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					                                              Nursing Home Cost Report Main Schedule
                                      Nursing Home Name                                                  NH ID
                                               Year Ended
                                              Book                                  Adjustments                Adjusted NH
Cost Classification                Schedule Amount        From Item    Increase     to Item     Decrease       Cost
Column I                           Col. II    Col. III    Col. IV      Col. V       Col. VI     Col. VII       Col. VIII
1. Salaries and Wages                   A
2. Outside Professional Fees            B
3. Employee Benefits                    C
4. Staff Development Training           D
5. Taxes (Non-payroll related)          E
6. Office Supplies & Expense
7. Telephone
8. Utilities
9. Insurance                            F
10. Dues and Publications
11. Public Relations
12. Automobile Expense
13. Maintenance
14. Laundry & Linen
15. Housekeeping Supplies
16. Food and Kitchen Supplies
17. Social Services Supplies
18. Drugs & Medical Supplies            G
19. Capital Related Costs               H
20. Administrative Services             I
21. Other Expense                       J
22. TOTAL
23. Primary Cost TOTAL (Line 22
less Lines 19 and 20)
                                                                     Total Patient Days
                                                                            (Per Page 1)
                                                                Cost Per Patient Day =
                                  (Total Adjusted NH Cost divided by Total Patient Days)



                                                               4
                                                  Addendum Main Schedule
                                   Nursing Home Cost Report Main Schedule for Homes With SNF Units
                                         Nursing Home Name
                                                   Year Ended
                                                          NH ID
                                   Costs Directly Attributable to SNF Unit
                                                  Book
Cost Classification                Schedule       Amount
Column I                           Col. II        Col. III
1. Salaries and Wages                    A
2. Outside Professional Fees *           B                          * Do not include this amount in the regular cost report
3. Employee Benefits                     C
4. Staff Development/Training            D
5. Taxes (Non-payroll related)           E
6. Office Supplies & Expense
7. Telephone
8. Utilities
9. Insurance                                 F
10. Dues and Publications
11. Public Relations
12. Automobile Expense
13. Maintenance
14. Laundry & Linen
15. Housekeeping Supplies
16. Food and Kitchen Supplies
17. Social Services Supplies
18. Drugs & Medical Supplies *               G                      * Do not include this amount in the regular cost report
19. Capital Related Costs                    H
20. Administrative Services                  I
21. Other Expense                            J
22. TOTAL
* All of the above costs are those directly attributable to the SNF unit and with the exception of (2) and (18)
should also be reported on Page 4, the main schedule.

                                                         4a
             Nursing Home Name                                           Salaries and Wages   Schedule A
                          NH ID



                                                                Adjustments       Adjusted    NH
Classification                      Book Amount   Hours   Amount      Hours       Cost        Hours
Direct Care:
1. Registered Nurses
2. Licensed Practical Nurses
3. Director of Nursing
4. Nurse Aides
5. CMA Aides
6. QMRP's (ICF/MR only)
7. Medical Director
Therapy Services:
8. Physical Therapist (Prof.)
9. Occupational Therapist (Prof.)
10. Respiratory Therapist (Prof.)
11. Speech Therapist (Prof.)
12. Therapy Aide/Assistant
Administrative:
13. Administrator
14. Assistant Administrator
15. Accountant/Bookeeper
16. Other Office Staff
Sub-Total for Page 5 only


                                                               5
                     Nursing Home Name                                          Salaries and Wages   Schedule A
                                  NH ID                                                              (continued)

                                                                       Adjustments       Adjusted    NH
       Classification                     Book Amount   Hours    Amount      Hours       Cost        Hours
      Social Services:
17.   Soc. Serv. Dir./Social Worker
18.   Other Social Serv. Staff
19.   Activities Director
20.   Other Activities Staff
21.   Comb. Soc. Serv./Activities
      Dietary:
22.   Dietician
23.   Other Dietary Staff
      Housekeeping:
24.   Housekeeping Supervisor
25.   Other Housekeeping Staff
      Maintenance:
26.   Maintenance Supervisor
27.   Other Maintenance Staff
      Laundry:
28.   Laundry Supervisor
29.   Other Laundry Staff
      Other:
30.   Medical Records
31.
32. TOTAL (Page 5 + Page 5C)
      Total from Page 5 Schedule A

                                                            5c
                                               Outside Professional                                      Schedule B
                                Nursing Home Name
                                             NH ID
                                                                               Adjustments    Adjusted   NH
 Classification                       Book Amount Hours              Amount           Hours   Cost       Hours
1. Contract Registered Nurse
2. Contract Lic. Practical Nurse
3. Contract Nurse Aides
4. Medical Director
** 5. Therapists (itemize by type of
therapist below)
6. Consulting Social Worker
7. Dietician
8. Pharmacist
9. Dentist
10. Accountants
11. Legal (See below)
12. Housekeeping
13. Maintenance
14. Other (Specify below)
15. Computer Programmer
TOTAL (Should agree to Line 2,
Main Schedule, Col. VIII)
* If Available
** Do not include therapy costs directly attributable to a SNF (Medicare) skilled unit.

LEGAL SERVICES (Nature of services performed)

           THERAPY SERVICES (Itemized by type)

                 OTHER (Explanation, if necessary)



                                                             6
                            Employee Benefits and Payroll-Related Expense                                         Schedule C
                  Nursing Home Name
                               NH ID

                                                Book Amount                   Adjustments        Nursing Home Cost Report
1. FICA
2. Unemployment Compensation Tax
3. Workman's Compensation Ins.
4. Group Health & Dental Ins. *
5. Life Insurance *
6. Retirement and Pension *
7. Other Employee Benefits *
TOTAL (Should agree to Line 3, Main
Schedule)

* List below those job classifications (from Schedule A) for whom this benefit is provided and paid for by nursing home.
** Do not include benefits paid for owners whose salaries are reported on Schedule I.

Group Health and Dental                 Life Insurance                  Retirement & Pension     Other Employee Benefits




                                                                    7
                                      Staff Development and Training                          Schedule D
                    Nursing Home Name
                                 NH ID

Required Training

                                               Book Amount             Adjustments   Adjusted Total
1. Nurse Aide Competency Eval.

2. Other Licensed Direct Care
Personnel Training (Describe below)


Other Staff Development

                                               Book Amount             Adjustments   Adjusted Total
3. Other (Describe below)
TOTAL (Should agree to Line 4, Main
Schedule)

Required Training Other:



Other Staff Development:



                                                                   8
                                      Taxes - Non-Payroll Related                              Schedule E
                Nursing Home Name
                             NH ID


                                            Book Amount                 Adjustments   Adjusted Total
1. Excise Tax
2. Corporation License
3. Ad Valorem
4. Auto Tag/Registration
5. Other (Specify below)
TOTAL (Should agree to Line 5, Main
Schedule)


Other:




                                                                    9
                                      Insurance - Non-Employee Related                                                                Schedule F
                      Nursing Home Name
                                   NH ID


                                                         Book Amount                        Adjustments                      Adjusted Total
1. Building Insurance
2. Automobile Insurance
3. Other Insurance
TOTAL (Should agree to Line 9, Main
Schedule)


Other Insurance:

(Explanation)

Building Insurance Policy Information

1. Building Insured Value

2. Contents Insured Value



Note: Include any insurance paid by the facility on behalf of the patients for Dental and Eyeglass coverage on Line 3 and Explain.




                                                                                 10
                                         Drugs and Medical Supplies                                         Schedule G
                  Nursing Home Name
                               NH ID

Drugs and Medical Supplies

                                                 Book Amount                  Adjustments          Adjusted Total
1. Drugs & Medical Supplies
1a. Over-the-Counter Medication
2. Specialized Adaptive Medical
Equipment and Other Durable Medical
Equipment
TOTAL (Should agree to Line 18, Main
Schedule)

* Amount of Over-the-Counter medications included in Line 1.
  Total should equal Line 1 plus Line 2 and not include Line1a which is in the total for Line 1.
** Do not include costs directly attributable to a SNF (Medicare) skilled unit.




                                                                     11
                                            Capital-Related Cost                                                      Schedule H
                   Nursing Home Name                                                                                   Section A
                                NH ID

     Section A                          Rent and Lease

                                        Part I - Equipment Rented or Leased (Includes Auto)


                                                                                                      Current Year's Cost Per
     LandLord - Lessor                  Leased Item                      Lease Period                 Books
1.
2.
3.
4.
5.
6.

                                                                                 Equipment Total:

                                        Part II - Facillities Rented or Leased

                                                                                                      Current Year's Cost Per
     LandLord - Lessor                  Leased Item                      Lease Period                 Books
1.
2.
3.

                                                                                    Facility Total:

                                             Section A Total - Equipment & Facility Rent/Lease


                                                                    12
                                            Capital-Related Cost                                            Schedule H
                                                                                                             Section B
                       Nursing Home Name
                                    NH ID
                                            Section B - Interest Expense


                                                            Original                  Principal
                               Issuance                     Loan           Interest   Balance          Current Years
      Payee                    Date *       Maturity Date * Amount         Rate       Year End         Interest Expense
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.


                                                                 Section B Total - Interest Expense:

      * If available


                                                            13
                                            Capital-Related Cost                                               Schedule H
                Nursing Home Name                                                                             Section C - D
                             NH ID

Section A

                                        Section C - Depreciation Summary


                                                                     This Years Depreciation
Summary Description                     Acquisition Cost             Cost Per Books
1. Building & Improvements                                                                      See Sub-Schedule H - 1
2. Land Improvements                                                                            See Sub-Schedule H - 2
3. Leasehold & Improvements                                                                     See Sub-Schedule H - 2
4. Equipment (Includes Auto)                                                                    See Sub-Schedule H - 3

             Section C *       TOTALS
                                              Acquisition Total            Depreciation Total

                                        Section D - Total Capital Cost

                                        TOTAL CAPITAL COST (Sum of Section (A, B, and C)
                                                               (Should agree to Col. VIII. Line 19 of Main Schedule)




                                                                     14
                                                                                                 Sub-Schedule H - 1
                                                              Depreciation - Building & Improvements
                               Nursing Home Name
                                            NH ID                        TYPE OF
Building & Improvements                                                  DEPRECIATION

Check    Check
Acq      Con     Description         Date of Acq Date of Con Life Years Cost or Basis Current Years Depreciation




ACQ = Acquisition                                               TOTAL
CON = Construction
                                                              Total should agree to Schedule H, Section C, Line 1.




                                                    15
                                                                                           Sub-Schedule H - 2
                            Depreciation - Land and Leasehold Improvements
                        Nursing Home Name                                TYPE OF
                                      NH ID                              DEPRECIATION



Land Improvements            Date Acquired   Life Years    Cost or Basis    Current Years Depreciation




                                                  TOTAL
                                                           Cost Total       Depreciation Total
                                             (Totals should agree to Schedule H, Section C, Line 2).

Leasehold and Improvements   Date Acquired   Life Years    Cost or Basis    Current Years Depreciation




                                                  TOTAL
                                                           Cost Total       Depreciation Total
                                             (Totals should agree to Schedule H, Section C, Line 3).


                                             16
                                                                                                           Sub-Schedule H - 3
                                    Depreciation - Equipment
                                Nursing Home Name                                           TYPE OF
                                              NH ID                                         DEPRECIATION



Movable Equipment Description       Date Acquired   Life Years        Cost Years or Basis   Current Years Depreciation




                                                       TOTAL
                                                                  Cost Total            Depreciation Total
                                                    (Totals should agree to Schedule H, Section C, Line 4).



                                                                 17
                                            Administrative Services                                    Schedule I
                                    Nursing Home Name
                                              NH ID



Item

                Owner's Non-salary Compensation       1.
                            Owner's Salaries Paid *   2.
             Benefits on owner's salaries on Line 2   3.
                                    Director's Fees   4.
       Management Fees Paid (Administrative only)     5.
               Home Office Costs (** Detail below)    6.
       Total Administrative Services (Sum 1 thru 6)   7.                   (Should agree to Line 20,
                                                                           Main Schedule)

** Home Office Costs:

                 Item Description                          Cost




                           Total Home Office Cost




                                                                      18
                                        Other Expenses                                 Schedule J
                     Nursing Home Name
                                  NH ID
                  Description           Book Amount           Adjustment   Adjusted Total
1.    Hepatitis Vaccination Costs
2.    Provider Fees
3.    Eyeglasses and Services
4.    Dentures and Services
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
    TOTAL (Should agree to Line 21 of
29. Main Schedule)


                                                         19
                                             Related Organization                                          Schedule K
                                 Nursing Home Name
                                                NH ID
     A "related organization" is defined as an individual or organization related to the NH by common
     ownership or control who is also a vendor or provider of services, facilities, or supplies
     furnished to the NH. If there were reorganizations, you should complete this schedule.

     List name and percentage of ownership in the related organization:

                       Name of Owner                           Name of Related Organization   Percent of Ownership

1.
2.
3.
4.
5.
6.

Cost incurred as a result of transactions with related organizations:

                  NH Report Line Number                                 Description                     Amount

1.
2.
3.
4.
5.
6.

If further space is needed, attach extra pages, if necessary


                                                               20
     ADDENDUM SCHEDULE TO COST REPORT
                        DENTAL AND EYEGLASS INSURANCE COVERAGE-NON NURSING HOME
                                      Nursing Home Name
                                                   NH ID

     THIS SCHEDULE IS TO BE USED TO REPORT THE INSURANCE COVERAGE FOR MEDICAID CLIENTS
     PAID BY THE CLIENT THEMSELVES OR BY OTHERS (NON-NURSING FACILITY) ON THEIR BEHALF.



                                                                            NUMBER OF MEDICAID                         AVERAGE MONTHLY
     TYPE OF COVERAGE                                                        CLIENTS COVERED                               PREMIUM
1. EYEGLASSES
2. DENTURES
3. COMBINED
4.
5.
6.

     Note: This schedule is to be used to report insurance premiums paid by the client or by others (non-nursing home) on their
     behalf for eyeglass and denture coverage. If the facility purchases the insurance on behalf of the clients out of facility funds
     then these facility costs should be reported on Schedule F, Non-Payroll Insurance Cost.

                                                                                         21

				
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