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2010 RCF_IPC

VIEWS: 11 PAGES: 17

									                                                  RESIDENTIAL CARE FACILITY                                                         RCF.IPC Cost Report

                                                    GENERAL INFORMATION
                                                          Facility Name                                                    RC####
1st FACILITY - Name and Provider Number:
2nd FACILITY - Name and Provider Number:
3rd FACILITY - Name and Provider Number:
4th FACILITY - Name and Provider Number:
               COST REPORT PERIOD:                         7/1/2009 - 6/30/2010                                  (Due Sept 1, 2010)

1. FACILITY DATA

NAME          0                                                                                            PROVIDER #      0

FACILITY LOCATION (STREET ADDRESS)

MAILING ADDRESS (STREET OR P.O. BOX)

CITY                                                           STATE                                            ZIP CODE

PHONE # (Area Code)                                                                    FAX #

EMAIL

CONTROL TYPE (X one):                  FOR-PROFIT                             NON-PROFIT                                   GOVERNMENT

2. ADMINISTRATOR DATA

NAME                                                                        LICENSE NO.

3. IF YOU HAVE AN ACCOUNTING FIRM, PLEASE COMPLETE

ACCOUNTING FIRM

ADDRESS

PHONE

4. REPORT PREPARER-PLEASE LIST THE NAME OF THE PERSON COMPLETING THIS FORM

NAME

ADDRESS

PHONE

5. FACILITY OPERATOR AND COST REPORT PREPARER CERTIFICATION

Under penalties of perjury, I declare that I have examined this cost report, including any accompanying
schedule and/or statement, and to the best of my knowledge and belief, it is true, correct, and complete.
Declaration of the preparer (other than facility owners/personnel) is based on all information of which
preparer has knowledge.


Owner's Name and Signature                                Report Preparer's Name                                 Date

6. OPERATING OWNER(S) (OWNER OF CURRENTLY LICENSED BUSINESS)

NAME

ADDRESS

PHONE



   SCDHHS-Division of LTC
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                                                         RESIDENTIAL CARE FACILITY                                                            RCF.IPC Cost Report

                                                           GENERAL INFORMATION

                                 1st FACILITY Name:              0
                                 COST REPORT PERIOD: 7/1/2009 - 6/30/2010
                                 Provider #:                     0

7. OWNER(S) OF THE RCF BUILDING AND LAND

NAME

ADDRESS

PHONE


8. IS THE RCF OWNER A PAID EMPLOYEE OF THE RCF?
           No. The Owner is not paid and is not an employee. GO TO QUESTION 9.
           No. The Owner is NOT paid, but IS AN EMPLOYEE--COMPLETE name, job title, & hours worked at the RCF below.
           YES. The Owner IS an employee AND is PAID--COMPLETE box below (this would include any owner draws
           from the RCF bank account).

NOTE: If the owner and/or an owner relative of the RCF is the administrator and also performs other tasks within the RCF
(e.g. Dietary, Maintenance, etc.), all salary costs may be claimed under Administration if you are unable to allocate
the salary to the other cost areas.
               NAME                      JOB TITLE      (if several      TOTAL       YEARLY SALARY Cost Report Reference             Did owner work at another RCF
                                          jobs, please list each)       HOURS                                                         facility during the cost report
                                                                       WORKED                                                                     period?
                                                                                         AMOUNT              PAGE             LINE




9. DOES THE RCF OWNER EMPLOY RELATIVES WHO ARE PAID ?
          No. The Relative is not paid and is not an employee. GO TO QUESTION 10.
          No. The Relative is not paid, but IS AN EMPLOYEE--COMPLETE name, job title, and hours worked at the RCF below.
          YES. The Relative IS an employee AND is PAID--COMPLETE box below.

             NAME                  JOB TITLE (if several              TOTAL        YEARLY SALARY Cost Report Reference               Did owner work at another RCF
                                    jobs, please list each)           HOURS                                                           facility during the cost report
                                                                     WORKED                                                                       period?
                                                                                         AMOUNT              PAGE             LINE




10. IF THE OWNER OF THE LICENSED RCF OWNS ANY OTHER RCF FACILITY, PLEASE LIST

        FACILITY NAME                        RC #                                             LOCATION



                                                                                  CITY                              STATE




    SCDHHS-Division of LTC
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                                        RESIDENTIAL CARE FACILITY                  RCF.IPC Cost Report

                  GENERAL INFORMATION; CONSTRUCTION, RENTAL OR ACQUISITION COST OF RCF

                                1st FACILITY Name:           0
                                COST REPORT PERIOD: 7/1/2009 - 6/30/2010
                                Provider #:        0

11. DOES THE RCF DO BUSINESS WITH OTHER BUSINESSES OWNED BY THE RCF OWNER?
    (Includes a related party lease)
              No. You do not need to complete this section.
              Yes. The following information must be completed.
EXAMPLE
The owner of the Residential Care Facility also owns a grocery store. The owner purchases groceries from his grocery store
for his Residential Care Facility and charges the Residential Care Facility $100. The $100 would be the cost to the Residential
Care Facility. The owner’s actual cost of the groceries is $80, which is the cost to the related business.

EXPENSES (SUPPLIES, RENT, MANAGEMENT FEES, ETC.)
  RELATED BUSINESS NAME            ITEM DESCRIPTION              COST TO           COST TO            Cost Report Reference
                                                                 THE RCF           RELATED
                                                                                   BUSINESS
                                                                                                         PAGE             LINE




12. IS THE RCF RENTED OR LEASED?
            No. Go to QUESTION #13 below.
            Yes. The following information must be completed.

             ASSET               # OF MONTHS OR YEARS                EXPIRATION DATE                   MONTHLY PAYMENT
                                       OF LEASE

Building Only

Equipment and Furniture Only

Building, Equipment and
Furniture



13. PLEASE LIST THE CONSTRUCTION OR PURCHASE PRICE OF THE RCF

 ORIGINAL PURCHASE PRICE                YEAR                            SQUARE FEET                    # OF DHEC LICENSED            CONSTRUCTION COST
       OF BUILDING                                                                                          RCF BEDS




    BUILDING ADDITIONS
        (DESCRIBE)




                             TOTALS                                                               -                              -                       $0




    SCDHHS-Division of LTC
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                                                  RESIDENTIAL CARE FACILITY                                                           RCF.IPC Cost Report

                                              CENSUS REPORT AND SQUARE FOOTAGE

                                1st FACILITY Name:             0
                                COST REPORT PERIOD: 7/1/2009 - 6/30/2010
                                Provider #:                    0

COMPLETE THE FOLLOWING RESIDENT DAY INFORMATION CORRECTLY . REFER TO YOUR MONTHLY TAD
OR DHEC STATISTICAL REPORT DURING THE COST REPORT PERIOD. COMPLETE TOTAL DAYS FOR
ALL RESIDENTS.
Ex: IF YOU HAVE 4 OSS RESIDENTS FOR ALL 31 DAYS IN JULY, THEN TOTAL OSS DAYS FOR JULY
WOULD BE 124 DAYS OR (4 x 31).
IF YOU HAVE 1 PRIVATE PAY RESIDENT FOR ONLY 15 DAYS IN JULY, THEN TOTAL PRIVATE PAY DAYS
FOR JULY WOULD BE 15 DAYS OR (1 x 15).
TOTAL DAYS FOR JULY WOULD BE 139 OR (124 + 15).

                            Private Pay Days                                     OSS Days                                  IPC Days               Total
                                                                                                                                                  Days
July Days                                                                                                                                                     0
Aug Days                                                                                                                                                      0
Sept Days                                                                                                                                                     0
Oct Days                                                                                                                                                      0
Nov Days                                                                                                                                                      0
Dec Days                                                                                                                                                      0
Jan Days                                                                                                                                                      0
Feb Days                                                                                                                                                      0
Mar Days                                                                                                                                                      0
Apr Days                                                                                                                                                      0
May Days                                                                                                                                                      0
June Days                                                                                                                                                     0
GRAND                                                      0                                                      0                        0                  0
TOTAL

Are you an IPC Provider?
              YES
              NO



       Number of DHEC Licensed RCF BEDS @ 7/01/09:
       Number of DHEC Licensed RCF BEDS @ 6/30/10:


If you had licensed bed changes during the cost reporting period, please identify date of change
and number of licensed RCF beds:




   SCDHHS-Division of LTC
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                                                     RESIDENTIAL CARE FACILITY                                                          RCF.IPC Cost Report

                                                      INCOME/MONIES RECEIVED

                              1st FACILITY Name:             0
                              COST REPORT PERIOD: 7/1/2009 - 6/30/2010
                              Provider #:                    0
ONLY COMPLETE AREAS THAT APPLY. ROUND TO THE NEAREST DOLLAR.
*NOTE: If you do not have account numbers, this column will not apply.
                   ACCOUNT    PLEASE ENSURE THAT YOUR REPORT COVERS 12 MONTHS                                                 INCOME
                   NUMBER*                  INCOME AND EXPENSES                                                           (Do Not Estimate)
                              INCOME (Post as positive)
1                             ROOM & BOARD INCOME - PRIVATE
2                             ROOM & BOARD INCOME - OSS less Personal Needs Allowance

3                             ROOM & BOARD INCOME - Social Security and SSI
4                             INTEGRATED PERSONAL CARE (IPC) INCOME
5                             ROOM & BOARD INCOME - Dept of Mental Health (DMH)
6                             ROOM & BOARD INCOME - Dept of Disabilities and Special
                              Needs (DDSN)
7                             MEALS ON WHEELS INCOME
8                             ADULT DAY CARE INCOME
9                             RESIDENT HEALTH SUPPLIES INCOME – OSS
10                            RESIDENT HEALTH SUPPLIES INCOME - OTHER
11                            PHARMACY INCOME - PRIVATE
12                            PHARMACY INCOME - OSS
13                            OTHER SERVICES INCOME - PRIVATE
14                            EMPLOYEE & GUEST MEAL INCOME
15                            BEAUTY & BARBER INCOME
16                            VENDING MACHINE INCOME
17                            TELEPHONE INCOME
18                            INTEREST INCOME-BANKS & SAVINGS
19                            RENTAL INCOME
20                            CONTRIBUTION INCOME
21                            CABLE T.V. INCOME
22                            GRANT INCOME
23                            OTHER INCOME
24                            RESIDENT REFUNDS - OSS                 (negative amount)
25                            RESIDENT REFUNDS - Other (negative amount)
26                            TOTAL INCOME                                                                                                $0
27                            PATIENT PERSONAL NEEDS ALLOWANCE - INCOME
28                            PATIENT PERSONAL NEEDS ALLOWANCE -
                              DISBURSEMENTS (negative amount)
Notes:




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                                                     RESIDENTIAL CARE FACILITY                                                          RCF.IPC Cost Report

                                                      ADMINISTRATIVE EXPENSE

                              1st FACILITY Name:             0
                              COST REPORT PERIOD: 7/1/2009 - 6/30/2010
                              Provider #:                    0
ONLY COMPLETE AREAS THAT APPLY. ROUND TO THE NEAREST DOLLAR.
*NOTE: If you do not have account numbers, this column will not apply.


                   ACCOUNT    PLEASE ENSURE THAT YOUR REPORT COVERS 12 MONTHS                                                  COST
                   NUMBER*                  INCOME AND EXPENSES                                                           (Do Not Estimate)

                              ADMINISTRATION EXPENSES
1                             ADMINISTRATOR SALARIES
2                             ASSISTANT ADMINISTRATOR SALARIES
3                             BOOKKEEPING SALARIES
4                             SECRETARY SALARIES
5                             ADVERTISING
6                             MANAGEMENT FEES
7                             PURCHASED SERVICES
8                             PRINTING AND COPIER
9                             DUES
10                            SUBSCRIPTIONS
11                            OFFICE SUPPLIES AND POSTAGE
12                            PROFESSIONAL ACCOUNTING
13                            PROFESSIONAL OTHER
14                            TELEPHONE - LAND and MOBILE LINES
15                            SEMINARS AND TRAINING
16                            EQUIPMENT RENTAL
17                            BANK AND FREIGHT CHARGES
18                            SMALL EQUIPMENT (LESS THAN $5,000)
19                            AUTO EXPENSE and MILEAGE REIMBURSEMENT
20                            LEGAL FEES
21                            ADMINISTRATION-OTHER

                              EMPLOYEE BENEFITS AND FRINGES
22                            FUTA, SUTA, FICA
23                            WORKMEN'S COMPENSATION
24                            HEALTH AND LIFE INSURANCE
25                            TOTAL ADMINISTRATION EXPENSES                                                                               $0
Notes:




     SCDHHS-Division of LTC
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                                                 RESIDENTIAL CARE FACILITY                                                             RCF.IPC Cost Report

                                            RESIDENT CARE AND ACTIVITY EXPENSE

                              1st FACILITY Name:            0
                              COST REPORT PERIOD: 7/1/2009 - 6/30/2010
                              Provider #:                   0

ONLY COMPLETE AREAS THAT APPLY. ROUND TO THE NEAREST DOLLAR.
*NOTE: If you do not have account numbers, this column will not apply.

                   ACCOUNT    PLEASE ENSURE THAT YOUR REPORT COVERS 12 MONTHS                                                 COST
                   NUMBER*                  INCOME AND EXPENSES                                                          (Do Not Estimate)

                              RESIDENT CARE AND ACTIVITY EXPENSES
1                             RESIDENT CARE SUPERVISOR SALARIES
2                             CARE GIVER SALARIES
3                             ACTIVITIES & SOCIAL SERVICES SALARIES
4                             INTEGRATED PERSONAL CARE (IPC) - RN and LPN SALARIES
5                             INTEGRATED PERSONAL CARE (IPC) - AIDE SALARIES
6                             INTERATED PERSONAL CARE (IPC) - CONTRACTED SVCS
7                             INTERATED PERSONAL CARE (IPC) - AMERICAN DISABILITY
                              ACT (ADA) -BUILDING and EQUIPMENT
8                             OVER THE COUNTER DRUGS
9                             PRESCRIPTION DRUGS
10                            DIAPERS AND UNDERPADS
11                            MEDICAL TRANSPORTATION COST
12                            ACTIVITY TRANSPORTATION COST
13                            RESIDENT HEALTH SUPPLIES (Toothbrush, Toothpaste, Soap,
                              Deodorant, Razor, Etc.)
14                            RCF PET CARE
15                            EMPLOYEE UNIFORM
16                            EMPLOYEE BLOOD TEST/SKIN TEST
17                            ACTIVITY SUPPLIES
18                            SMALL EQUIPMENT (LESS THAN $5,000)
19                            DRUG and BACKGROUND CHECKS
20                            RESIDENT CARE-OTHER

                              EMPLOYEE BENEFITS AND FRINGES
21                            FUTA, SUTA, FICA
22                            WORKMEN'S COMPENSATION
23                            HEALTH AND LIFE INSURANCE
24                            INTEGRATED PERSONAL CARE - RN, LPN and AIDE
                              BENEFITS AND PAYROLL TAXES
25                            TOTAL RESIDENT CARE AND ACTIVITY EXPENSES
                                                                                                                                         $0
Notes:




     SCDHHS-Division of LTC
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                                                     RESIDENTIAL CARE FACILITY                                                          RCF.IPC Cost Report

                                                         DIETARY EXPENSE

                              1st FACILITY Name:             0
                              COST REPORT PERIOD: 7/1/2009 - 6/30/2010
                              Provider #:                    0
ONLY COMPLETE AREAS THAT APPLY. ROUND TO THE NEAREST DOLLAR.
*NOTE: If you do not have account numbers, this column will not apply.


                   ACCOUNT    PLEASE ENSURE THAT YOUR REPORT COVERS 12 MONTHS                                                  COST
                   NUMBER*                  INCOME AND EXPENSES                                                           (Do Not Estimate)

                              DIETARY EXPENSES
1                             DIETARY SALARIES

2                             DIETARY CONSULTANT

3                             DIETARY AIDES

4                             SMALL EQUIPMENT (LESS THAN $5,000)

5                             FOOD

6                             DIETARY SUPPLIES

7                             DISHES AND UTENSILS

8                             DIETARY EQUIPMENT RENTAL

9                             MENU PLANS

10                            PURCHASED SERVICES

11                            DIETARY-OTHER

                              EMPLOYEE BENEFITS AND FRINGES
12                            FUTA, SUTA, FICA

13                            WORKMEN'S COMPENSATION

14                            HEALTH AND LIFE INSURANCE

15                            TOTAL DIETARY EXPENSES
                                                                                                                                          $0
Notes:




     SCDHHS-Division of LTC
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                                           RESIDENTIAL CARE FACILITY                                                                    RCF.IPC Cost Report

                               LAUNDRY, HOUSEKEEPING AND MAINTENANCE EXPENSES

                              1st FACILITY Name:             0
                              COST REPORT PERIOD: 7/1/2009 - 6/30/2010
                              Provider #:                    0
ONLY COMPLETE AREAS THAT APPLY. ROUND TO THE NEAREST DOLLAR.
*NOTE: If you do not have account numbers, this column will not apply.


                   ACCOUNT    PLEASE ENSURE THAT YOUR REPORT COVERS 12 MONTHS                                                  COST
                   NUMBER*                  INCOME AND EXPENSES                                                           (Do Not Estimate)
                              LAUNDRY, HOUSEKEEPING, MAINTENANCE
                              EXPENSES
1                             LAUNDRY SALARIES

2                             HOUSEKEEPING SALARIES

3                             MAINTENANCE SALARIES

4                             MAINTENANCE TRUCK

5                             LINENS

6                             LAUNDRY, HOUSEKEEPING AND MAINTENANCE SUPPLIES

7                             PURCHASED SERVICES

8                             FIRE ALARM AND LIFE SAFETY CERTIFICATION

9                             SECURITY (ALARM)

10                            PAINTING

11                            REPAIRS

12                            PEST CONTROL

13                            LAWN and GARDENING

14                            SMALL EQUIPMENT (LESS THAN $5,000)

15                            LAUNDRY, HOUSEKEEPING, MAINTENANCE-OTHER

                              EMPLOYEE BENEFITS AND FRINGES
16                            FUTA, SUTA, FICA

17                            WORKMEN'S COMPENSATION

18                            HEALTH AND LIFE INSURANCE

19                            TOTAL LAUNDRY, HOUSEKEEPING AND
                              MAINTENANCE EXPENSES                                                                                        $0

Notes:




     SCDHHS-Division of LTC
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                                                 RESIDENTIAL CARE FACILITY                                                                RCF.IPC Cost Report

                                                    UTILITIES EXPENSES
                                         TAXES, INSURANCE AND LICENSE EXPENSES

                                1st FACILITY Name:             0
                                COST REPORT PERIOD: 7/1/2009 - 6/30/2010
                                Provider #:                    0
ONLY COMPLETE AREAS THAT APPLY. ROUND TO THE NEAREST DOLLAR.
*NOTE: If you do not have account numbers, this column will not apply.


                     ACCOUNT    PLEASE ENSURE THAT YOUR REPORT COVERS 12 MONTHS                                                  COST
                     NUMBER*                  INCOME AND EXPENSES                                                           (Do Not Estimate)

                                UTILITIES EXPENSES
1                               HEATING
2                               ELECTRICITY
3                               WATER
4                               SEWER
5                               GARBAGE
6                               CABLE OR SATELLITE
7                               UTILITIES-OTHER
8                               TOTAL UTILITIES EXPENSES                                                                                    $0
Notes:



ONLY COMPLETE AREAS THAT APPLY. ROUND TO THE NEAREST DOLLAR.
*NOTE: If you do not have account numbers, this column will not apply.


                     ACCOUNT    PLEASE ENSURE THAT YOUR REPORT COVERS 12 MONTHS                                                  COST
                     NUMBER*                  INCOME AND EXPENSES                                                           (Do Not Estimate)


                                TAXES, INSURANCE AND LICENSES EXPENSES (1)
9                               TAXES - PROPERTY
10                              TAXES - PERSONAL
11                              TAXES - BUSINESS
12                              INSURANCE - PROPERTY
13                              INSURANCE - LIABILITY
14                              INSURANCE - GENERAL
15                              LICENSES
16                              TAXES, INSURANCE, LICENSES-OTHER
17                              TOTAL TAXES, INSURANCE AND LICENSES
                                EXPENSES                                                                                                    $0
(1)
      State and Federal Income Tax Expense should not be included here, but under “OTHER EXPENSES” on Page 11.

Notes:




       SCDHHS-Division of LTC
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                                                    RESIDENTIAL CARE FACILITY                                                           RCF.IPC Cost Report

                                                    COST OF CAPITAL EXPENSES
                                                        OTHER EXPENSES

                              1st FACILITY Name:             0
                              COST REPORT PERIOD: 7/1/2009 - 6/30/2010
                              Provider #:                    0
ONLY COMPLETE AREAS THAT APPLY. ROUND TO THE NEAREST DOLLAR.
*NOTE: If you do not have account numbers, this column will not apply.


                   ACCOUNT    PLEASE ENSURE THAT YOUR REPORT COVERS 12 MONTHS                                                  COST
                   NUMBER*                  INCOME AND EXPENSES                                                           (Do Not Estimate)

                              COST OF CAPITAL EXPENSES
1                             DEPRECIATION - CAPITAL IMPROVEMENTS
2                             DEPRECIATION - BUILDING
3                             DEPRECIATION - EQUIPMENT AND FURNITURE
4                             RENT - BUILDING
5                             RENT - EQUIPMENT AND FURNITURE
6                             AMORTIZATION
7                             INTEREST - BUILDING                           (Identify on Page 12)
8                             INTEREST - EQUIPMENT AND FURNITURE (Id on Page 12)
9                             INTEREST - OTHER                              (Identify on page 12)
10                            COST OF CAPITAL-OTHER
11                            TOTAL COST OF CAPITAL EXPENSES                                                                              $0
Notes:



ONLY COMPLETE AREAS THAT APPLY. ROUND TO THE NEAREST DOLLAR.
*NOTE: If you do not have account numbers, this column will not apply.


                   ACCOUNT    PLEASE ENSURE THAT YOUR REPORT COVERS 12 MONTHS                                                  COST
                   NUMBER*                  INCOME AND EXPENSES                                                           (Do Not Estimate)

                              OTHER EXPENSES
12                            VENDING MACHINE
13                            FEDERAL INCOME TAX
14                            STATE INCOME TAX
15                            PENALTIES AND FINES
16                            CONTRIBUTIONS
17                            OTHER
18                            TOTAL OTHER EXPENSES                                                                                        $0

Notes:




     SCDHHS-Division of LTC
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                                             RESIDENTIAL CARE FACILITY                                                               RCF.IPC Cost Report

                                       LOAN PAYMENTS AND MAJOR PURCHASES

                             1st FACILITY Name:            0
                             COST REPORT PERIOD: 7/1/2009 - 6/30/2010
                             Provider #:                   0


MORTGAGE(S) AND ALL OTHER LOANS PAYABLE



                                                             INTEREST                                                                          ENDING
                                                                         COST REPORT REFERENCE
 INTEREST                                                   PAID 7/1/08-                                                NAME OF LENDING      BALANCE @
   RATE          TYPE DEBT    REASON FOR FINANCING             6/30/09   PAGE         LINE                                 INSTITUTE           6/30/09




         Totals                                                         $0                                                                              $0


Notes:




   SCDHHS-Division of LTC
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                                          RESIDENTIAL CARE FACILITY                                                          RCF.IPC Cost Report

                                       SUMMARY OF INCOME AND EXPENSES

                         1st FACILITY Name:            0
                         COST REPORT PERIOD: 7/1/2009 - 6/30/2010
                         Provider #:                   0



                                                       ACCOUNT                                                      AMOUNT
                         1                             TOTAL INCOME                                                             $0


                                                       EXPENSES


                         2                             Administration                                                           $0


                         3                             Resident Care & Activity                                                 $0


                         4                             Dietary                                                                  $0


                         5                             Laundry, Housekeeping and                                                $0
                                                       Maintenance


                         6                             Utilities                                                                $0


                         7                             Taxes, Insurance and Licenses                                            $0


                         8                             Cost of Capital                                                          $0


                         9                             Other                                                                    $0


                         10                            TOTAL EXPENSES                                                           $0


                         11                            NET INCOME OR (LOSS)                                                     $0




SCDHHS-Division of LTC
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L:/Reimmeth/RCF6-30-10/Cost Report Form & Medstat Reports                                       File Name:                                                    RCF.IPC Guide
                                                                                                       Tab: Guide
                                                                                                  Pprd By:

                                                GUIDE FOR RCF.IPC COST REPORT
                                                          7/1/2009 - 6/30/2010


Provider:
RC#:            0                      0                  0                  0

                # Medstat Report                                                               Notes:
Per C/R                                                                                    0
Per Medstat                                                                      #VALUE!
Per DHEC - W eb address below. Ck variance w/ K. Varn.
www.scdhec.net/hr/licen/hrtypfac.htm
Max # recips served- Will not apply for 6/30/2005 and fwd                                      Problems w/ Errors in Reporting that I.T. is not correcting.
If Max Recips Svd is > # beds, see "Director"

                       # DAYS                                                    OSS/SSI             IPC            Private       Notes:

Per C/R                                                                                    0                 0                0
Per Medstat                                                                      #VALUE!           #VALUE!

Variance                                                      #VALUE!            #VALUE!           #VALUE!
                      If close, no change necessary.

                      INCOME                                                     OSS/SSI             IPC            Private       Notes:

Per C/R                                                                                    0                 0                0
Per Medstat                                                                      #VALUE!           #VALUE!
   Formula = (OSS Net Payment) + (SSI) + (Calculated IPC SSI) - (PNA)
Variance                                                      #VALUE!            #VALUE!           #VALUE!
                     If close, no adjustment necessary.

Calculated IPC - SSI

Personal Needs Income July - Dec                                                 #VALUE!
Personal Needs Income Jan - Jun                                                  #VALUE!
Total Personal Needs Income                                                      #VALUE!


Ensure the following expenses are reported:                                                                      (Key DA# &/or any explanations below)
            Fringe Benefits (in salaried cost centers)                                         N
                               Total Salaries                            0
                               Total Fringes                             0
            Telephone                                                                          N
            OTC's                                                                              N
            Prescription Drugs                                                                 N
            Food                                                                               N
            Utilities                                                                          N
            Property Tax                                                                       N
            Building Depreciation                                                              N                 Prepare DAA
            Building Rent                                                                      N

ESTIMATED Expenses

DDSN Facility                                                                                  N
DMH Facility                                                                                   N
IPC Facility                                                                                   N

DAA Made                                                                                       N

Filed Electronic or Manual

Notes:




     SCDHHS-Division of LTC Reimbursements             D:\Docstoc\Working\pdf\8f4b7060-c8e4-4d11-ab97-b2286e505e1f.xls Tab: Guide                              Page 14 of 17
                                                                                                                      RCF.IPC Adjustments




L:/Reimmeth/RCF6-30-10/Cost Report Form & Medstat Reports                                           File Name:
                                                                                                          Tab: adjustments
                                                                                                      Pprd By:

               SUMMARY OF RCF DESK AUDIT ADJUSTMENTS

      PROVIDER:
      RC#
      REPORTING PERIOD:                                 7/1/2009 - 6/30/2010


      COST CENTER                                                  DEBIT                                CREDIT

      ADMINISTRATION                                                       0

      RESIDENT CARE & ACTIVITY                                                                                    0

      DIETARY

      LAUNDRY, HSKPG & MAINT

      UTILITIES

      TAXES, INSUR, & LICEN

      COST OF CAPITAL                                                      0

      OTHER                                                                                                       0



          SUB-TOTAL EXPENSES                                             $0                                      $0



      INCOME                                                               0                                      0
      EQUITY                                                               0                                      0




          GRAND TOTAL                                                    $0                                      $0




                               D:\Docstoc\Working\pdf\8f4b7060-c8e4-4d11-ab97-b2286e505e1f.xls Tab:adjustments
SCDHHS-Division of LTC Reimbursements                                                                                       Page 15 of 17
                                                                                                                      RCF.IPC Adjustments




                   RCF DESK AUDIT ADJUSTMENTS

       PROVIDER:
       MMIS NUMBER:
       REPORTING PERIOD:                                7/1/2009 - 6/30/2010


       ACCOUNT DESCRIPTION                                         DEBIT                                CREDIT

   1 Equity                                                              $0
       Income                                                                                                    $0

       Increase provider's OSS/SSI income to agree with Medstat report


   2 Income                                                              $0
        Equity                                                                                                   $0

       Reduce provider's OSS/SSI income to agree to Medstat report


   3 Cost of Capital                                                     $0
       Other                                                                                                     $0

       Post building depreciation @ 40 yrs based on page 3, item 13
       OR post building rent if either is omitted by provider


   4 Administration                                                      $0
       Resident Care and Activity                                                                                $0


       To reclassify cell phone expense


   5                                                                     $0
                                                                                                                 $0




          GRAND TOTAL                                                    $0                                      $0




                               D:\Docstoc\Working\pdf\8f4b7060-c8e4-4d11-ab97-b2286e505e1f.xls Tab:adjustments
SCDHHS-Division of LTC Reimbursements                                                                                       Page 16 of 17
                                                                                                                           RCF.IPC Rate Sheet




            PROVIDER NAME:
       PROVIDER NUMBER:
       REPORTING PERIOD:        7/1/2009 - 6/30/2010




  OSS/IPC RESIDENT DAYS: 0                                                                   OSS/IPC % OCC: #VALUE!
    TOTAL RESIDENT DAYS: 0                                                                    TOTAL % OCC: #VALUE!
   TOTAL PROVIDER BEDS: #VALUE!                                                           OSS/IPC to TOTAL: #VALUE!
TOTAL ALLOWABLE DAYS            #VALUE!            #VALUE!



                    SUMMARY OF PROVIDER'S REPORTED INCOME, COSTS and PER PATIENT DAY COSTS


                                     AS FILED          DEBITS        CREDITS                        ADJUSTED     PER DIEM


INCOME                                       0               0               0                               0   #DIV/0!




     Operating Expenses                          No DAA Made


ADMINISTRATION                               0               0               0                               0   #DIV/0!


RESIDENT CARE & ACTIVITY                     0               0               0                               0   #DIV/0!


DIETARY                                      0               0               0                               0   #DIV/0!


LAUNDRY, HSKPG & MAINT                       0               0               0                               0   #DIV/0!


UTILITIES                                    0               0               0                               0   #DIV/0!


TAXES, INSUR, & LICEN                        0               0               0                               0   #DIV/0!


COST OF CAPITAL                              0               0               0                               0   #DIV/0!




          SUBTOTAL                           0               0               0                               0   #DIV/0!




OTHER                                        0               0               0                               0   #DIV/0!




       TOTAL EXPENSES                        0               0               0                               0   #DIV/0!




     NET INCOME/(LOSS)                       0               0               0                               0   #DIV/0!
                                                                                                             0




                                 D:\Docstoc\Working\pdf\8f4b7060-c8e4-4d11-ab97-b2286e505e1f.xls Tab:RateSheet
SCDHHS-Division of LTC Reimbursements                                                                                           Page 17 of 17

								
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