18 19 20 21 Amount CNA Employee Salary Cost CNA Employee Hours Worked CNA Employee Paid Leave Hours CNA Outside Agency Personnel Cost CNA Outside Agency Hours Purchased CNA Corporate Agency and/or Related Party Personnel Cost CNA Corporate Agency and/or Related Party Hours Purchased Amount LPN Employee Salary Cost LPN Employee Hours Worked LPN Employee Paid Leave Hours LPN Outside Agency Personnel Cost LPN Outside Agency Hours Purchased LPN Corporate Agency and/or Related Party Personnel Cost LPN Corporate Agency and/or Related Party Hours Purchased Amount RN Employee Salary Cost RN Employee Hours Worked RN Employee Paid Leave Hours RN Outside Agency Personnel Cost RN Outside Agency Hours Purchased RN Corporate Agency and/or Related Party Personnel Cost RN Corporate Agency and/or Related Party Hours Purchased

PART IV: NON-NURSING DATA (Reference Schedule A-3 or Line 55 of B-5, Part 1 of the PIRS 1090 Series as a basis for allocations. Do not
include therapy costs in this part or costs allocated from the home office).

Amount

22 23 24 25 26 27 28

Non-Nursing Employee Salary Cost Non-Nursing Employee Hours Worked Non-Nursing Employee Paid Leave Hours Non-Nursing Outside Agency Personnel Cost Non-Nursing Outside Agency Hours Purchased Non-Nursing Corporate Agency and/or Related Party Personnel Cost Non-Nursing Corporate Agency and/or Related Party Hours Purchased Amount

PART V: THERAPIST DATA (Employees only, not agency personnel) Therapist Employee Salary Cost (IT/RT, PT, OT & Speech) 29 PART VI: TOTAL SALARY COSTS (Sum of lines 1, 8, 15, 22, and 29) Salary Costs of All Nursing Home Employees 30

Amount

PART VII: BENEFIT COST DATA (Include all nurse and therapist employee, corporate and applicable related party benefits) Employee Total Benefit Costs 31 PART VIII: LIABILITY INSURANCE DATA (If separate premiums for Professional, General and Umbrella Coverage are not available, provide total premium only). Past Year (2004) Insurance Premium Paid Professional Liability Premium 32 General Liability Premium 33 Umbrella Coverage Premium 34 Total Premium (Professional Liability, General Liability and Umbrella Coverage Premiums) 35 Past Year Deductibles Paid 36 Coming Year (2005) Insurance Premium Total Premium (Professional Liability, General Liability and Umbrella Coverage Premiums) 37

Amount

Amount

Amount

VALUES CALCULATED FROM REPORTED DATA - TO BE USED IN ESTIMATING INFLATION FACTOR Calendar Year 2004 CALCULATED AMOUNT #DIV/0! #DIV/0!

VALUE CNA Employee Salary Per Paid Hour

COMMENTS Equals line 1, divided by the sum of lines 2 and 3.

Agency CNA Cost Per Hour Equals the sum of lines 4 and 6, divided by the sum of lines 5 and 7. LPN Employee Salary per Paid Hour. Agency LPN Cost Per Hour RN Employee Salar Per Paid Hour Agency RN Cost Per Hour Non-Nursing Employee Salary Per Paid Hour Agency Non-Nursing Cost Per Hour Labor Costs (except benefits) for all Employees (except therapists) Non Therapist Percent of All Salaries Benefits Allocated to NonTherapists Benefit Cost Per Paid Hour

Equals line 8, divided the the sum of lines 9 and 10. Equals the sum of lines 11 and 13, divided by the sum of lines 12 and 14.

#DIV/0! #DIV/0!

Equals line 15, divided by the sum of the lines 16 and 17. Equals the sum of lines 18 and 20, divided by the sum of lines 19 and 21.

#DIV/0! #DIV/0!

Equals line 22, divided the the sum of lines 23 and 24. Equals the sum of lines 25 and 27, divided by the sum of lines 26 and 28.

#DIV/0! #DIV/0!

Equals the sum of line 1, 8, 15, and 22. Equals the value from the above line, divided by line 30. Equals the value from the above line, times line 31. Equals the value from the line above, divided by the sum of lines 2, 3, 9, 10, 16, 17, 23 and 24. #DIV/0! #DIV/0! #DIV/0!

0

Please provide the name and address of the person to whom future surveys should be sent, if different from where this survey was sent.

PROVIDER NUMBER: FACILITY NAME: FACILITY ADDRESS: NAME OF CONTACT:


				
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