Assisted Living Organizational Chart by sxl13928

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									                                  Checklist
                          TX Medicaid Cost Report
                  Assisted Living Residential Care (AL/RC)



1.     Texas Contract Number (9 Digit)
2.     Copy of prior year enhanced report (if applicable)
3.     Census days by payor source and level of care (Medicaid / Private)
4.     Date certified by Medicaid
5.     Operating entity name & address
6.     Ownership entity name & address
7.     Related programs included at site?
8.     Apartment or non-apartment setting?
9.     Is Facility located with a nursing facility?
10.    Total number of Personal Care licensed beds?
11.    Number of single occupancy AL/RC beds?
12.    Number of double occupancy AL/RC beds?
13.    Square footage of facility for:
               Resident rooms
               Resident common areas
               Areas not used for AL/RC
               Total building
14.    Wages and hours for fiscal year for attendants (See Form Below)
15.    Employee organizational chart
16.    Amount company paid during fiscal year for DIRECT CARE STAFF benefits
including:
               State unemployment taxes (SUTA)
               Federal unemployment taxes (FUTA)
               Worker’s compensation insurance
               Employee on-the-job injury expense (self insurance)
               Health insurance
17.    Amount company paid during fiscal year for OTHER STAFF benefits including:
               State unemployment taxes (SUTA)
               Federal unemployment taxes (FUTA)
               Worker’s compensation insurance
               Employee on-the-job injury expense (self insurance)
               Health insurance
18.    Detail of any other attendant benefits paid
19.    Yearend Trial Balance
Cost Report Form
Departmental Hours & Wages


                                Hours            Wages


Attendants                   ______________   _____________

Medication Aides             ______________   _____________

Drivers                      ______________   _____________

Contracted Dir Care          ______________   _____________




Activities Director          ______________   ______________

RN                           ______________   _____________

LVN                          ______________   _____________

Housekeeping/Laundry         ______________   _____________

Food Service                 ______________   _____________

Other _____________          ______________   _____________

Other _____________          ______________   _____________

								
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