Health Financial Systems MCRIF32 FOR SULLIVAN COUNTY ... · health financial systems mcrif32 for sullivan county community hospital in lieu of form cms-2552-96 (12/2008) contd i provider

Health Financial Systems MCRIF32 FOR SULLIVAN COUNTY COMMUNITY HOSPITAL IN LIEU OF FORM CMS-2552-96 (12/2008)

I PROVIDER NO: I PERIOD: I PREPARED 5/15/2009

HOSPITAL & HOSPITAL HEALTH CARE COMPLEX I 15-1327 I FROM 1/ 1/2008 I WORKSHEET S-2

IDENTIFICATION DATA I I TO 12/31/2008 I

HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX ADDRESS

1 STREET: 2200 NORTH SECTION STREET P.O. BOX: 10

1.01 CITY: SULLIVAN STATE: IN ZIP CODE: 47882- COUNTY: SULLIVAN

HOSPITAL AND HOSPITAL-BASED COMPONENT IDENTIFICATION; PAYMENT SYSTEM

DATE (P,T,O OR N)

COMPONENT COMPONENT NAME PROVIDER NO. NPI NUMBER CERTIFIED V XVIII XIX

0 1 2 2.01 3 4 5 6

02.00 HOSPITAL SULLIVAN COUNTY COMMUNITY HOSPITAL 15-1327 6/ 1/2005 N O N

04.00 SWING BED - SNF SULLIVAN COUNTY COMMUNITY HOSPITAL 15-Z327 6/ 1/2005 N O N

09.00 HOSPITAL-BASED HHA SULLIVAN COUNTY HOME HEALTH 15-7542 7/23/2002 N P N

17 COST REPORTING PERIOD (MM/DD/YYYY) FROM: 1/ 1/2008 TO: 12/31/2008

1 2

18 TYPE OF CONTROL 9

TYPE OF HOSPITAL/SUBPROVIDER

19 HOSPITAL 1

20 SUBPROVIDER

OTHER INFORMATION

21 INDICATE IF YOUR HOSPITAL IS EITHER (1)URBAN OR (2)RURAL AT THE END OF THE COST REPORT PERIOD

IN COLUMN 1. IF YOUR HOSPITAL IS GEOGRAPHICALLY CLASSIFIED OR LOCATED IN A RURAL AREA, IS

YOUR BED SIZE IN ACCORDANCE WITH CFR 42 412.105 LESS THAN OR EQUAL TO 100 BEDS, ENTER IN

COLUMN 2 "Y" FOR YES OR "N" FOR NO.

21.01 DOES YOUR FACILITY QUALIFY AND IS CURRENTLY RECEIVING PAYMENT FOR DISPROPORTIONATE

SHARE HOSPITAL ADJUSTMENT IN ACCORDANCE WITH 42 CFR 412.106? N

21.02 HAS YOUR FACILITY RECEIVED A NEW GEOGRAPHIC RECLASSICATION STATUS CHANGE AFTER THE FIRST DAY

OF THE COST REPORTING PERIOD FROM RURAL TO URBAN AND VICE VERSA? ENTER "Y" FOR YES AND "N"

FOR NO. IF YES, ENTER IN COLUMN 2 THE EFFECTIVE DATE (MM/DD/YYYY) (SEE INSTRUCTIONS).

21.03 ENTER IN COLUMN 1 YOUR GEOGRAPHIC LOCATION EITHER (1)URBAN OR (2)RURAL. IF YOU ANSWERED URBAN

IN COLUMN 1 INDICATE IF YOU RECEIVED EITHER A WAGE OR STANDARD GEOGRAPHICAL RECLASSIFICATION

TO A RURAL LOCATION, ENTER IN COLUMN 2 "Y" FOR YES AND "N" FOR NO. IF COLUMN 2 IS YES, ENTER

IN COLUMN 3 THE EFFECTIVE DATE (MM/DD/YYYY)(SEE INSTRUCTIONS) DOES YOUR FACILITY CONTAIN

100 OR FEWER BEDS IN ACCORDANCE WITH 42 CFR 412.105? ENTER IN COLUMN 4 "Y" OR "N". ENTER IN

COLUMN 5 THE PROVIDERS ACTUAL MSA OR CBSA. 2 N Y

21.04 FOR STANDARD GEOGRAPHIC CLASSIFICATION (NOT WAGE), WHAT IS YOUR STATUS AT THE

BEGINNING OF THE COST REPORTING PERIOD. ENTER (1)URBAN OR (2)RURAL 2

21.05 FOR STANDARD GEOGRAPHIC CLASSIFICATION (NOT WAGE), WHAT IS YOUR STATUS AT THE

END OF THE COST REPORTING PERIOD. ENTER (1)URBAN OR (2)RURAL 2

21.06 DOES THIS HOSPITAL QUALIFY FOR THE 3-YEAR TRANSITION OF HOLD HARMLESS PAYMENTS

FOR SMALL RURAL HOSPITAL UNDER THE PROSPECTIVE PAYMENT SYSTEM FOR HOSPITAL

OUTPATIENT SERVICES UNDER DRA SECTION 5105? ENTER "Y" FOR YES, AND "N" FOR NO. N

22 ARE YOU CLASSIFIED AS A REFERRAL CENTER? N

23 DOES THIS FACILITY OPERATE A TRANSPLANT CENTER? IF YES, ENTER CERTIFICATION DATE(S) BELOW. N

23.01 IF THIS IS A MEDICARE CERTIFIED KIDNEY TRANSPLANT CENTER, ENTER THE CERTIFICATION DATE IN / / / /

COL. 2 AND TERMINATION IN COL. 3.

23.02 IF THIS IS A MEDICARE CERTIFIED HEART TRANSPLANT CENTER, ENTER THE CERTIFICATION DATE IN / / / /


23.03 IF THIS IS A MEDICARE CERTIFIED LIVER TRANSPLANT CENTER, ENTER THE CERTIFICATION DATE IN / / / /


23.04 IF THIS IS A MEDICARE CERTIFIED LUNG TRANSPLANT CENTER, ENTER THE CERTIFICATION DATE IN / / / /


23.05 IF MEDICARE PANCREAS TRANSPLANTS ARE PERFORMED SEE INSTRUCTIONS FOR ENTERING CERTIFICATION / / / /

AND TERMINATION DATE.

23.06 IF THIS IS A MEDICARE CERTIFIED INTESTINAL TRANSPLANT CENTER, ENTER THE CERTIFICATION DATE IN / / / /


23.07 IF THIS IS A MEDICARE CERTIFIED ISLET TRANSPLANT CENTER, ENTER THE CERTIFICATION DATE IN / / / /


24 IF THIS IS AN ORGAN PROCUREMENT ORGANIZATION (OPO), ENTER THE OPO NUMBER IN COLUMN 2 AND / /

CERTIFICATION DATE OR RECERTIFICATION DATE (AFTER 12/26/2007) in column 3 (mm/dd/yyyy)

24.01 IF THIS IS A MEDICARE TRANSPLANT CENTER; ENTER THE CCN (PROVIDER NUMBER) IN COLUMN 2, THE / /

CERTIFICATION DATE OR RECERTIFICATION DATE (AFTER 12/26/2007) IN COLUMN 3 (mm/dd/yyyy).

25 IS THIS A TEACHING HOSPITAL OR AFFILIATED WITH A TEACHING HOSPITAL AND YOU ARE RECEIVING

PAYMENTS FOR I&R? N

25.01 IS THIS TEACHING PROGRAM APPROVED IN ACCORDANCE WITH CMS PUB. 15-I, CHAPTER 4?

25.02 IF LINE 25.01 IS YES, WAS MEDICARE PARTICIPATION AND APPROVED TEACHING PROGRAM STATUS IN

EFFECT DURING THE FIRST MONTH OF THE COST REPORTING PERIOD? IF YES, COMPLETE WORKSHEET

E-3, PART IV. IF NO, COMPLETE WORKSHEET D-2, PART II.

25.03 AS A TEACHING HOSPITAL, DID YOU ELECT COST REIMBURSEMENT FOR PHYSICIANS' SERVICES AS

DEFINED IN CMS PUB. 15-I, SECTION 2148? IF YES, COMPLETE WORKSHEET D-9. N

25.04 ARE YOU CLAIMING COSTS ON LINE 70 OF WORKSHEET A? IF YES, COMPLETE WORKSHEET D-2, PART I. N

25.05 HAS YOUR FACILITY DIRECT GME FTE CAP (COLUMN 1) OR IME FTE CAP (COLUMN 2) BEEN REDUCED

UNDER 42 CFR 413.79(c)(3) OR 42 CFR 412.105(f)(1)(iv)(B)? ENTER "Y" FOR YES AND "N" FOR

NO IN THE APPLICABLE COLUMNS. (SEE INSTRUCTIONS)

Health Financial Systems MCRIF32 FOR SULLIVAN COUNTY COMMUNITY HOSPITAL IN LIEU OF FORM CMS-2552-96 (12/2008) CONTD




25.06 HAS YOUR FACILITY RECEIVED ADDITIONAL DIRECT GME FTE RESIDENT CAP SLOTS OR IME FTE

RESIDENTS CAP SLOTS UNDER 42 CFR 413.79(c)(4) OR 42 CFR 412.105(f)(1)(iv)(C)? ENTER "Y"

FOR YES AND "N" FOR NO IN THE APPLICABLE COLUMNS (SEE INSTRUCTIONS)

26 IF THIS IS A SOLE COMMUNITY HOSPITAL (SCH),ENTER THE NUMBER OF PERIODS SCH STATUS IN EFFECT

IN THE C/R PERIOD. ENTER BEGINNING AND ENDING DATES OF SCH STATUS ON LINE 26.01.

SUBSCRIPT LINE 26.01 FOR NUMBER OF PERIODS IN EXCESS OF ONE AND ENTER SUBSEQUENT DATES. 0

26.01 ENTER THE APPLICABLE SCH DATES: BEGINNING: / / ENDING: / /

26.02 ENTER THE APPLICABLE SCH DATES: BEGINNING: / / ENDING: / /

27 DOES THIS HOSPITAL HAVE AN AGREEMENT UNDER EITHER SECTION 1883 OR SECTION 1913 N / /

FOR SWING BEDS. IF YES, ENTER THE AGREEMENT DATE (MM/DD/YYYY) IN COLUMN 2.

28 IF THIS FACILITY CONTAINS A HOSPITAL-BASED SNF, ARE ALL PATIENTS UNDER MANAGED CARE OR

THERE WERE NO MEDICARE UTILIZATION ENTER "Y", IF "N" COMPLETE LINES 28.01 AND 28.02

28.01 IF HOSPITAL BASED SNF, ENTER APPROPRIATE TRANSITION PERIOD 1, 2, 3, OR 100 IN COLUMN 1. 1 2 3 4

ENTER IN COLUMNS 2 AND 3 THE WAGE INDEX ADJUSTMENT FACTOR BEFORE AND ON OR AFTER THE ------- ------- ------- ------

OCTOBER 1ST (SEE INSTRUCTIONS) 0 0.0000 0.0000

28.02 ENTER IN COLUMN 1 THE HOSPITAL BASED SNF FACILITY SPECIFIC RATE(FROM YOUR FISCAL

INTERMEDIARY) IF YOU HAVE NOT TRANSITIONED TO 100% PPS SNF PPS PAYMENT. IN COLUMN 2 ENTER 0.00 0

THE FACILITY CLASSIFICATION URBAN(1) OR RURAL (2). IN COLUMN 3 ENTER THE SNF MSA CODE OR

TWO CHARACTER STATE CODE IF A RURAL BASED FACILITY. IN COLUMN 4, ENTER THE SNF CBSA CODE

OR TWO CHARACTER CODE IF RURAL BASED FACILITY

A NOTICE PUBLISHED IN THE "FEDERAL REGISTER" VOL. 68, NO. 149 AUGUST 4, 2003 PROVIDED FOR AN

INCREASE IN THE RUG PAYMENTS BEGINNING 10/01/2003. CONGRESS EXPECTED THIS INCREASE TO BE

USED FOR DIRECT PATIENT CARE AND RELATED EXPENSES. ENTER IN COLUMN 1 THE PERCENTAGE OF TOTAL

EXPENSES FOR EACH CATEGORY TO TOTAL SNF REVENUE FROM WORKSHEET G-2, PART I, LINE 6, COLUMN

3. INDICATE IN COLUMN 2 "Y" FOR YES OR "N" FOR NO IF THE SPENDING REFLECTS INCREASES

ASSOCIATED WITH DIRECT PATIENT CARE AND RELATED EXPENSES FOR EACH CATEGORY. (SEE INSTR) % Y/N

28.03 STAFFING 0.00%

28.04 RECRUITMENT 0.00%

28.05 RETENTION 0.00%

28.06 TRAINING 0.00%

28.07 0.00%

28.08 0.00%

28.09 0.00%

28.10 0.00%

28.11 0.00%

28.12 0.00%

28.13 0.00%

28.14 0.00%

28.15 0.00%

28.16 0.00%

28.17 0.00%

28.18 0.00%

28.19 0.00%

28.20 0.00%

29 IS THIS A RURAL HOSPITAL WITH A CERTIFIED SNF WHICH HAS FEWER THAN 50 BEDS IN THE N

AGGREGATE FOR BOTH COMPONENTS, USING THE SWING BED OPTIONAL METHOD OF REIMBURSEMENT?

30 DOES THIS HOSPITAL QUALIFY AS A RURAL PRIMARY CARE HOSPITAL (RPCH)/CRITICAL ACCESS Y

HOSPITAL(CAH)? (SEE 42 CFR 485.606ff)

30.01 IF SO, IS THIS THE INITIAL 12 MONTH PERIOD FOR THE FACILITY OPERATED AS AN RPCH/CAH?

SEE 42 CFR 413.70 N

30.02 IF THIS FACILITY QUALIFIES AS AN RPCH/CAH, HAS IT ELECTED THE ALL-INCLUSIVE METHOD OF

PAYMENT FOR OUTPATIENT SERVICES? (SEE INSTRUCTIONS) N

30.03 IF THIS FACILITY QUALIFIES AS A CAH, IS IT ELIBIBLE FOR COST REIMBURSEMENT FOR AMBULANCE

SERVICES? IF YES, ENTER IN COLUMN 2 THE DATE OF ELIGIBILITY DETERMINATION (DATE MUST

BE ON OR AFTER 12/21/2000). N

30.04 IF THIS FACILITY QUALIFIES AS A CAH, IS IT ELIBIBLE FOR COST REIMBURSEMENT FOR I&R

TRAINING PROGRAMS? ENTER "Y" FOR YES AND "N" FOR NO. IF YES, THE GME ELIMINATION WOULD

NOT BE ON WORKSHEET B, PART I, COLUMN 26 AND THE PROGRAM WOULD BE COST REIMBURSED. IF

YES COMPLETE WORKSHEET D-2, PART II N

31 IS THIS A RURAL HOSPITAL QUALIFYING FOR AN EXCEPTION TO THE CRNA FEE SCHEDULE? SEE 42

CFR 412.113(c). N

31.01 IS THIS A RURAL SUBPROVIDER 1 QUALIFYING FOR AN EXCEPTION TO THE CRNA FEE SCHEDULE? SEE 42

CFR 412.113(c). N


CFR 412.113(c). N


CFR 412.113(c). N


CFR 412.113(c). N


CFR 412.113(c). N

MISCELLANEOUS COST REPORT INFORMATION

32 IS THIS AN ALL-INCLUSIVE PROVIDER? IF YES, ENTER THE METHOD USED (A, B, OR E ONLY) COL 2. N

33 IS THIS A NEW HOSPITAL UNDER 42 CFR 412.300 PPS CAPITAL? ENTER "Y" FOR YES AND "N" FOR NO

IN COLUMN 1. IF YES, FOR COST REPORTING PERIODS BEGINNING ON OR AFTER OCTOBER 1, 2002, DO

YOU ELECT TO BE REIMBURSED AT 100% FEDERAL CAPITAL PAYMENT? ENTER "Y" FOR YES AND "N" FOR

NO IN COLUMN 2 N

34 IS THIS A NEW HOSPITAL UNDER 42 CFR 413.40 (f)(1)(i) TEFRA? N

35 HAVE YOU ESTABLISHED A NEW SUBPROVIDER (EXCLUDED UNIT) UNDER 42 CFR 413.40(f)(1)(i)? N

35.01 HAVE YOU ESTABLISHED A NEW SUBPROVIDER (EXCLUDED UNIT) UNDER 42 CFR 413.40(f)(1)(i)? N

35.02 HAVE YOU ESTABLISHED A NEW SUBPROVIDER (EXCLUDED UNIT) UNDER 42 CFR 413.40(f)(1)(i)?



V XVIII XIX

PROSPECTIVE PAYMENT SYSTEM (PPS)-CAPITAL 1 2 3

36 DO YOU ELECT FULLY PROSPECTIVE PAYMENT METHODOLOGY FOR CAPITAL COSTS? (SEE INSTRUCTIONS) N N N

36.01 DOES YOUR FACILITY QUALIFY AND RECEIVE PAYMENT FOR DISPROPORTIONATE SHARE IN ACCORDANCE





WITH 42 CFR 412.320? (SEE INSTRUCTIONS) N N N

37 DO YOU ELECT HOLD HARMLESS PAYMENT METHODOLOGY FOR CAPITAL COSTS? (SEE INSTRUCTIONS) N N N

37.01 IF YOU ARE A HOLD HARMLESS PROVIDER, ARE YOU FILING ON THE BASIS OF 100% OF THE FED RATE?

TITLE XIX INPATIENT SERVICES

38 DO YOU HAVE TITLE XIX INPATIENT HOSPITAL SERVICES? Y

38.01 IS THIS HOSPITAL REIMBURSED FOR TITLE XIX THROUGH THE COST REPORT EITHER IN FULL OR IN PART? Y

38.02 DOES THE TITLE XIX PROGRAM REDUCE CAPITAL FOLLOWING THE MEDICARE METHODOLOGY? N

38.03 ARE TITLE XIX NF PATIENTS OCCUPYING TITLE XVIII SNF BEDS (DUAL CERTIFICATION)? N

38.04 DO YOU OPERATE AN ICF/MR FACILITY FOR PURPOSES OF TITLE XIX? N

40 ARE THERE ANY RELATED ORGANIZATION OR HOME OFFICE COSTS AS DEFINED IN CMS PUB 15-I, CHAP 10?

IF YES, AND THERE ARE HOME OFFICE COSTS, ENTER IN COL 2 THE HOME OFFICE PROVIDER NUMBER.

IF THIS FACILITY IS PART OF A CHAIN ORGANIZATION ENTER THE NAME AND ADDRESS OF THE HOME OFFICE N

40.01 NAME: FI/CONTRACTOR NAME FI/CONTRACTOR #

40.02 STREET: P.O. BOX:

40.03 CITY: STATE: ZIP CODE: -

41 ARE PROVIDER BASED PHYSICIANS' COSTS INCLUDED IN WORKSHEET A? Y

42 ARE PHYSICAL THERAPY SERVICES PROVIDED BY OUTSIDE SUPPLIERS? N

42.01 ARE OCCUPATIONAL THERAPY SERVICES PROVIDED BY OUTSIDE SUPPLIERS? N

42.02 ARE SPEECH PATHOLOGY SERVICES PROVIDED BY OUTSIDE SUPPLIERS? N

43 ARE RESPIRATORY THERAPY SERVICES PROVIDED BY OUTSIDE SUPPLIERS? N

44 IF YOU ARE CLAIMING COST FOR RENAL SERVICES ON WORKSHEET A, ARE THEY INPATIENT SERVICES ONLY? N

45 HAVE YOU CHANGED YOUR COST ALLOCATION METHODOLOGY FROM THE PREVIOUSLY FILED COST REPORT? N 00/00/0000

SEE CMS PUB. 15-II, SECTION 3617. IF YES, ENTER THE APPROVAL DATE IN COLUMN 2.

45.01 WAS THERE A CHANGE IN THE STATISTICAL BASIS?

45.02 WAS THERE A CHANGE IN THE ORDER OF ALLOCATION?

45.03 WAS THE CHANGE TO THE SIMPLIFIED COST FINDING METHOD?

46 IF YOU ARE PARTICIPATING IN THE NHCMQ DEMONSTRATION PROJECT (MUST HAVE A HOSPITAL-BASED SNF)

DURING THIS COST REPORTING PERIOD, ENTER THE PHASE (SEE INSTRUCTIONS).

IF THIS FACILITY CONTAINS A PROVIDER THAT QUALIFIES FOR AN EXEMPTION FROM THE APPLICATION OF THE LOWER OF COSTS OR

CHARGES, ENTER "Y" FOR EACH COMPONENT AND TYPE OF SERVICE THAT QUALIFIES FOR THE EXEMPTION. ENTER "N" IF NOT EXEMPT.

(SEE 42 CFR 413.13.)

OUTPATIENT OUTPATIENT OUTPATIENT

PART A PART B ASC RADIOLOGY DIAGNOSTIC

1 2 3 4 5

47.00 HOSPITAL N N N N N

50.00 HHA N N

52 DOES THIS HOSPITAL CLAIM EXPENDITURES FOR EXTRAORDINARY CIRCUMSTANCES IN ACCORDANCE WITH

42 CFR 412.348(e)? (SEE INSTRUCTIONS) N

52.01 IF YOU ARE A FULLY PROSPECTIVE OR HOLD HARMLESS PROVIDER ARE YOU ELIGIBLE FOR THE SPECIAL

EXCEPTIONS PAYMENT PURSUANT TO 42 CFR 412.348(g)? IF YES, COMPLETE WORKSHEET L, PART IV N

53 IF YOU ARE A MEDICARE DEPENDENT HOSPITAL (MDH), ENTER THE NUMBER OF PERIODS MDH STATUS IN

EFFECT. ENTER BEGINNING AND ENDING DATES OF MDH STATUS ON LINE 53.01. SUBSCRIPT LINE

53.01 FOR NUMBER OF PERIODS IN EXCESS OF ONE AND ENTER SUBSEQUENT DATES. 0

53.01 MDH PERIOD: BEGINNING: / / ENDING: / /

54 LIST AMOUNTS OF MALPRACTICE PREMIUMS AND PAID LOSSES:

PREMIUMS: 0

PAID LOSSES: 0

AND/OR SELF INSURANCE: 0

54.01 ARE MALPRACTICE PREMIUMS AND PAID LOSSES REPORTED IN OTHER THAN THE ADMINISTRATIVE AND

GENERAL COST CENTER? IF YES, SUBMIT SUPPORTING SCHEDULE LISTING COST CENTERS AND AMOUNTS

CONTAINED THEREIN. N

55 DOES YOUR FACILITY QUALIFY FOR ADDITIONAL PROSPECTIVE PAYMENT IN ACCORDANCE WITH

42 CFR 412.107. ENTER "Y" FOR YES AND "N" FOR NO. N

56 ARE YOU CLAIMING AMBULANCE COSTS? IF YES, ENTER IN COLUMN 2 THE PAYMENT LIMIT

PROVIDED FROM YOUR FISCAL INTERMEDIARY AND THE APPLICABLE DATES FOR THOSE LIMITS DATE Y OR N LIMIT Y OR N FEES

IN COLUMN 0. IF THIS IS THE FIRST YEAR OF OPERATION NO ENTRY IS REQUIRED IN COLUMN 0 1 2 3 4

2. IF COLUMN 1 IS Y, ENTER Y OR N IN COLUMN 3 WHETHER THIS IS YOUR FIRST YEAR OF -------------------------------------------

OPERATIONS FOR RENDERING AMBULANCE SERVICES. ENTER IN COLUMN 4, IF APPLICABLE, N 0.00 0

THE FEE SCHEDULES AMOUNTS FOR THE PERIOD BEGINNING ON OR AFTER 4/1/2002.

56.01 ENTER SUBSEQUENT AMBULANCE PAYMENT LIMIT AS REQUIRED. SUBSCRIPT IF MORE THAN 2 0.00 0

LIMITS APPLY. ENTER IN COLUMN 4 THE FEE SCHEDULES AMOUNTS FOR INITIAL OR

SUBSEQUENT PERIOD AS APPLICABLE.

56.02 THIRD AMBULANCE LIMIT AND FEE SCHEDULE IF NECESSARY. 0.00 0

56.03 FOURTH AMBULANCE LIMIT AND FEE SCHEDULE IF NECESSARY. 0.00 0

57 ARE YOU CLAIMING NURSING AND ALLIED HEALTH COSTS? N

58 ARE YOU AN INPATIENT REHABILITATION FACILITY(IRF), OR DO YOU CONTAIN AN IRF SUBPROVIDER?

ENTER IN COLUMN 1 "Y" FOR YES AND "N" FOR NO. IF YES HAVE YOU MADE THE ELECTION FOR 100%

FEDERAL PPS REIMBURSEMENT? ENTER IN COLUMN 2 "Y" FOR YES AND "N" FOR NO. THIS OPTION IS N

ONLY AVAILABLE FOR COST REPORTING PERIODS BEGINNING ON OR AFTER 1/1/2002 AND BEFORE

10/1/2002.

58.01 IF LINE 58 COLUMN 1 IS Y, DOES THE FACILITY HAVE A TEACHING PROGRAM IN THE MOST RECENT COST 0

REPORTING PERIOD ENDING ON OR BEFORE NOVEMBER 15, 2004? ENTER "Y" FOR YES OR "N" FOR NO. IS

THE FACILITY TRAINING RESIDENTS IN A NEW TEACHING PROGRAM IN ACCORDANCE WITH 42 CFR SEC.

412.424(d)(1)(iii)(2)? ENTER IN COLUMN 2 "Y"FOR YES OR "N" FOR NO. IF COLUMN 2 IS Y, ENTER

1, 2 OR 3 RESPECTIVELY IN COLUMN 3 (SEE INSTRUCTIONS). IF THE CURRENT COST REPORTING PERIOD

COVERS THE BEGINNING OF THE FOURTH ENTER 4 IN COLUMN 3, OR IF THE SUBSEQUENT ACADEMIC YEARS

OF THE NEW TEACHING PROGRAM IN EXISTENCE, ENTER 5. (SEE INSTR).

59 ARE YOU A LONG TERM CARE HOSPITAL (LTCH)? ENTER IN COLUMN 1 "Y" FOR YES AND "N" FOR NO.

IF YES, HAVE YOU MADE THE ELECTION FOR 100% FEDERAL PPS REIMBURSEMENT? ENTER IN COLUMN 2

"Y" FOR YES AND "N" FOR NO. (SEE INSTRUCTIONS) N

60 ARE YOU AN INPATIENT PSYCHIATRIC FACILITY (IPF), OR DO YOU CONTAIN AN IPF SUBPROVIDER?

ENTER IN COLUMN 1 "Y" FOR YES AND "N" FOR NO. IF YES, IS THE IPF OR IPF SUBPROVIDER A NEW

FACILITY? ENTER IN COLUMN 2 "Y" FOR YES AND "N" FOR NO. (SEE INSTRUCTIONS) N





60.01 IF LINE 60 COLUMN 1 IS Y, AND THE FACILITY IS AN IPF SUBPROVIDER, WERE RESIDENTS TRAINING IN N 0

THIS FACILITY IN ITS MOST RECENT COST REPORT FILED BEFORE NOV. 15, 2004? ENTER "Y" FOR YES OR

"N" FOR NO. IS THIS FACILITY TRAINING RESIDENTS IN A NEW TEACHING PROGRAM IN ACCORDANCE WITH

42 CFR SEC. 412.424(d)(1)(iii)(2)? ENTER IN COL. 2 "Y" FOR YES OR "N" FOR NO. IF COL. 2 IS Y,

ENTER 1, 2 OR 3 RESPECTIVELY IN COL. 3. (SEE INSTRUCTIONS). IF THE CURRENT COST REPORTING

PERIOD COVERS THE BEGINNING OF THE FOURTH ENTER 4 IN COLUMN 3, OR IF THE SUBSEQUENT ACADEMIC

YEARS OF THE NEW TEACHING PROGRAM IN EXISTENCE, ENTER 5. (SEE INSTRUCTIONS)

MULTICAMPUS

61.00 IS THIS FACILITY PART OF A MULTICAMPUS HOSPITAL THAT HAS ONE OR MORE CAMPUSES IN DIFFERENT CBSA?

ENTER "Y" FOR YES AND "N" FOR NO.

IF LINE 61 IS YES, ENTER THE NAME IN COL. 0, COUNTY IN COL. 1, STATE IN COL.2, ZIP IN COL 3,

CBSA IN COL. 4 AND FTE/CAMPUS IN COL. 5.

NAME COUNTY STATE ZIP CODE CBSA FTE/CAMPUS

------------------------------------ ------------------------------------ ----- ---------- ----- ----------

62.00 0.00

62.01 0.00

62.02 0.00

62.03 0.00

62.04 0.00

62.05 0.00

62.06 0.00

62.07 0.00

62.08 0.00

62.09 0.00

SETTLEMENT DATA

63.00 WAS THE COST REPORT FILED USING THE PS&R (EITHER IN ITS ENTIRETY OR FOR TOTAL CHARGES AND DAYS / /

ONLY)? ENTER "Y" FOR YES AND "N" FOR NO IN COL. 1. IF COL. 1 IS "Y", ENTER THE "PAID THROUGH"

DATE OF THE PS&R IN COL. 2 (MM/DD/YYYY).



HOSPITAL AND HOSPITAL HEALTH CARE I 15-1327 I FROM 1/ 1/2008 I WORKSHEET S-3

COMPLEX STATISTICAL DATA I I TO 12/31/2008 I PART I

-------- I/P DAYS / O/P VISITS / TRIPS --------

NO. OF BED DAYS CAH TITLE TITLE NOT LTCH TOTAL

COMPONENT BEDS AVAILABLE HOURS V XVIII N/A TITLE XIX

1 2 2.01 3 4 4.01 5

1 ADULTS & PEDIATRICS 21 7,686 70,032.00 1,751 461

2 HMO

2 01 HMO - (IRF PPS SUBPROVIDER)

3 ADULTS & PED-SB SNF 380

4 ADULTS & PED-SB NF 22

5 TOTAL ADULTS AND PEDS 21 7,686 70,032.00 2,131 483

6 INTENSIVE CARE UNIT 4 1,464 9,720.00 251 38

11 NURSERY 148

12 TOTAL 25 9,150 79,752.00 2,382 669

13 RPCH VISITS

18 HOME HEALTH AGENCY 2,844

21 HOSPICE

25 TOTAL 25

26 OBSERVATION BED DAYS 332

27 AMBULANCE TRIPS

28 EMPLOYEE DISCOUNT DAYS

28 01 EMP DISCOUNT DAYS -IRF

---------- I/P DAYS / O/P VISITS / TRIPS ------------ -- INTERNS & RES. FTES --

TITLE XIX OBSERVATION BEDS TOTAL TOTAL OBSERVATION BEDS LESS I&R REPL

COMPONENT ADMITTED NOT ADMITTED ALL PATS ADMITTED NOT ADMITTED TOTAL NON-PHYS ANES

5.01 5.02 6 6.01 6.02 7 8

1 ADULTS & PEDIATRICS 2,892

2 HMO


3 ADULTS & PED-SB SNF 380

4 ADULTS & PED-SB NF 22

5 TOTAL ADULTS AND PEDS 3,294

6 INTENSIVE CARE UNIT 405

11 NURSERY 243

12 TOTAL 3,942

13 RPCH VISITS


21 HOSPICE

25 TOTAL

26 OBSERVATION BED DAYS 40 292 1,938 67 1,871

27 AMBULANCE TRIPS

28 EMPLOYEE DISCOUNT DAYS 13


I & R FTES --- FULL TIME EQUIV --- --------------- DISCHARGES ------------------

EMPLOYEES NONPAID TITLE TITLE TITLE TOTAL ALL

COMPONENT NET ON PAYROLL WORKERS V XVIII XIX PATIENTS

9 10 11 12 13 14 15

1 ADULTS & PEDIATRICS 606 164 1,042

2 HMO


3 ADULTS & PED-SB SNF

4 ADULTS & PED-SB NF

5 TOTAL ADULTS AND PEDS

6 INTENSIVE CARE UNIT

11 NURSERY

12 TOTAL 191.48 606 164 1,042

13 RPCH VISITS

18 HOME HEALTH AGENCY 9.00

21 HOSPICE

25 TOTAL 200.48

26 OBSERVATION BED DAYS

27 AMBULANCE TRIPS

28 EMPLOYEE DISCOUNT DAYS


Health Financial Systems MCRIF32 FOR SULLIVAN COUNTY COMMUNITY HOSPITAL IN LIEU OF FORM CMS-2552-96 S-4 (05/2008)


HOSPITAL-BASED HOME HEALTH AGENCY I 15-1327 I FROM 1/ 1/2008 I WORKSHEET S-4

STATISTICAL DATA I HHA NO: I TO 12/31/2008 I

I 15-7542 I I

HOME HEALTH AGENCY STATISTICAL DATA COUNTY:

HHA 1

TITLE TITLE TITLE

V XVIII XIX OTHER

1 2 3 4

1 HOME HEALTH AIDE HOURS 0 2,378 0 0

2 UNDUPLICATED CENSUS COUNT 132.00

TOTAL

5

1 HOME HEALTH AIDE HOURS 2,378

2 UNDUPLICATED CENSUS COUNT

HOME HEALTH AGENCY - NUMBER OF EMPLOYEES

(FULL TIME EQUIVALENT)

ENTER THE NUMBER OF HOURS IN YOUR NORMAL WORK WEEK

HHA NO. OF FTE EMPLOYEES (2080 HRS)

STAFF CONTRACT TOTAL

1 2 3

3 ADMINISTRATOR AND ASSISTANT ADMINISTRATOR(S) 2.45 2.45

4 DIRECTOR(S) AND ASSISTANT DIRECTOR(S)

5 OTHER ADMINISTRATIVE PERSONEL

6 DIRECTING NURSING SERVICE 3.33 3.33

7 NURSING SUPERVISOR

8 PHYSICAL THERAPY SERVICE 2.04 2.04

9 PHYSICAL THERAPY SUPERVISOR

10 OCCUPATIONAL THERAPY SERVICE .41 .41

11 OCCUPATIONAL THERAPY SUPERVISOR

12 SPEECH PATHOLOGY SERVICE .08 .08

13 SPEECH PATHOLOGY SUPERVISOR

14 MEDICAL SOCIAL SERVICE .08 .08

15 MEDICAL SOCIAL SERVICE SUPERVISOR

16 HOME HEALTH AIDE .61 .61

17 HOME HEALTH AIDE SUPERVISOR

18

HOME HEALTH AGENCY MSA CODES 1 1.01

19 HOW MANY MSAs IN COL. 1 OR CBSAs IN COL. 1.01 DID 0 0

YOU PROVIDER SERVICES TO DURING THE C/R PERIOD?

20 LIST THOSE MSA CODE(S) IN COL. 1 & CBSA CODE(S) IN

COL. 1.01 SERVICED DURING THIS C/R PERIOD (LINE 20

CONTAINS THE FIRST CODE).

PPS ACTIVITY DATA - APPLICABLE FOR SERVICES ON

OR AFTER OCTOBER 1, 2000

FULL EPISODES

WITHOUT WITH LUPA PEP ONLY

OUTLIERS OUTLIERS EPISODES EPISODES

1 2 3 4

21 SKILLED NURSING VISITS 1,121 0 26 16

22 SKILLED NURSING VISIT CHARGES 161,046 0 12,634 2,224

23 PHYSICAL THERAPY VISITS 662 0 10 3

24 PHYSICAL THERAPY VISIT CHARGES 90,570 0 8,605 405

25 OCCUPATIONAL THERAPY VISITS 194 0 1 2

26 OCCUPATIONAL THERAPY VISIT CHARGES 26,730 0 945 270

27 SPEECH PATHOLOGY VISITS 15 0 0 0

28 SPEECH PATHOLOGY VISIT CHARGES 2,325 0 0 0

29 MEDICAL SOCIAL SERVICE VISITS 13 0 2 0

30 MEDICAL SOCIAL SERVICE VISIT CHARGES 2,242 0 338 0

31 HOME HEALTH AIDE VISITS 703 0 6 0

32 HOME HEALTH AIDE VISIT CHARGES 62,645 0 6,460 0

33 TOTAL VISITS (SUM OF LINES 21,23,25,27,29 & 31) 2,708 0 45 21

34 OTHER CHARGES 0 0 0 0

35 TOTAL CHARGES (SUM OF LNS 22,24,26,28,30,32 & 34) 345,558 0 28,982 2,899

36 TOTAL NUMBER OF EPISODES (STANDARD/NON OUTLIER) 0 0 0 0

37 TOTAL NUMBER OF OUTLIER EPISODES 0 0 0 0

38 TOTAL NON-ROUTINE MEDICAL SUPPLY CHARGES 8,097 0 569 93

Health Financial Systems MCRIF32 FOR SULLIVAN COUNTY COMMUNITY HOSPITAL IN LIEU OF FORM CMS-2552-96 S-4 (05/2008)


HOSPITAL-BASED HOME HEALTH AGENCY I 15-1327 I FROM 1/ 1/2008 I WORKSHEET S-4

STATISTICAL DATA I HHA NO: I TO 12/31/2008 I

I 15-7542 I I

HOME HEALTH AGENCY STATISTICAL DATA COUNTY:

HHA 1

PPS ACTIVITY DATA - APPLICABLE FOR SERVICES ON

OR AFTER OCTOBER 1, 2000

SCIC WITHIN SCIC ONLY TOTAL

A PEP EPISODES (COLS. 1-6)

5 6 7

21 SKILLED NURSING VISITS 0 10 1,173

22 SKILLED NURSING VISIT CHARGES 0 1,940 177,844

23 PHYSICAL THERAPY VISITS 0 10 685

24 PHYSICAL THERAPY VISIT CHARGES 0 1,600 101,180

25 OCCUPATIONAL THERAPY VISITS 0 0 197

26 OCCUPATIONAL THERAPY VISIT CHARGES 0 0 27,945

27 SPEECH PATHOLOGY VISITS 0 0 15

28 SPEECH PATHOLOGY VISIT CHARGES 0 0 2,325

29 MEDICAL SOCIAL SERVICE VISITS 0 0 15

30 MEDICAL SOCIAL SERVICE VISIT CHARGES 0 0 2,580

31 HOME HEALTH AIDE VISITS 0 0 709

32 HOME HEALTH AIDE VISIT CHARGES 0 0 69,105

33 TOTAL VISITS (SUM OF LINES 21,23,25,27,29 & 31) 0 20 2,794

34 OTHER CHARGES 0 0 0

35 TOTAL CHARGES (SUM OF LNS 22,24,26,28,30,32 & 34) 0 3,540 380,979

36 TOTAL NUMBER OF EPISODES (STANDARD/NON OUTLIER) 0 0 0

37 TOTAL NUMBER OF OUTLIER EPISODES 0 0 0

38 TOTAL NON-ROUTINE MEDICAL SUPPLY CHARGES 0 296 9,055

Health Financial Systems MCRIF32 FOR SULLIVAN COUNTY COMMUNITY HOSPITAL IN LIEU OF FORM CMS-2552-96(9/1996)


RECLASSIFICATION AND ADJUSTMENT OF I 15-1327 I FROM 1/ 1/2008 I WORKSHEET A

TRIAL BALANCE OF EXPENSES I I TO 12/31/2008 I

COST COST CENTER DESCRIPTION SALARIES OTHER TOTAL RECLASS- RECLASSIFIED

CENTER IFICATIONS TRIAL BALANCE

1 2 3 4 5

GENERAL SERVICE COST CNTR

3 0300 NEW CAP REL COSTS-BLDG & FIXT 714,703 714,703 150,108 864,811

4 0400 NEW CAP REL COSTS-MVBLE EQUIP 1,341,666 1,341,666 -165,786 1,175,880

5 0500 EMPLOYEE BENEFITS 88,467 2,398,011 2,486,478 2,486,478

6.01 0610 IS/ACCOUNTING/MARKETING 348,911 248,673 597,584 -186,991 410,593

6.02 0611 BUSINESS OFFICE & ADMITTING 484,033 204,461 688,494 688,494

6.03 0660 OTHER ADMINISTRATIVE AND GENERAL 116,707 1,088,245 1,204,952 1,204,952

8 0800 OPERATION OF PLANT 325,768 573,514 899,282 899,282

9 0900 LAUNDRY & LINEN SERVICE 31,481 18,855 50,336 50,336

10 1000 HOUSEKEEPING 268,122 33,466 301,588 301,588

11 1100 DIETARY 277,474 168,120 445,594 445,594

12 1200 CAFETERIA

14 1400 NURSING ADMINISTRATION 259,415 35,881 295,296 -64,043 231,253

15 1500 CENTRAL SERVICES & SUPPLY 115,128 5,087 120,215 120,215

16 1600 PHARMACY 264,435 724,544 988,979 988,979

17 1700 MEDICAL RECORDS & LIBRARY 249,902 63,115 313,017 313,017

INPAT ROUTINE SRVC CNTRS

25 2500 ADULTS & PEDIATRICS 1,478,112 74,359 1,552,471 425,129 1,977,600

26 2600 INTENSIVE CARE UNIT 434,815 27,838 462,653 462,653

33 3300 NURSERY 85,289 85,289

ANCILLARY SRVC COST CNTRS

37 3700 OPERATING ROOM 462,005 403,234 865,239 -383,255 481,984

39 3900 DELIVERY ROOM & LABOR ROOM 430,899 33,107 464,006 -446,375 17,631

40 4000 ANESTHESIOLOGY 424,831 424,831 424,831

41 4100 RADIOLOGY-DIAGNOSTIC 456,055 333,255 789,310 789,310

41.01 4101 ULTRASOUND 216,442 216,442 216,442

43 4300 RADIOISOTOPE 146,231 146,231 146,231

44 4400 LABORATORY 467,221 550,926 1,018,147 -83,919 934,228

47 4700 BLOOD STORING, PROCESSING & TRANS. 125,104 125,104 125,104

48 4800 INTRAVENOUS THERAPY 19,377 19,377 19,377

49 4900 RESPIRATORY THERAPY 354,316 71,973 426,289 -26,918 399,371

50 5000 PHYSICAL THERAPY 400,352 11,201 411,553 411,553

50.01 5001 SPORTS THERAPY 48,636 512 49,148 49,148

51 5100 OCCUPATIONAL THERAPY 99,626 1,789 101,415 101,415

52 5200 SPEECH PATHOLOGY 49,144 1,629 50,773 50,773

53 5300 ELECTROCARDIOLOGY

54 5400 ELECTROENCEPHALOGRAPHY

54.01 5401 CARDIOPULMONARY 29,801 1,244 31,045 31,045

55 5500 MEDICAL SUPPLIES CHARGED TO PATIENTS 235,174 235,174 333,358 568,532

56 5600 DRUGS CHARGED TO PATIENTS

58 5800 ASC (NON-DISTINCT PART)

OUTPAT SERVICE COST CNTRS

61 6100 EMERGENCY 660,743 368,557 1,029,300 81,358 1,110,658

62 6200 OBSERVATION BEDS (NON-DISTINCT PART)

OTHER REIMBURS COST CNTRS

71 7100 HOME HEALTH AGENCY 417,080 54,533 471,613 471,613

SPEC PURPOSE COST CENTERS

93 9300 HOSPICE

95 SUBTOTALS 8,618,648 10,719,657 19,338,305 -282,045 19,056,260

NONREIMBURS COST CENTERS

96 9600 GIFT, FLOWER, COFFEE SHOP & CANTEEN

98 9800 PHYSICIANS' PRIVATE OFFICES 92,357 92,357

98.01 9801 CARLISLE CLINIC 55,550 135,918 191,468 15,678 207,146

98.02 9802 HOSPICE 81,084 9,468 90,552 90,552

100 7950 MEALS ON WHEELS

100.01 7951 GUEST MEALS

100.02 7952 MARKETING 174,010 174,010

101 TOTAL 8,755,282 10,865,043 19,620,325 -0- 19,620,325



RECLASSIFICATION AND ADJUSTMENT OF I 15-1327 I FROM 1/ 1/2008 I WORKSHEET A

TRIAL BALANCE OF EXPENSES I I TO 12/31/2008 I

COST COST CENTER DESCRIPTION ADJUSTMENTS NET EXPENSES

CENTER FOR ALLOC

6 7


3 0300 NEW CAP REL COSTS-BLDG & FIXT 864,811

4 0400 NEW CAP REL COSTS-MVBLE EQUIP -112,931 1,062,949

5 0500 EMPLOYEE BENEFITS -414,516 2,071,962

6.01 0610 IS/ACCOUNTING/MARKETING -5,407 405,186

6.02 0611 BUSINESS OFFICE & ADMITTING 688,494

6.03 0660 OTHER ADMINISTRATIVE AND GENERAL -155,716 1,049,236

8 0800 OPERATION OF PLANT -7,657 891,625

9 0900 LAUNDRY & LINEN SERVICE 50,336

10 1000 HOUSEKEEPING 301,588

11 1100 DIETARY -33,546 412,048

12 1200 CAFETERIA

14 1400 NURSING ADMINISTRATION -7,123 224,130

15 1500 CENTRAL SERVICES & SUPPLY -1,556 118,659

16 1600 PHARMACY -8,840 980,139

17 1700 MEDICAL RECORDS & LIBRARY -4,704 308,313


25 2500 ADULTS & PEDIATRICS 1,977,600

26 2600 INTENSIVE CARE UNIT 462,653

33 3300 NURSERY 85,289


37 3700 OPERATING ROOM -676 481,308

39 3900 DELIVERY ROOM & LABOR ROOM 17,631

40 4000 ANESTHESIOLOGY -424,360 471

41 4100 RADIOLOGY-DIAGNOSTIC 789,310

41.01 4101 ULTRASOUND 216,442

43 4300 RADIOISOTOPE 146,231

44 4400 LABORATORY 934,228

47 4700 BLOOD STORING, PROCESSING & TRANS. 125,104

48 4800 INTRAVENOUS THERAPY 19,377

49 4900 RESPIRATORY THERAPY 399,371

50 5000 PHYSICAL THERAPY 411,553

50.01 5001 SPORTS THERAPY 49,148

51 5100 OCCUPATIONAL THERAPY 101,415

52 5200 SPEECH PATHOLOGY 50,773

53 5300 ELECTROCARDIOLOGY

54 5400 ELECTROENCEPHALOGRAPHY

54.01 5401 CARDIOPULMONARY 31,045

55 5500 MEDICAL SUPPLIES CHARGED TO PATIENTS 568,532

56 5600 DRUGS CHARGED TO PATIENTS

58 5800 ASC (NON-DISTINCT PART)


61 6100 EMERGENCY 1,110,658

62 6200 OBSERVATION BEDS (NON-DISTINCT PART)


71 7100 HOME HEALTH AGENCY 471,613


93 9300 HOSPICE

95 SUBTOTALS -1,177,032 17,879,228


96 9600 GIFT, FLOWER, COFFEE SHOP & CANTEEN

98 9800 PHYSICIANS' PRIVATE OFFICES 92,357

98.01 9801 CARLISLE CLINIC 207,146

98.02 9802 HOSPICE 90,552

100 7950 MEALS ON WHEELS

100.01 7951 GUEST MEALS

100.02 7952 MARKETING 174,010

101 TOTAL -1,177,032 18,443,293



COST CENTERS USED IN COST REPORT I 15-1327 I FROM 1/ 1/2008 I NOT A CMS WORKSHEET

I I TO 12/31/2008 I

LINE NO. COST CENTER DESCRIPTION CMS CODE STANDARD LABEL FOR NON-STANDARD CODES

GENERAL SERVICE COST

3 NEW CAP REL COSTS-BLDG & FIXT 0300

4 NEW CAP REL COSTS-MVBLE EQUIP 0400

5 EMPLOYEE BENEFITS 0500

6.01 IS/ACCOUNTING/MARKETING 0610 NONPATIENT TELEPHONES

6.02 BUSINESS OFFICE & ADMITTING 0611 NONPATIENT TELEPHONES

6.03 OTHER ADMINISTRATIVE AND GENERAL 0660 OTHER ADMINISTRATIVE AND GENERAL

8 OPERATION OF PLANT 0800

9 LAUNDRY & LINEN SERVICE 0900

10 HOUSEKEEPING 1000

11 DIETARY 1100

12 CAFETERIA 1200

14 NURSING ADMINISTRATION 1400

15 CENTRAL SERVICES & SUPPLY 1500

16 PHARMACY 1600

17 MEDICAL RECORDS & LIBRARY 1700

INPAT ROUTINE SRVC C

25 ADULTS & PEDIATRICS 2500

26 INTENSIVE CARE UNIT 2600

33 NURSERY 3300

ANCILLARY SRVC COST

37 OPERATING ROOM 3700

39 DELIVERY ROOM & LABOR ROOM 3900

40 ANESTHESIOLOGY 4000

41 RADIOLOGY-DIAGNOSTIC 4100

41.01 ULTRASOUND 4101 RADIOLOGY-DIAGNOSTIC

43 RADIOISOTOPE 4300

44 LABORATORY 4400

47 BLOOD STORING, PROCESSING & TRANS. 4700

48 INTRAVENOUS THERAPY 4800

49 RESPIRATORY THERAPY 4900

50 PHYSICAL THERAPY 5000

50.01 SPORTS THERAPY 5001 PHYSICAL THERAPY

51 OCCUPATIONAL THERAPY 5100

52 SPEECH PATHOLOGY 5200

53 ELECTROCARDIOLOGY 5300

54 ELECTROENCEPHALOGRAPHY 5400

54.01 CARDIOPULMONARY 5401 ELECTROENCEPHALOGRAPHY

55 MEDICAL SUPPLIES CHARGED TO PATIENTS 5500

56 DRUGS CHARGED TO PATIENTS 5600

58 ASC (NON-DISTINCT PART) 5800

OUTPAT SERVICE COST

61 EMERGENCY 6100

62 OBSERVATION BEDS (NON-DISTINCT PART) 6200

OTHER REIMBURS COST

71 HOME HEALTH AGENCY 7100

SPEC PURPOSE COST CE

93 HOSPICE 9300

95 SUBTOTALS OLD CAP REL COSTS-BLDG & FIXT

NONREIMBURS COST CEN

96 GIFT, FLOWER, COFFEE SHOP & CANTEEN 9600

98 PHYSICIANS' PRIVATE OFFICES 9800

98.01 CARLISLE CLINIC 9801 PHYSICIANS' PRIVATE OFFICES

98.02 HOSPICE 9802 PHYSICIANS' PRIVATE OFFICES

100 MEALS ON WHEELS 7950 OTHER NONREIMBURSABLE COST CENTERS

100.01 GUEST MEALS 7951 OTHER NONREIMBURSABLE COST CENTERS

100.02 MARKETING 7952 OTHER NONREIMBURSABLE COST CENTERS

101 TOTAL OLD CAP REL COSTS-BLDG & FIXT


| PROVIDER NO: | PERIOD: | PREPARED 5/15/2009

RECLASSIFICATIONS | 151327 | FROM 1/ 1/2008 | WORKSHEET A-6

| | TO 12/31/2008 |

----------------------------------- INCREASE -----------------------------------

CODE LINE

EXPLANATION OF RECLASSIFICATION (1) COST CENTER NO SALARY OTHER

1 2 3 4 5

1 FIRE INSURNACE RECLASS B NEW CAP REL COSTS-BLDG & FIXT 3 29,351

2 ADVERTISING RECLASS C MARKETING 100.02 52,629 121,381

3 DELIVERY ROOM RECLASS D ADULTS & PEDIATRICS 25 345,789 15,297

4 NURSERY 33 76,457 8,832

5 PLANNING AND BOND INSURANCE RECLASS E NEW CAP REL COSTS-BLDG & FIXT 3 131,803

6 IV THERAPY COSTS RECLASS F EMERGENCY 61 77,564 3,794

7 OR SUPPLY COSTS RECLASS G MEDICAL SUPPLIES CHARGED TO PATIENTS 55 306,440

8

9 MOB EXPENSE RECLASS H PHYSICIANS' PRIVATE OFFICES 98 12,981

10 MOB LABORATORY EXPENSE RECLASS I PHYSICIANS' PRIVATE OFFICES 98 23,754 55,622

11 OXYGEN RECLASS J MEDICAL SUPPLIES CHARGED TO PATIENTS 55 26,918

12 DISCHARGE PLANNING RECLASS K ADULTS & PEDIATRICS 25 64,043

13 CARLISLE CLINIC DEPRECIATION RECLASS L CARLISLE CLINIC 98.01 15,678

14

36 TOTAL RECLASSIFICATIONS 640,236 728,097

________________________________________________________________________________________________________________________________

(1) A letter (A, B, etc) must be entered on each line to identify each reclassification entry.

Transfer the amounts in columns 4, 5, 8, and 9 to Worksheet A, column 4, lines as appropriate.

See instructions for column 10 referencing to Worksheet A-7, Part III, columns 9 through 14.




| | TO 12/31/2008 |

----------------------------------- DECREASE -----------------------------------

CODE LINE A-7

EXPLANATION OF RECLASSIFICATION (1) COST CENTER NO SALARY OTHER REF

1 6 7 8 9 10

1 FIRE INSURNACE RECLASS B NEW CAP REL COSTS-MVBLE EQUIP 4 29,351 12

2 ADVERTISING RECLASS C IS/ACCOUNTING/MARKETING 6.01 52,629 121,381

3 DELIVERY ROOM RECLASS D DELIVERY ROOM & LABOR ROOM 39 422,246 24,129

4

5 PLANNING AND BOND INSURANCE RECLASS E NEW CAP REL COSTS-MVBLE EQUIP 4 131,803 9

6 IV THERAPY COSTS RECLASS F OPERATING ROOM 37 77,564 3,794

7 OR SUPPLY COSTS RECLASS G OPERATING ROOM 37 301,897

8 LABORATORY 44 4,543

9 MOB EXPENSE RECLASS H IS/ACCOUNTING/MARKETING 6.01 12,981

10 MOB LABORATORY EXPENSE RECLASS I LABORATORY 44 23,754 55,622

11 OXYGEN RECLASS J RESPIRATORY THERAPY 49 26,918

12 DISCHARGE PLANNING RECLASS K NURSING ADMINISTRATION 14 64,043

13 CARLISLE CLINIC DEPRECIATION RECLASS L NEW CAP REL COSTS-BLDG & FIXT 3 11,046 9

14 NEW CAP REL COSTS-MVBLE EQUIP 4 4,632 9

36 TOTAL RECLASSIFICATIONS 640,236 728,097

________________________________________________________________________________________________________________________________

(1) A letter (A, B, etc) must be entered on each line to identify each reclassification entry.

Transfer the amounts in columns 4, 5, 8, and 9 to Worksheet A, column 4, lines as appropriate.

See instructions for column 10 referencing to Worksheet A-7, Part III, columns 9 through 14.




| | TO 12/31/2008 | NOT A CMS WORKSHEET

RECLASS CODE: B

EXPLANATION : FIRE INSURNACE RECLASS

----------------------- INCREASE --------------------- ----------------------- DECREASE ---------------------

LINE COST CENTER LINE AMOUNT COST CENTER LINE AMOUNT

1.00 NEW CAP REL COSTS-BLDG & FIXT 3 29,351 NEW CAP REL COSTS-MVBLE EQUIP 4 29,351

TOTAL RECLASSIFICATIONS FOR CODE B 29,351 29,351

RECLASS CODE: C

EXPLANATION : ADVERTISING RECLASS



1.00 MARKETING 100.02 174,010 IS/ACCOUNTING/MARKETING 6.01 174,010

TOTAL RECLASSIFICATIONS FOR CODE C 174,010 174,010

RECLASS CODE: D

EXPLANATION : DELIVERY ROOM RECLASS



1.00 ADULTS & PEDIATRICS 25 361,086 DELIVERY ROOM & LABOR ROOM 39 446,375

2.00 NURSERY 33 85,289 0

TOTAL RECLASSIFICATIONS FOR CODE D 446,375 446,375

RECLASS CODE: E

EXPLANATION : PLANNING AND BOND INSURANCE RECLASS



1.00 NEW CAP REL COSTS-BLDG & FIXT 3 131,803 NEW CAP REL COSTS-MVBLE EQUIP 4 131,803

TOTAL RECLASSIFICATIONS FOR CODE E 131,803 131,803

RECLASS CODE: F

EXPLANATION : IV THERAPY COSTS RECLASS



1.00 EMERGENCY 61 81,358 OPERATING ROOM 37 81,358

TOTAL RECLASSIFICATIONS FOR CODE F 81,358 81,358

RECLASS CODE: G

EXPLANATION : OR SUPPLY COSTS RECLASS



1.00 MEDICAL SUPPLIES CHARGED TO PA 55 306,440 OPERATING ROOM 37 301,897

2.00 0 LABORATORY 44 4,543

TOTAL RECLASSIFICATIONS FOR CODE G 306,440 306,440

RECLASS CODE: H

EXPLANATION : MOB EXPENSE RECLASS



1.00 PHYSICIANS' PRIVATE OFFICES 98 12,981 IS/ACCOUNTING/MARKETING 6.01 12,981

TOTAL RECLASSIFICATIONS FOR CODE H 12,981 12,981

RECLASS CODE: I

EXPLANATION : MOB LABORATORY EXPENSE RECLASS



1.00 PHYSICIANS' PRIVATE OFFICES 98 79,376 LABORATORY 44 79,376

TOTAL RECLASSIFICATIONS FOR CODE I 79,376 79,376

RECLASS CODE: J

EXPLANATION : OXYGEN RECLASS



1.00 MEDICAL SUPPLIES CHARGED TO PA 55 26,918 RESPIRATORY THERAPY 49 26,918

TOTAL RECLASSIFICATIONS FOR CODE J 26,918 26,918




| | TO 12/31/2008 | NOT A CMS WORKSHEET

RECLASS CODE: K

EXPLANATION : DISCHARGE PLANNING RECLASS



1.00 ADULTS & PEDIATRICS 25 64,043 NURSING ADMINISTRATION 14 64,043

TOTAL RECLASSIFICATIONS FOR CODE K 64,043 64,043

RECLASS CODE: L

EXPLANATION : CARLISLE CLINIC DEPRECIATION RECLASS



1.00 CARLISLE CLINIC 98.01 15,678 NEW CAP REL COSTS-BLDG & FIXT 3 11,046

2.00 0 NEW CAP REL COSTS-MVBLE EQUIP 4 4,632

TOTAL RECLASSIFICATIONS FOR CODE L 15,678 15,678


ANALYSIS OF CHANGES DURING COST REPORTING PERIOD IN CAPITAL I PROVIDER NO: I PERIOD: I PREPARED 5/15/2009

ASSET BALANCES OF HOSPITAL AND HOSPITAL HEALTH CARE I 15-1327 I FROM 1/ 1/2008 I WORKSHEET A-7

COMPLEX CERTIFIED TO PARTICIPATE IN HEALTH CARE PROGRAMS I I TO 12/31/2008 I PARTS I & II

PART I - ANALYSIS OF CHANGES IN OLD CAPITAL ASSET BALANCES

DESCRIPTION ACQUISITIONS DISPOSALS FULLY

BEGINNING AND ENDING DEPRECIATED

BALANCES PURCHASES DONATION TOTAL RETIREMENTS BALANCE ASSETS

1 2 3 4 5 6 7

1 LAND

2 LAND IMPROVEMENTS

3 BUILDINGS & FIXTURE

4 BUILDING IMPROVEMEN

5 FIXED EQUIPMENT

6 MOVABLE EQUIPMENT

7 SUBTOTAL

8 RECONCILING ITEMS

9 TOTAL

PART II - ANALYSIS OF CHANGES IN NEW CAPITAL ASSET BALANCES

DESCRIPTION ACQUISITIONS DISPOSALS FULLY

BEGINNING AND ENDING DEPRECIATED

BALANCES PURCHASES DONATION TOTAL RETIREMENTS BALANCE ASSETS

1 2 3 4 5 6 7

1 LAND 1,054,504 125,758 125,758 1,180,262

2 LAND IMPROVEMENTS 17,577 17,577

3 BUILDINGS & FIXTURE 16,241,062 156,770 156,770 16,397,832

4 BUILDING IMPROVEMEN

5 FIXED EQUIPMENT 741,686 47,213 47,213 788,899

6 MOVABLE EQUIPMENT 8,510,714 832,991 832,991 65,002 9,278,703

7 SUBTOTAL 26,565,543 1,162,732 1,162,732 65,002 27,663,273

8 RECONCILING ITEMS

9 TOTAL 26,565,543 1,162,732 1,162,732 65,002 27,663,273


RECONCILIATION OF CAPITAL COSTS CENTERS I PROVIDER NO: I PERIOD: I PREPARED 5/15/2009

I 15-1327 I FROM 1/ 1/2008 I WORKSHEET A-7

I I TO 12/31/2008 I PARTS III & IV

PART III - RECONCILIATION OF CAPITAL COST CENTERS

DESCRIPTION COMPUTATION OF RATIOS ALLOCATION OF OTHER CAPITAL

GROSS CAPITLIZED GROSS ASSETS OTHER CAPITAL

ASSETS LEASES FOR RATIO RATIO INSURANCE TAXES RELATED COSTS TOTAL

* 1 2 3 4 5 6 7 8

3 NEW CAP REL COSTS-BL 18,384,570 18,384,570 .664584

4 NEW CAP REL COSTS-MV 9,278,703 9,278,703 .335416

5 TOTAL 27,663,273 27,663,273 1.000000

DESCRIPTION SUMMARY OF OLD AND NEW CAPITAL

OTHER CAPITAL

DEPRECIATION LEASE INTEREST INSURANCE TAXES RELATED COST TOTAL (1)

* 9 10 11 12 13 14 15

3 NEW CAP REL COSTS-BL 835,460 29,351 864,811

4 NEW CAP REL COSTS-MV 1,143,631 -51,331 -29,351 1,062,949

5 TOTAL 1,979,091 -51,331 1,927,760

PART IV - RECONCILIATION OF AMOUNTS FROM WORKSHEET A, COLUMN 2, LINES 1 THRU 4

DESCRIPTION SUMMARY OF OLD AND NEW CAPITAL

OTHER CAPITAL

DEPRECIATION LEASE INTEREST INSURANCE TAXES RELATED COST TOTAL (1)

* 9 10 11 12 13 14 15

3 NEW CAP REL COSTS-BL 714,703 714,703

4 NEW CAP REL COSTS-MV 1,341,666 1,341,666

5 TOTAL 2,056,369 2,056,369

____________________________________________________________________________________________________________________________________

* All lines numbers except line 5 are to be consistent with Workhseet A line numbers for capital cost centers.

(1) The amounts on lines 1 thru 4 must equal the corresponding amounts on Worksheet A, column 7, lines 1 thru 4.

Columns 9 through 14 should include related Worksheet A-6 reclassifications and Worksheet A-8 adjustments. (See instructions).



ADJUSTMENTS TO EXPENSES I 15-1327 I FROM 1/ 1/2008 I WORKSHEET A-8

I I TO 12/31/2008 I

EXPENSE CLASSIFICATION ON

DESCRIPTION (1) WORKSHEET A TO/FROM WHICH THE WKST.

(2) AMOUNT IS TO BE ADJUSTED A-7

BASIS/CODE AMOUNT COST CENTER LINE NO REF.

1 2 3 4 5

1 INVST INCOME-OLD BLDGS AND FIXTURES **COST CENTER DELETED** 1

2 INVESTMENT INCOME-OLD MOVABLE EQUIP **COST CENTER DELETED** 2

3 INVST INCOME-NEW BLDGS AND FIXTURES NEW CAP REL COSTS-BLDG & 3

4 INVESTMENT INCOME-NEW MOVABLE EQUIP B -51,003 NEW CAP REL COSTS-MVBLE E 4 11

5 INVESTMENT INCOME-OTHER

6 TRADE, QUANTITY AND TIME DISCOUNTS

7 REFUNDS AND REBATES OF EXPENSES

8 RENTAL OF PRVIDER SPACE BY SUPPLIERS

9 TELEPHONE SERVICES A -1,673 OTHER ADMINISTRATIVE AND 6.03

10 TELEVISION AND RADIO SERVICE A -4,021 OPERATION OF PLANT 8

11 PARKING LOT

12 PROVIDER BASED PHYSICIAN ADJUSTMENT A-8-2 -424,360

13 SALE OF SCRAP, WASTE, ETC.

14 RELATED ORGANIZATION TRANSACTIONS A-8-1

15 LAUNDRY AND LINEN SERVICE

16 CAFETERIA--EMPLOYEES AND GUESTS B -33,546 DIETARY 11

17 RENTAL OF QTRS TO EMPLYEE AND OTHRS

18 SALE OF MED AND SURG SUPPLIES B -271 CENTRAL SERVICES & SUPPLY 15

19 SALE OF DRUGS TO OTHER THAN PATIENTS B -8,840 PHARMACY 16

20 SALE OF MEDICAL RECORDS & ABSTRACTS B -4,704 MEDICAL RECORDS & LIBRARY 17

21 NURSG SCHOOL(TUITN,FEES,BOOKS, ETC.)

22 VENDING MACHINES B -1,884 OTHER ADMINISTRATIVE AND 6.03

23 INCOME FROM IMPOSITION OF INTEREST

24 INTRST EXP ON MEDICARE OVERPAYMENTS

25 ADJUSTMENT FOR RESPIRATORY THERAPY A-8-3/A-8-4 RESPIRATORY THERAPY 49

26 ADJUSTMENT FOR PHYSICAL THERAPY A-8-3/A-8-4 PHYSICAL THERAPY 50

27 ADJUSTMENT FOR HHA PHYSICAL THERAPY A-8-3

28 UTILIZATION REVIEW-PHYSIAN COMP **COST CENTER DELETED** 89

29 DEPRECIATION-OLD BLDGS AND FIXTURES **COST CENTER DELETED** 1

30 DEPRECIATION-OLD MOVABLE EQUIP **COST CENTER DELETED** 2

31 DEPRECIATION-NEW BLDGS AND FIXTURES NEW CAP REL COSTS-BLDG & 3

32 DEPRECIATION-NEW MOVABLE EQUIP NEW CAP REL COSTS-MVBLE E 4

33 NON-PHYSICIAN ANESTHETIST **COST CENTER DELETED** 20

34 PHYSICIANS' ASSISTANT

35 ADJUSTMENT FOR OCCUPATIONAL THERAPY A-8-4 OCCUPATIONAL THERAPY 51

36 ADJUSTMENT FOR SPEECH PATHOLOGY A-8-4 SPEECH PATHOLOGY 52

37 TELEPHONE DEPRECIATION A -1,922 NEW CAP REL COSTS-MVBLE E 4 9

38 PHYSICIAN RECRUITMENT A -136,677 OTHER ADMINISTRATIVE AND 6.03

39 FLOWERS AND PLANTS A -1,567 OTHER ADMINISTRATIVE AND 6.03

40 SALES TAX A -7,467 OTHER ADMINISTRATIVE AND 6.03

41 NON-ALLOWABLE 1998 BOND INTEREST EXP A -59,678 NEW CAP REL COSTS-MVBLE E 4 9

42 LOBBYING EXPENSES A -1,125 OTHER ADMINISTRATIVE AND 6.03

43 FITNESS CENTER - ADMIN A -2,995 OTHER ADMINISTRATIVE AND 6.03

44 DOMESTIC HEALTHCARE CLAIMS B -413,529 EMPLOYEE BENEFITS 5

45 FITNESS CENTER - FISCAL ACTNG, I/S A -3,307 IS/ACCOUNTING/MARKETING 6.01

46 FITNESS CENTER - HR A -987 EMPLOYEE BENEFITS 5

47 FITNESS CENTER - MAINT A -3,636 OPERATION OF PLANT 8

48 FITNESS CENTER - MATERIALS MGMT A -1,285 CENTRAL SERVICES & SUPPLY 15

49 FITNESS CENTER - PROP INSURANCE A -328 NEW CAP REL COSTS-MVBLE E 4 11

49.02 ATM RENTAL AND COMMISSION B -1,576 OTHER ADMINISTRATIVE AND 6.03

49.03 MISCELLANEOUS INCOME B -619 OTHER ADMINISTRATIVE AND 6.03

49.04 EDUCATION REVENUE B -7,123 NURSING ADMINISTRATION 14

49.05 SURETY BONDS B -2,100 IS/ACCOUNTING/MARKETING 6.01

49.06 SILVER RECOVERY B -676 OPERATING ROOM 37

49.07 OTHER AGENCIES RECOVERY B -133 OTHER ADMINISTRATIVE AND 6.03

50 TOTAL (SUM OF LINES 1 THRU 49) -1,177,032

____________________________________________________________________________________________________________________________________

(1) Description - all chapter references in this columnpertain to CMS Pub. 15-I.

(2) Basis for adjustment (see instructions).

A. Costs - if cost, including applicable overhead, can be determined.

B. Amount Received - if cost cannot be determined.

(3) Additional adjustments may be made on lines 37 thru 49 and subscripts thereof.

Note: See instructions for column 5 referencing to Worksheet A-7



PROVIDER BASED PHYSICIAN ADJUSTMENTS I 15-1327 I FROM 1/ 1/2008 I WORKSHEET A-8-2

I I TO 12/31/2008 I GROUP 1

PHYSICIAN/

COST CENTER/ TOTAL PROFES- PROVIDER 5 PERCENT OF

WKSHT A PHYSICIAN REMUN- SIONAL PROVIDER RCE COMPONENT UNADJUSTED UNADJUSTED

LINE NO. IDENTIFIER ERATION COMPONENT COMPONENT AMOUNT HOURS RCE LIMIT RCE LIMIT

1 2 3 4 5 6 7 8 9

1 40 ANESTHESIOLOGY 424,360 424,360

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

101 TOTAL 424,360 424,360



PROVIDER BASED PHYSICIAN ADJUSTMENTS I 15-1327 I FROM 1/ 1/2008 I WORKSHEET A-8-2

I I TO 12/31/2008 I GROUP 1

COST OF PROVIDER PHYSICIAN PROVIDER

COST CENTER/ MEMBERSHIPS COMPONENT COST OF COMPONENT ADJUSTED RCE

WKSHT A PHYSICIAN & CONTINUING SHARE OF MALPRACTICE SHARE OF RCE DIS-

LINE NO. IDENTIFIER EDUCATION COL 12 INSURANCE COL 14 LIMIT ALLOWANCE ADJUSTMENT

10 11 12 13 14 15 16 17 18

1 40 ANESTHESIOLOGY 424,360

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

101 TOTAL 424,360



COST ALLOCATION STATISTICS I 15-1327 I FROM 1/ 1/2008 I NOT A CMS WORKSHEET

I I TO 12/31/2008 I

LINE NO. COST CENTER DESCRIPTION STATISTICS CODE STATISTICS DESCRIPTION


3 NEW CAP REL COSTS-BLDG & FIXT 3 SQUARE FEET ENTERED

4 NEW CAP REL COSTS-MVBLE EQUIP 3 SQUARE FEET ENTERED

5 EMPLOYEE BENEFITS S GROSS SALARIES ENTERED

6.01 IS/ACCOUNTING/MARKETING 6 ACCUM. COST ENTERED

6.02 BUSINESS OFFICE & ADMITTING 60 ACCUM. COST ENTERED

6.03 OTHER ADMINISTRATIVE AND GENERAL # ACCUM. COST NOT ENTERED

8 OPERATION OF PLANT 7 SQUARE FEET ENTERED

9 LAUNDRY & LINEN SERVICE 8 POUNDS OF LAUNDRY ENTERED

10 HOUSEKEEPING 7 SQUARE FEET ENTERED

11 DIETARY 11 MEALS SERVED ENTERED

12 CAFETERIA 12 FTE'S ENTERED

14 NURSING ADMINISTRATION 13 DIRECT NRSING HRS ENTERED

15 CENTRAL SERVICES & SUPPLY 14 COSTED REQUIS. ENTERED

16 PHARMACY 15 COSTED REQUIS. ENTERED

17 MEDICAL RECORDS & LIBRARY C GROSS CHARGES ENTERED



COST ALLOCATION - GENERAL SERVICE COSTS I 15-1327 I FROM 1/ 1/2008 I WORKSHEET B

I I TO 12/31/2008 I PART I

NET EXPENSES NEW CAP REL C NEW CAP REL C EMPLOYEE BENE IS/ACCOUNTING BUSINESS OFFI SUBTOTAL

COST CENTER FOR COST OSTS-BLDG & OSTS-MVBLE E FITS /MARKETING CE & ADMITTI

DESCRIPTION ALLOCATION

0 3 4 5 6.01 6.02 6a.02


003 NEW CAP REL COSTS-BLDG & 864,811 864,811

004 NEW CAP REL COSTS-MVBLE E 1,062,949 1,062,949

005 EMPLOYEE BENEFITS 2,071,962 4,778 5,872 2,082,612

006 01 IS/ACCOUNTING/MARKETING 405,186 12,050 14,810 71,196 503,242

006 02 BUSINESS OFFICE & ADMITTI 688,494 17,671 21,719 116,312 23,745 867,941

006 03 OTHER ADMINISTRATIVE AND 1,049,236 28,974 35,612 28,044 32,058 58,029 1,231,953

008 OPERATION OF PLANT 891,625 93,148 114,489 78,281 33,045 59,816 1,270,404

009 LAUNDRY & LINEN SERVICE 50,336 4,857 5,970 7,565 1,930 3,494 74,152

010 HOUSEKEEPING 301,588 11,338 13,936 64,429 11,009 19,928 422,228

011 DIETARY 412,048 23,739 29,178 66,676 14,487 26,223 572,351

012 CAFETERIA 8,062 9,910 500 905 19,377

014 NURSING ADMINISTRATION 224,130 4,953 6,088 46,947 8,379 15,166 305,663

015 CENTRAL SERVICES & SUPPLY 118,659 20,674 25,411 27,665 5,411 9,794 207,614

016 PHARMACY 980,139 12,568 15,447 63,543 30,112 54,507 1,156,316

017 MEDICAL RECORDS & LIBRARY 308,313 26,172 32,168 60,051 11,993 21,709 460,406


025 ADULTS & PEDIATRICS 1,977,600 136,550 167,837 453,670 76,502 138,472 2,950,631

026 INTENSIVE CARE UNIT 462,653 36,509 44,874 104,485 18,235 33,008 699,764

033 NURSERY 85,289 2,925 3,595 18,372 3,100 5,612 118,893


037 OPERATING ROOM 481,308 118,530 145,686 92,380 25,393 45,965 909,262

039 DELIVERY ROOM & LABOR ROO 17,631 4,101 5,041 2,079 809 1,464 31,125

040 ANESTHESIOLOGY 471 13 24 508

041 RADIOLOGY-DIAGNOSTIC 789,310 49,657 61,034 109,589 28,368 51,350 1,089,308

041 01 ULTRASOUND 216,442 2,986 3,670 6,262 11,336 240,696

043 RADIOISOTOPE 146,231 3,689 4,534 4,335 7,846 166,635

044 LABORATORY 934,228 26,611 32,708 106,564 30,922 55,972 1,187,005

047 BLOOD STORING, PROCESSING 125,104 1,669 2,051 3,616 6,546 138,986

048 INTRAVENOUS THERAPY 19,377 2,960 3,638 728 1,317 28,020

049 RESPIRATORY THERAPY 399,371 22,703 27,904 85,141 15,050 27,243 577,412

050 PHYSICAL THERAPY 411,553 31,538 38,764 96,203 16,253 29,419 623,730

050 01 SPORTS THERAPY 49,148 5,612 6,898 11,687 73,345

051 OCCUPATIONAL THERAPY 101,415 4,242 5,214 23,940 3,793 6,866 145,470

052 SPEECH PATHOLOGY 50,773 1,625 1,997 11,809 3,929 7,111 77,244

053 ELECTROCARDIOLOGY

054 ELECTROENCEPHALOGRAPHY 1,941 2,386 120 218 4,665

054 01 CARDIOPULMONARY 31,045 10,118 12,436 7,161 1,703 3,083 65,546

055 MEDICAL SUPPLIES CHARGED 568,532 15,956 28,882 613,370

056 DRUGS CHARGED TO PATIENTS

058 ASC (NON-DISTINCT PART)


061 EMERGENCY 1,110,658 51,615 63,441 177,413 37,555 67,979 1,508,661

062 OBSERVATION BEDS (NON-DIS


071 HOME HEALTH AGENCY 471,613 10,811 13,288 100,223 16,772 30,358 643,065


093 HOSPICE

095 SUBTOTALS 17,879,228 795,376 977,606 2,031,425 482,083 829,642 17,613,805


096 GIFT, FLOWER, COFFEE SHOP 4,628 5,689 287 520 11,124

098 PHYSICIANS' PRIVATE OFFIC 92,357 62,330 76,610 5,708 6,622 11,986 255,613

098 01 CARLISLE CLINIC 207,146 13,348 6,307 11,416 238,217

098 02 HOSPICE 90,552 19,484 2,543 4,602 117,181

100 MEALS ON WHEELS

100 01 GUEST MEALS

100 02 MARKETING 174,010 2,477 3,044 12,647 5,400 9,775 207,353

101 CROSS FOOT ADJUSTMENT

102 NEGATIVE COST CENTER

103 TOTAL 18,443,293 864,811 1,062,949 2,082,612 503,242 867,941 18,443,293

Health Financial Systems MCRIF32 FOR SULLIVAN COUNTY COMMUNITY HOSPITAL IN LIEU OF FORM CMS-2552-96(9/1997)CONTD



I I TO 12/31/2008 I PART I

OTHER ADMINIS OPERATION OF LAUNDRY & LIN HOUSEKEEPING DIETARY CAFETERIA NURSING ADMIN

COST CENTER TRATIVE AND PLANT EN SERVICE ISTRATION

DESCRIPTION

6.03 8 9 10 11 12 14


003 NEW CAP REL COSTS-BLDG &

004 NEW CAP REL COSTS-MVBLE E

005 EMPLOYEE BENEFITS

006 01 IS/ACCOUNTING/MARKETING

006 02 BUSINESS OFFICE & ADMITTI

006 03 OTHER ADMINISTRATIVE AND 1,231,953

008 OPERATION OF PLANT 90,933 1,361,337

009 LAUNDRY & LINEN SERVICE 5,308 9,142 88,602

010 HOUSEKEEPING 30,222 21,343 473,793

011 DIETARY 40,968 44,686 477 15,909 674,391

012 CAFETERIA 1,387 15,176 178 5,403 228,963 270,484

014 NURSING ADMINISTRATION 21,879 9,324 3,319 7,167 347,352

015 CENTRAL SERVICES & SUPPLY 14,861 38,917 13,855 5,566

016 PHARMACY 82,767 23,657 8,422 9,289

017 MEDICAL RECORDS & LIBRARY 32,955 49,266 17,539 14,650


025 ADULTS & PEDIATRICS 211,200 257,045 37,193 91,509 126,404 79,918 176,683

026 INTENSIVE CARE UNIT 50,088 68,724 2,377 24,466 13,023 14,185 31,395

033 NURSERY 8,510 5,505 1,756 1,960 2,699 6,029


037 OPERATING ROOM 65,083 223,117 12,060 79,431 5,175 15,358 34,382

039 DELIVERY ROOM & LABOR ROO 2,228 7,720 1,704 2,749 298 682


041 RADIOLOGY-DIAGNOSTIC 77,970 93,473 5,523 33,277 17,666

041 01 ULTRASOUND 17,229 5,621 2,001 1,824

043 RADIOISOTOPE 11,927 6,943 2,472 1,526

044 LABORATORY 84,963 50,092 263 17,833 22,320

047 BLOOD STORING, PROCESSING 9,948 3,141 1,118

048 INTRAVENOUS THERAPY 2,006 5,571 1,983

049 RESPIRATORY THERAPY 41,330 42,736 410 15,214 12,696

050 PHYSICAL THERAPY 44,645 59,367 9,715 21,135 10,443

050 01 SPORTS THERAPY 5,250 10,564 3,761 3,723

051 OCCUPATIONAL THERAPY 10,412 7,985 2,843 3,090

052 SPEECH PATHOLOGY 5,529 3,058 1,089 1,694


054 ELECTROENCEPHALOGRAPHY 334 3,654 1,301

054 01 CARDIOPULMONARY 4,692 19,045 6,780

055 MEDICAL SUPPLIES CHARGED 43,904




061 EMERGENCY 107,987 97,159 16,946 34,589 24,424 54,713



071 HOME HEALTH AGENCY 46,029 20,351 7,245 16,754 37,535


093 HOSPICE

095 SUBTOTALS 1,172,580 1,202,382 88,602 417,203 373,565 265,290 341,419


096 GIFT, FLOWER, COFFEE SHOP 796 8,712 3,102

098 PHYSICIANS' PRIVATE OFFIC 18,296 117,328 41,770 1,862

098 01 CARLISLE CLINIC 17,051 28,253 10,058

098 02 HOSPICE 8,388 2,643 5,933

100 MEALS ON WHEELS 228,910

100 01 GUEST MEALS 71,916

100 02 MARKETING 14,842 4,662 1,660 689



103 TOTAL 1,231,953 1,361,337 88,602 473,793 674,391 270,484 347,352




I I TO 12/31/2008 I PART I

CENTRAL SERVI PHARMACY MEDICAL RECOR SUBTOTAL I&R COST TOTAL

COST CENTER CES & SUPPLY DS & LIBRARY POST STEP-

DESCRIPTION DOWN ADJ

15 16 17 25 26 27







006 03 OTHER ADMINISTRATIVE AND

008 OPERATION OF PLANT

009 LAUNDRY & LINEN SERVICE

010 HOUSEKEEPING

011 DIETARY

012 CAFETERIA

014 NURSING ADMINISTRATION

015 CENTRAL SERVICES & SUPPLY 280,813

016 PHARMACY 3,341 1,283,792

017 MEDICAL RECORDS & LIBRARY 14 574,830


025 ADULTS & PEDIATRICS 14,262 66,540 4,011,385 4,011,385

026 INTENSIVE CARE UNIT 1,717 8,464 914,203 914,203

033 NURSERY 673 1,912 147,937 147,937


037 OPERATING ROOM 21,654 39,411 1,404,933 1,404,933

039 DELIVERY ROOM & LABOR ROO 653 1,855 49,014 49,014

040 ANESTHESIOLOGY 4,112 4,656 4,656

041 RADIOLOGY-DIAGNOSTIC 8,979 106,179 1,432,375 1,432,375

041 01 ULTRASOUND 22,505 289,876 289,876

043 RADIOISOTOPE 6,083 195,586 195,586

044 LABORATORY 15,184 88,448 1,466,108 1,466,108



049 RESPIRATORY THERAPY 11,656 21,691 723,145 723,145

050 PHYSICAL THERAPY 946 17,232 787,213 787,213

050 01 SPORTS THERAPY 81 3,066 99,790 99,790

051 OCCUPATIONAL THERAPY 54 1,783 171,637 171,637

052 SPEECH PATHOLOGY 112 890 89,616 89,616





056 DRUGS CHARGED TO PATIENTS 1,283,792 33,136 1,316,928 1,316,928



061 EMERGENCY 6,900 83,695 1,935,074 1,935,074



071 HOME HEALTH AGENCY 937 771,916 771,916


093 HOSPICE

095 SUBTOTALS 278,217 1,283,792 574,830 17,024,338 17,024,338


096 GIFT, FLOWER, COFFEE SHOP 23,734 23,734

098 PHYSICIANS' PRIVATE OFFIC 2,596 437,465 437,465

098 01 CARLISLE CLINIC 293,579 293,579

098 02 HOSPICE 134,145 134,145

100 MEALS ON WHEELS 228,910 228,910

100 01 GUEST MEALS 71,916 71,916

100 02 MARKETING 229,206 229,206



103 TOTAL 280,813 1,283,792 574,830 18,443,293 18,443,293



ALLOCATION OF NEW CAPITAL RELATED COSTS I 15-1327 I FROM 1/ 1/2008 I WORKSHEET B

I I TO 12/31/2008 I PART III

DIR ASSGNED NEW CAP REL C NEW CAP REL C EMPLOYEE BENE IS/ACCOUNTING BUSINESS OFFI

COST CENTER NEW CAPITAL OSTS-BLDG & OSTS-MVBLE E SUBTOTAL FITS /MARKETING CE & ADMITTI

DESCRIPTION REL COSTS

0 3 4 4a 5 6.01 6.02




005 EMPLOYEE BENEFITS 4,778 5,872 10,650 10,650

006 01 IS/ACCOUNTING/MARKETING 12,050 14,810 26,860 364 27,224

006 02 BUSINESS OFFICE & ADMITTI 17,671 21,719 39,390 595 1,285 41,270

006 03 OTHER ADMINISTRATIVE AND 28,974 35,612 64,586 143 1,734 2,760

008 OPERATION OF PLANT 93,148 114,489 207,637 400 1,788 2,845

009 LAUNDRY & LINEN SERVICE 4,857 5,970 10,827 39 104 166

010 HOUSEKEEPING 11,338 13,936 25,274 330 596 948

011 DIETARY 23,739 29,178 52,917 341 784 1,247

012 CAFETERIA 8,062 9,910 17,972 27 43

014 NURSING ADMINISTRATION 4,953 6,088 11,041 240 453 721

015 CENTRAL SERVICES & SUPPLY 20,674 25,411 46,085 141 293 466

016 PHARMACY 12,568 15,447 28,015 325 1,629 2,592

017 MEDICAL RECORDS & LIBRARY 26,172 32,168 58,340 307 649 1,032


025 ADULTS & PEDIATRICS 136,550 167,837 304,387 2,321 4,134 6,576

026 INTENSIVE CARE UNIT 36,509 44,874 81,383 534 987 1,570

033 NURSERY 2,925 3,595 6,520 94 168 267


037 OPERATING ROOM 118,530 145,686 264,216 472 1,374 2,186

039 DELIVERY ROOM & LABOR ROO 4,101 5,041 9,142 11 44 70

040 ANESTHESIOLOGY 1 1

041 RADIOLOGY-DIAGNOSTIC 49,657 61,034 110,691 560 1,535 2,442

041 01 ULTRASOUND 2,986 3,670 6,656 339 539

043 RADIOISOTOPE 3,689 4,534 8,223 235 373

044 LABORATORY 26,611 32,708 59,319 545 1,673 2,662

047 BLOOD STORING, PROCESSING 1,669 2,051 3,720 196 311

048 INTRAVENOUS THERAPY 2,960 3,638 6,598 39 63

049 RESPIRATORY THERAPY 22,703 27,904 50,607 435 814 1,296

050 PHYSICAL THERAPY 31,538 38,764 70,302 492 879 1,399

050 01 SPORTS THERAPY 5,612 6,898 12,510 60

051 OCCUPATIONAL THERAPY 4,242 5,214 9,456 122 205 327

052 SPEECH PATHOLOGY 1,625 1,997 3,622 60 213 338


054 ELECTROENCEPHALOGRAPHY 1,941 2,386 4,327 7 10

054 01 CARDIOPULMONARY 10,118 12,436 22,554 37 92 147

055 MEDICAL SUPPLIES CHARGED 863 1,374




061 EMERGENCY 51,615 63,441 115,056 907 2,032 3,233



071 HOME HEALTH AGENCY 10,811 13,288 24,099 513 907 1,444


093 HOSPICE

095 SUBTOTALS 795,376 977,606 1,772,982 10,388 26,079 39,448


096 GIFT, FLOWER, COFFEE SHOP 4,628 5,689 10,317 16 25

098 PHYSICIANS' PRIVATE OFFIC 62,330 76,610 138,940 29 358 570

098 01 CARLISLE CLINIC 68 341 543

098 02 HOSPICE 100 138 219

100 MEALS ON WHEELS

100 01 GUEST MEALS

100 02 MARKETING 2,477 3,044 5,521 65 292 465

101 CROSS FOOT ADJUSTMENTS


103 TOTAL 864,811 1,062,949 1,927,760 10,650 27,224 41,270





OTHER ADMINIS OPERATION OF LAUNDRY & LIN HOUSEKEEPING DIETARY CAFETERIA NURSING ADMIN

COST CENTER TRATIVE AND PLANT EN SERVICE ISTRATION

DESCRIPTION

6.03 8 9 10 11 12 14







006 03 OTHER ADMINISTRATIVE AND 69,223

008 OPERATION OF PLANT 5,110 217,780

009 LAUNDRY & LINEN SERVICE 298 1,463 12,897

010 HOUSEKEEPING 1,698 3,414 32,260

011 DIETARY 2,302 7,149 69 1,083 65,892

012 CAFETERIA 78 2,428 26 368 22,371 43,313

014 NURSING ADMINISTRATION 1,229 1,492 226 1,148 16,550

015 CENTRAL SERVICES & SUPPLY 835 6,226 943 891

016 PHARMACY 4,651 3,785 573 1,487

017 MEDICAL RECORDS & LIBRARY 1,852 7,881 1,194 2,346


025 ADULTS & PEDIATRICS 11,867 41,119 5,414 6,233 12,350 12,800 8,419

026 INTENSIVE CARE UNIT 2,814 10,994 346 1,666 1,272 2,271 1,496

033 NURSERY 478 881 256 133 432 287


037 OPERATING ROOM 3,657 35,693 1,755 5,408 506 2,459 1,638

039 DELIVERY ROOM & LABOR ROO 125 1,235 248 187 48 32


041 RADIOLOGY-DIAGNOSTIC 4,381 14,953 804 2,266 2,829

041 01 ULTRASOUND 968 899 136 292

043 RADIOISOTOPE 670 1,111 168 244

044 LABORATORY 4,774 8,014 38 1,214 3,574

047 BLOOD STORING, PROCESSING 559 502 76

048 INTRAVENOUS THERAPY 113 891 135

049 RESPIRATORY THERAPY 2,322 6,837 60 1,036 2,033


050 01 SPORTS THERAPY 295 1,690 256 596

051 OCCUPATIONAL THERAPY 585 1,277 194 495

052 SPEECH PATHOLOGY 311 489 74 271


054 ELECTROENCEPHALOGRAPHY 19 584 89

054 01 CARDIOPULMONARY 264 3,047 462

055 MEDICAL SUPPLIES CHARGED 2,467




061 EMERGENCY 6,068 15,543 2,467 2,355 3,911 2,607



071 HOME HEALTH AGENCY 2,586 3,256 493 2,683 1,788


093 HOSPICE

095 SUBTOTALS 65,887 192,350 12,897 28,407 36,499 42,482 16,267


096 GIFT, FLOWER, COFFEE SHOP 45 1,394 211

098 PHYSICIANS' PRIVATE OFFIC 1,028 18,770 2,844 298

098 01 CARLISLE CLINIC 958 4,520 685

098 02 HOSPICE 471 423 283



100 02 MARKETING 834 746 113 110



103 TOTAL 69,223 217,780 12,897 32,260 65,892 43,313 16,550





CENTRAL SERVI PHARMACY MEDICAL RECOR SUBTOTAL POST TOTAL

COST CENTER CES & SUPPLY DS & LIBRARY STEPDOWN

DESCRIPTION ADJUSTMENT

15 16 17 25 26 27







006 03 OTHER ADMINISTRATIVE AND


009 LAUNDRY & LINEN SERVICE

010 HOUSEKEEPING

011 DIETARY

012 CAFETERIA

014 NURSING ADMINISTRATION

015 CENTRAL SERVICES & SUPPLY 55,880

016 PHARMACY 665 43,722

017 MEDICAL RECORDS & LIBRARY 3 73,604


025 ADULTS & PEDIATRICS 2,838 8,520 426,978 426,978

026 INTENSIVE CARE UNIT 342 1,084 106,759 106,759

033 NURSERY 134 245 9,895 9,895


037 OPERATING ROOM 4,309 5,046 328,719 328,719

039 DELIVERY ROOM & LABOR ROO 130 238 11,510 11,510

040 ANESTHESIOLOGY 526 530 530

041 RADIOLOGY-DIAGNOSTIC 1,787 13,598 155,846 155,846

041 01 ULTRASOUND 2,882 12,711 12,711

043 RADIOISOTOPE 779 11,803 11,803

044 LABORATORY 3,022 11,325 96,160 96,160

047 BLOOD STORING, PROCESSING 678 6,042 6,042

048 INTRAVENOUS THERAPY 959 8,798 8,798



050 01 SPORTS THERAPY 16 393 15,816 15,816

051 OCCUPATIONAL THERAPY 11 228 12,900 12,900

052 SPEECH PATHOLOGY 22 114 5,514 5,514



054 01 CARDIOPULMONARY 273 26,876 26,876


056 DRUGS CHARGED TO PATIENTS 43,722 4,243 47,965 47,965



061 EMERGENCY 1,373 10,716 166,268 166,268



071 HOME HEALTH AGENCY 187 37,956 37,956


093 HOSPICE

095 SUBTOTALS 55,363 43,722 73,604 1,706,110 1,706,110


096 GIFT, FLOWER, COFFEE SHOP 12,008 12,008

098 PHYSICIANS' PRIVATE OFFIC 517 163,354 163,354

098 01 CARLISLE CLINIC 7,115 7,115

098 02 HOSPICE 1,634 1,634

100 MEALS ON WHEELS 22,366 22,366

100 01 GUEST MEALS 7,027 7,027

100 02 MARKETING 8,146 8,146



103 TOTAL 55,880 43,722 73,604 1,927,760 1,927,760



COST ALLOCATION - STATISTICAL BASIS I 15-1327 I FROM 1/ 1/2008 I WORKSHEET B-1

I I TO 12/31/2008 I

COST CENTER NEW CAP REL C NEW CAP REL C EMPLOYEE BENE IS/ACCOUNTING BUSINESS OFFI

DESCRIPTION OSTS-BLDG & OSTS-MVBLE E FITS /MARKETING CE & ADMITTI

(SQUARE (SQUARE ( GROSS (ACCUM. COS(ACCUM. COS RECONCIL-

FEET ) FEET ) SALARIES )T )T ) IATION

3 4 5 6.01 6.02 6a.03


003 NEW CAP REL COSTS-BLD 98,469

004 NEW CAP REL COSTS-MVB 98,469

005 EMPLOYEE BENEFITS 544 544 8,666,815

006 01 IS/ACCOUNTING/MARKETI 1,372 1,372 296,282 17,922,908

006 02 BUSINESS OFFICE & ADM 2,012 2,012 484,033 845,696 17,557,559

006 03 OTHER ADMINISTRATIVE 3,299 3,299 116,707 1,141,749 1,173,864 -1,231,953

008 OPERATION OF PLANT 10,606 10,606 325,768 1,176,910 1,210,014

009 LAUNDRY & LINEN SERVI 553 553 31,481 68,750 70,684

010 HOUSEKEEPING 1,291 1,291 268,122 392,091 403,120

011 DIETARY 2,703 2,703 277,474 515,955 530,468

012 CAFETERIA 918 918 17,809 18,310

014 NURSING ADMINISTRATIO 564 564 195,372 298,403 306,796

015 CENTRAL SERVICES & SU 2,354 2,354 115,128 192,704 198,124

016 PHARMACY 1,431 1,431 264,435 1,072,458 1,102,624

017 MEDICAL RECORDS & LIB 2,980 2,980 249,902 427,134 439,148

INPAT ROUTINE SRVC CN

025 ADULTS & PEDIATRICS 15,548 15,548 1,887,944 2,724,506 2,801,139

026 INTENSIVE CARE UNIT 4,157 4,157 434,815 649,452 667,720

033 NURSERY 333 333 76,457 110,415 113,521

ANCILLARY SRVC COST C

037 OPERATING ROOM 13,496 13,496 384,441 904,378 929,816

039 DELIVERY ROOM & LABOR 467 467 8,653 28,803 29,613

040 ANESTHESIOLOGY 471 484

041 RADIOLOGY-DIAGNOSTIC 5,654 5,654 456,055 1,010,336 1,038,755

041 01 ULTRASOUND 340 340 223,038 229,312

043 RADIOISOTOPE 420 420 154,379 158,721

044 LABORATORY 3,030 3,030 443,467 1,101,275 1,132,252

047 BLOOD STORING, PROCES 190 190 128,790 132,413

048 INTRAVENOUS THERAPY 337 337 25,914 26,643

049 RESPIRATORY THERAPY 2,585 2,585 354,316 536,021 551,098


050 01 SPORTS THERAPY 639 639 48,636

051 OCCUPATIONAL THERAPY 483 483 99,626 135,088 138,888

052 SPEECH PATHOLOGY 185 185 49,144 139,914 143,850


054 ELECTROENCEPHALOGRAPH 221 221 4,287 4,408

054 01 CARDIOPULMONARY 1,152 1,152 29,801 60,669 62,375

055 MEDICAL SUPPLIES CHAR 568,261 584,245

056 DRUGS CHARGED TO PATI

058 ASC (NON-DISTINCT PAR

OUTPAT SERVICE COST C

061 EMERGENCY 5,877 5,877 738,307 1,337,525 1,375,147

062 OBSERVATION BEDS (NON

OTHER REIMBURS COST C

071 HOME HEALTH AGENCY 1,231 1,231 417,080 597,319 614,120

SPEC PURPOSE COST CEN

093 HOSPICE

095 SUBTOTALS 90,563 90,563 8,453,798 17,169,342 16,782,796 -1,231,953

NONREIMBURS COST CENT

096 GIFT, FLOWER, COFFEE 527 527 10,224 10,512

098 PHYSICIANS' PRIVATE O 7,097 7,097 23,754 235,837 242,471

098 01 CARLISLE CLINIC 55,550 224,623 230,941

098 02 HOSPICE 81,084 90,552 93,099

100 MEALS ON WHEELS

100 01 GUEST MEALS

100 02 MARKETING 282 282 52,629 192,330 197,740



103 COST TO BE ALLOCATED 864,811 1,062,949 2,082,612 503,242 867,941

(WRKSHT B, PART I)

104 UNIT COST MULTIPLIER 8.782571 .240297 .049434

(WRKSHT B, PT I) 10.794758 .028078

105 COST TO BE ALLOCATED

(WRKSHT B, PART II)

106 UNIT COST MULTIPLIER

(WRKSHT B, PT II)

107 COST TO BE ALLOCATED 10,650 27,224 41,270

(WRKSHT B, PART III

108 UNIT COST MULTIPLIER .001229 .002351

(WRKSHT B, PT III) .001519




I I TO 12/31/2008 I

COST CENTER OTHER ADMINIS OPERATION OF LAUNDRY & LIN HOUSEKEEPING DIETARY CAFETERIA NURSING ADMIN

DESCRIPTION TRATIVE AND PLANT EN SERVICE ISTRATION

( ACCUM. (SQUARE (POUNDS OF (SQUARE (MEALS S(FTE'S (DIRECT NR

COST ) FEET ) LAUNDRY ) FEET )ERVED ) )SING HRS )

6.03 8 9 10 11 12 14


003 NEW CAP REL COSTS-BLD

004 NEW CAP REL COSTS-MVB


006 01 IS/ACCOUNTING/MARKETI

006 02 BUSINESS OFFICE & ADM

006 03 OTHER ADMINISTRATIVE 17,211,340

008 OPERATION OF PLANT 1,270,404 82,345

009 LAUNDRY & LINEN SERVI 74,152 553 121,962

010 HOUSEKEEPING 422,228 1,291 80,501

011 DIETARY 572,351 2,703 656 2,703 63,073

012 CAFETERIA 19,377 918 245 918 21,414 14,530

014 NURSING ADMINISTRATIO 305,663 564 564 385 173,292

015 CENTRAL SERVICES & SU 207,614 2,354 2,354 299

016 PHARMACY 1,156,316 1,431 1,431 499

017 MEDICAL RECORDS & LIB 460,406 2,980 2,980 787


025 ADULTS & PEDIATRICS 2,950,631 15,548 51,197 15,548 11,822 4,293 88,146

026 INTENSIVE CARE UNIT 699,764 4,157 3,272 4,157 1,218 762 15,663

033 NURSERY 118,893 333 2,417 333 145 3,008


037 OPERATING ROOM 909,262 13,496 16,601 13,496 484 825 17,153

039 DELIVERY ROOM & LABOR 31,125 467 2,345 467 16 340


041 RADIOLOGY-DIAGNOSTIC 1,089,308 5,654 7,603 5,654 949

041 01 ULTRASOUND 240,696 340 340 98

043 RADIOISOTOPE 166,635 420 420 82

044 LABORATORY 1,187,005 3,030 362 3,030 1,199

047 BLOOD STORING, PROCES 138,986 190 190

048 INTRAVENOUS THERAPY 28,020 337 337

049 RESPIRATORY THERAPY 577,412 2,585 565 2,585 682

050 PHYSICAL THERAPY 623,730 3,591 13,373 3,591 561

050 01 SPORTS THERAPY 73,345 639 639 200

051 OCCUPATIONAL THERAPY 145,470 483 483 166

052 SPEECH PATHOLOGY 77,244 185 185 91


054 ELECTROENCEPHALOGRAPH 4,665 221 221


055 MEDICAL SUPPLIES CHAR 613,370

056 DRUGS CHARGED TO PATI



061 EMERGENCY 1,508,661 5,877 23,326 5,877 1,312 27,296



071 HOME HEALTH AGENCY 643,065 1,231 1,231 900 18,726


093 HOSPICE

095 SUBTOTALS 16,381,852 72,730 121,962 70,886 34,938 14,251 170,332


096 GIFT, FLOWER, COFFEE 11,124 527 527

098 PHYSICIANS' PRIVATE O 255,613 7,097 7,097 100

098 01 CARLISLE CLINIC 238,217 1,709 1,709

098 02 HOSPICE 117,181 142 2,960



100 02 MARKETING 207,353 282 282 37



103 COST TO BE ALLOCATED 1,231,953 1,361,337 88,602 473,793 674,391 270,484 347,352

(WRKSHT B, PART I)

104 UNIT COST MULTIPLIER 16.532115 5.885554 18.615554

(WRKSHT B, PT I) .071578 .726472 10.692230 2.004432


(WRKSHT B, PART II)


(WRKSHT B, PT II)

107 COST TO BE ALLOCATED 69,223 217,780 12,897 32,260 65,892 43,313 16,550

(WRKSHT B, PART III

108 UNIT COST MULTIPLIER 2.644726 .400740 2.980936

(WRKSHT B, PT III) .004022 .105746 1.044694 .095504




I I TO 12/31/2008 I

COST CENTER CENTRAL SERVI PHARMACY MEDICAL RECOR

DESCRIPTION CES & SUPPLY DS & LIBRARY

(COSTED R(COSTED R( GROSS

EQUIS. )EQUIS. ) CHARGES )

15 16 17


003 NEW CAP REL COSTS-BLD

004 NEW CAP REL COSTS-MVB


006 01 IS/ACCOUNTING/MARKETI

006 02 BUSINESS OFFICE & ADM

006 03 OTHER ADMINISTRATIVE


009 LAUNDRY & LINEN SERVI

010 HOUSEKEEPING

011 DIETARY

012 CAFETERIA

014 NURSING ADMINISTRATIO

015 CENTRAL SERVICES & SU 789,400

016 PHARMACY 9,393 100

017 MEDICAL RECORDS & LIB 40 47,180,262


025 ADULTS & PEDIATRICS 40,093 5,461,233

026 INTENSIVE CARE UNIT 4,827 694,690

033 NURSERY 1,893 156,919


037 OPERATING ROOM 60,871 3,234,653

039 DELIVERY ROOM & LABOR 1,837 152,274

040 ANESTHESIOLOGY 337,471

041 RADIOLOGY-DIAGNOSTIC 25,241 8,715,751

041 01 ULTRASOUND 1,847,134

043 RADIOISOTOPE 499,301

044 LABORATORY 42,684 7,259,345

047 BLOOD STORING, PROCES 434,528

048 INTRAVENOUS THERAPY 615,046

049 RESPIRATORY THERAPY 32,767 1,780,285

050 PHYSICAL THERAPY 2,659 1,414,278

050 01 SPORTS THERAPY 227 251,616

051 OCCUPATIONAL THERAPY 153 146,315

052 SPEECH PATHOLOGY 314 73,054


054 ELECTROENCEPHALOGRAPH 53,354

054 01 CARDIOPULMONARY 174,930

055 MEDICAL SUPPLIES CHAR 537,071 4,289,172

056 DRUGS CHARGED TO PATI 100 2,719,656



061 EMERGENCY 19,398 6,869,257





093 HOSPICE

095 SUBTOTALS 782,103 100 47,180,262


096 GIFT, FLOWER, COFFEE

098 PHYSICIANS' PRIVATE O 7,297

098 01 CARLISLE CLINIC

098 02 HOSPICE

100 MEALS ON WHEELS

100 01 GUEST MEALS

100 02 MARKETING



103 COST TO BE ALLOCATED 280,813 1,283,792 574,830

(PER WRKSHT B, PART

104 UNIT COST MULTIPLIER 12,837.920000

(WRKSHT B, PT I) .355730 .012184


(PER WRKSHT B, PART


(WRKSHT B, PT II)

107 COST TO BE ALLOCATED 55,880 43,722 73,604

(PER WRKSHT B, PART

108 UNIT COST MULTIPLIER 437.220000

(WRKSHT B, PT III) .070788 .001560



COMPUTATION OF RATIO OF COSTS TO CHARGES I 15-1327 I FROM 1/ 1/2008 I WORKSHEET C

I I TO 12/31/2008 I PART I

WKST A COST CENTER DESCRIPTION WKST B, PT I THERAPY TOTAL RCE TOTAL

LINE NO. COL. 27 ADJUSTMENT COSTS DISALLOWANCE COSTS

1 2 3 4 5


25 ADULTS & PEDIATRICS 4,011,385 4,011,385 4,011,385

26 INTENSIVE CARE UNIT 914,203 914,203 914,203

33 NURSERY 147,937 147,937 147,937


37 OPERATING ROOM 1,404,933 1,404,933 1,404,933

39 DELIVERY ROOM & LABOR ROO 49,014 49,014 49,014

40 ANESTHESIOLOGY 4,656 4,656 4,656

41 RADIOLOGY-DIAGNOSTIC 1,432,375 1,432,375 1,432,375

41 01 ULTRASOUND 289,876 289,876 289,876

43 RADIOISOTOPE 195,586 195,586 195,586

44 LABORATORY 1,466,108 1,466,108 1,466,108



49 RESPIRATORY THERAPY 723,145 723,145 723,145

50 PHYSICAL THERAPY 787,213 787,213 787,213

50 01 SPORTS THERAPY 99,790 99,790 99,790

51 OCCUPATIONAL THERAPY 171,637 171,637 171,637

52 SPEECH PATHOLOGY 89,616 89,616 89,616


54 ELECTROENCEPHALOGRAPHY 10,604 10,604 10,604


55 MEDICAL SUPPLIES CHARGED 900,587 900,587 900,587

56 DRUGS CHARGED TO PATIENTS 1,316,928 1,316,928 1,316,928



61 EMERGENCY 1,935,074 1,935,074 1,935,074

62 OBSERVATION BEDS (NON-DIS 1,490,807 1,490,807 1,490,807


101 SUBTOTAL 17,743,229 17,743,229 17,743,229

102 LESS OBSERVATION BEDS 1,490,807 1,490,807 1,490,807

103 TOTAL 16,252,422 16,252,422 16,252,422




I I TO 12/31/2008 I PART I

WKST A COST CENTER DESCRIPTION INPATIENT OUTPATIENT TOTAL COST OR TEFRA INPAT- PPS INPAT-

LINE NO. CHARGES CHARGES CHARGES OTHER RATIO IENT RATIO IENT RATIO

6 7 8 9 10 11


25 ADULTS & PEDIATRICS 3,322,007 3,322,007


33 NURSERY 156,919 156,919


37 OPERATING ROOM 422,003 2,812,650 3,234,653 .434338 .434338 .434338

39 DELIVERY ROOM & LABOR ROO 119,034 33,240 152,274 .321880 .321880 .321880

40 ANESTHESIOLOGY 129,707 207,764 337,471 .013797 .013797 .013797

41 RADIOLOGY-DIAGNOSTIC 661,400 8,054,351 8,715,751 .164343 .164343 .164343

41 01 ULTRASOUND 385,398 1,461,736 1,847,134 .156933 .156933 .156933

43 RADIOISOTOPE 27,910 471,391 499,301 .391720 .391720 .391720

44 LABORATORY 928,675 6,330,670 7,259,345 .201961 .201961 .201961

47 BLOOD STORING, PROCESSING 175,957 258,571 434,528 .364734 .364734 .364734

48 INTRAVENOUS THERAPY 256,819 358,227 615,046 .073286 .073286 .073286

49 RESPIRATORY THERAPY 671,658 1,108,627 1,780,285 .406196 .406196 .406196

50 PHYSICAL THERAPY 48,373 1,365,905 1,414,278 .556618 .556618 .556618

50 01 SPORTS THERAPY 251,616 251,616 .396596 .396596 .396596

51 OCCUPATIONAL THERAPY 18,491 127,824 146,315 1.173065 1.173065 1.173065

52 SPEECH PATHOLOGY 13,772 59,282 73,054 1.226709 1.226709 1.226709


54 ELECTROENCEPHALOGRAPHY 7,210 46,144 53,354 .198748 .198748 .198748

54 01 CARDIOPULMONARY 174,930 174,930 .561333 .561333 .561333

55 MEDICAL SUPPLIES CHARGED 1,727,133 2,562,039 4,289,172 .209968 .209968 .209968

56 DRUGS CHARGED TO PATIENTS 1,275,358 1,444,298 2,719,656 .484226 .484226 .484226



61 EMERGENCY 608,301 6,260,956 6,869,257 .281701 .281701 .281701

62 OBSERVATION BEDS (NON-DIS 73,500 2,065,726 2,139,226 .696891 .696891 .696891


101 SUBTOTAL 11,724,315 35,455,947 47,180,262

102 LESS OBSERVATION BEDS

103 TOTAL 11,724,315 35,455,947 47,180,262

Health Financial Systems MCRIF32 FOR SULLIVAN COUNTY COMMUNITY HOSPITAL **NOT A CMS WORKSHEET ** (05/1999)



SPECIAL TITLE XIX WORKSHEET I I TO 12/31/2008 I PART I

WKST A COST CENTER DESCRIPTION WKST B, PT I THERAPY TOTAL RCE TOTAL

LINE NO. COL. 27 ADJUSTMENT COSTS DISALLOWANCE COSTS

1 2 3 4 5


25 ADULTS & PEDIATRICS 4,011,385 4,011,385 4,011,385

26 INTENSIVE CARE UNIT 914,203 914,203 914,203

33 NURSERY 147,937 147,937 147,937


37 OPERATING ROOM 1,404,933 1,404,933 1,404,933


40 ANESTHESIOLOGY 4,656 4,656 4,656


41 01 ULTRASOUND 289,876 289,876 289,876

43 RADIOISOTOPE 195,586 195,586 195,586

44 LABORATORY 1,466,108 1,466,108 1,466,108



49 RESPIRATORY THERAPY 723,145 723,145 723,145


50 01 SPORTS THERAPY 99,790 99,790 99,790






55 MEDICAL SUPPLIES CHARGED 900,587 900,587 900,587




61 EMERGENCY 1,935,074 1,935,074 1,935,074



101 SUBTOTAL 17,743,229 17,743,229 17,743,229


103 TOTAL 16,252,422 16,252,422 16,252,422




SPECIAL TITLE XIX WORKSHEET I I TO 12/31/2008 I PART I

WKST A COST CENTER DESCRIPTION INPATIENT OUTPATIENT TOTAL COST OR TEFRA INPAT- PPS INPAT-

LINE NO. CHARGES CHARGES CHARGES OTHER RATIO IENT RATIO IENT RATIO

6 7 8 9 10 11


25 ADULTS & PEDIATRICS 3,322,007 3,322,007


33 NURSERY 156,919 156,919


37 OPERATING ROOM 422,003 2,812,650 3,234,653 .434338 .434338 .434338

39 DELIVERY ROOM & LABOR ROO 119,034 33,240 152,274 .321880 .321880 .321880

40 ANESTHESIOLOGY 129,707 207,764 337,471 .013797 .013797 .013797

41 RADIOLOGY-DIAGNOSTIC 661,400 8,054,351 8,715,751 .164343 .164343 .164343

41 01 ULTRASOUND 385,398 1,461,736 1,847,134 .156933 .156933 .156933

43 RADIOISOTOPE 27,910 471,391 499,301 .391720 .391720 .391720

44 LABORATORY 928,675 6,330,670 7,259,345 .201961 .201961 .201961

47 BLOOD STORING, PROCESSING 175,957 258,571 434,528 .364734 .364734 .364734

48 INTRAVENOUS THERAPY 256,819 358,227 615,046 .073286 .073286 .073286

49 RESPIRATORY THERAPY 671,658 1,108,627 1,780,285 .406196 .406196 .406196

50 PHYSICAL THERAPY 48,373 1,365,905 1,414,278 .556618 .556618 .556618

50 01 SPORTS THERAPY 251,616 251,616 .396596 .396596 .396596

51 OCCUPATIONAL THERAPY 18,491 127,824 146,315 1.173065 1.173065 1.173065

52 SPEECH PATHOLOGY 13,772 59,282 73,054 1.226709 1.226709 1.226709


54 ELECTROENCEPHALOGRAPHY 7,210 46,144 53,354 .198748 .198748 .198748

54 01 CARDIOPULMONARY 174,930 174,930 .561333 .561333 .561333

55 MEDICAL SUPPLIES CHARGED 1,727,133 2,562,039 4,289,172 .209968 .209968 .209968

56 DRUGS CHARGED TO PATIENTS 1,275,358 1,444,298 2,719,656 .484226 .484226 .484226



61 EMERGENCY 608,301 6,260,956 6,869,257 .281701 .281701 .281701

62 OBSERVATION BEDS (NON-DIS 73,500 2,065,726 2,139,226 .696891 .696891 .696891


101 SUBTOTAL 11,724,315 35,455,947 47,180,262

102 LESS OBSERVATION BEDS

103 TOTAL 11,724,315 35,455,947 47,180,262


CALCULATION OF OUTPATIENT SERVICE COST TO I PROVIDER NO: I PERIOD: I PREPARED 5/15/2009

CHARGE RATIOS NET OF REDUCTIONS I 15-1327 I FROM 1/ 1/2008 I WORKSHEET C

I I TO 12/31/2008 I PART II

TOTAL COST CAPITAL COST OPERATING CAPITAL OPERATING COST COST NET OF

WKST A COST CENTER DESCRIPTION WKST B, PT I WKST B PT II COST NET OF REDUCTION REDUCTION CAP AND OPER

LINE NO. COL. 27 & III,COL. 27 CAPITAL COST AMOUNT COST REDUCTION

1 2 3 4 5 6


37 OPERATING ROOM 1,404,933 328,719 1,076,214 1,404,933

39 DELIVERY ROOM & LABOR ROO 49,014 11,510 37,504 49,014

40 ANESTHESIOLOGY 4,656 530 4,126 4,656

41 RADIOLOGY-DIAGNOSTIC 1,432,375 155,846 1,276,529 1,432,375

41 01 ULTRASOUND 289,876 12,711 277,165 289,876

43 RADIOISOTOPE 195,586 11,803 183,783 195,586

44 LABORATORY 1,466,108 96,160 1,369,948 1,466,108

47 BLOOD STORING, PROCESSING 158,487 6,042 152,445 158,487

48 INTRAVENOUS THERAPY 45,074 8,798 36,276 45,074


50 PHYSICAL THERAPY 787,213 91,997 695,216 787,213

50 01 SPORTS THERAPY 99,790 15,816 83,974 99,790




54 ELECTROENCEPHALOGRAPHY 10,604 5,119 5,485 10,604

54 01 CARDIOPULMONARY 98,194 26,876 71,318 98,194





61 EMERGENCY 1,935,074 166,268 1,768,806 1,935,074



101 SUBTOTAL 12,669,704 1,124,522 11,545,182 12,669,704


103 TOTAL 11,178,897 1,124,522 10,054,375 11,178,897




I I TO 12/31/2008 I PART II

TOTAL OUTPAT COST I/P PT B COST

WKST A COST CENTER DESCRIPTION CHARGES TO CHRG RATIO TO CHRG RATIO

LINE NO.

7 8 9


37 OPERATING ROOM 3,234,653 .434338 .434338

39 DELIVERY ROOM & LABOR ROO 152,274 .321880 .321880

40 ANESTHESIOLOGY 337,471 .013797 .013797

41 RADIOLOGY-DIAGNOSTIC 8,715,751 .164343 .164343

41 01 ULTRASOUND 1,847,134 .156933 .156933

43 RADIOISOTOPE 499,301 .391720 .391720

44 LABORATORY 7,259,345 .201961 .201961

47 BLOOD STORING, PROCESSING 434,528 .364734 .364734

48 INTRAVENOUS THERAPY 615,046 .073286 .073286

49 RESPIRATORY THERAPY 1,780,285 .406196 .406196

50 PHYSICAL THERAPY 1,414,278 .556618 .556618

50 01 SPORTS THERAPY 251,616 .396596 .396596

51 OCCUPATIONAL THERAPY 146,315 1.173065 1.173065

52 SPEECH PATHOLOGY 73,054 1.226709 1.226709


54 ELECTROENCEPHALOGRAPHY 53,354 .198748 .198748

54 01 CARDIOPULMONARY 174,930 .561333 .561333

55 MEDICAL SUPPLIES CHARGED 4,289,172 .209968 .209968

56 DRUGS CHARGED TO PATIENTS 2,719,656 .484226 .484226



61 EMERGENCY 6,869,257 .281701 .281701

62 OBSERVATION BEDS (NON-DIS 2,139,226 .696891 .696891


101 SUBTOTAL 43,006,646

102 LESS OBSERVATION BEDS 2,139,226

103 TOTAL 40,867,420




SPECIAL TITLE XIX WORKSHEET I I TO 12/31/2008 I PART II

TOTAL COST CAPITAL COST OPERATING CAPITAL OPERATING COST COST NET OF

WKST A COST CENTER DESCRIPTION WKST B, PT I WKST B PT II COST NET OF REDUCTION REDUCTION CAP AND OPER

LINE NO. COL. 27 & III,COL. 27 CAPITAL COST AMOUNT COST REDUCTION

1 2 3 4 5 6


37 OPERATING ROOM 1,404,933 328,719 1,076,214 1,404,933

39 DELIVERY ROOM & LABOR ROO 49,014 11,510 37,504 49,014

40 ANESTHESIOLOGY 4,656 530 4,126 4,656

41 RADIOLOGY-DIAGNOSTIC 1,432,375 155,846 1,276,529 1,432,375

41 01 ULTRASOUND 289,876 12,711 277,165 289,876

43 RADIOISOTOPE 195,586 11,803 183,783 195,586

44 LABORATORY 1,466,108 96,160 1,369,948 1,466,108

47 BLOOD STORING, PROCESSING 158,487 6,042 152,445 158,487

48 INTRAVENOUS THERAPY 45,074 8,798 36,276 45,074



50 01 SPORTS THERAPY 99,790 15,816 83,974 99,790




54 ELECTROENCEPHALOGRAPHY 10,604 5,119 5,485 10,604

54 01 CARDIOPULMONARY 98,194 26,876 71,318 98,194





61 EMERGENCY 1,935,074 166,268 1,768,806 1,935,074



101 SUBTOTAL 12,669,704 1,124,522 11,545,182 12,669,704


103 TOTAL 11,178,897 1,124,522 10,054,375 11,178,897




SPECIAL TITLE XIX WORKSHEET I I TO 12/31/2008 I PART II

TOTAL OUTPAT COST I/P PT B COST

WKST A COST CENTER DESCRIPTION CHARGES TO CHRG RATIO TO CHRG RATIO

LINE NO.

7 8 9


37 OPERATING ROOM 3,234,653 .434338 .434338

39 DELIVERY ROOM & LABOR ROO 152,274 .321880 .321880

40 ANESTHESIOLOGY 337,471 .013797 .013797

41 RADIOLOGY-DIAGNOSTIC 8,715,751 .164343 .164343

41 01 ULTRASOUND 1,847,134 .156933 .156933

43 RADIOISOTOPE 499,301 .391720 .391720

44 LABORATORY 7,259,345 .201961 .201961

47 BLOOD STORING, PROCESSING 434,528 .364734 .364734

48 INTRAVENOUS THERAPY 615,046 .073286 .073286

49 RESPIRATORY THERAPY 1,780,285 .406196 .406196

50 PHYSICAL THERAPY 1,414,278 .556618 .556618

50 01 SPORTS THERAPY 251,616 .396596 .396596

51 OCCUPATIONAL THERAPY 146,315 1.173065 1.173065

52 SPEECH PATHOLOGY 73,054 1.226709 1.226709


54 ELECTROENCEPHALOGRAPHY 53,354 .198748 .198748

54 01 CARDIOPULMONARY 174,930 .561333 .561333

55 MEDICAL SUPPLIES CHARGED 4,289,172 .209968 .209968

56 DRUGS CHARGED TO PATIENTS 2,719,656 .484226 .484226



61 EMERGENCY 6,869,257 .281701 .281701

62 OBSERVATION BEDS (NON-DIS 2,139,226 .696891 .696891


101 SUBTOTAL 43,006,646

102 LESS OBSERVATION BEDS 2,139,226

103 TOTAL 40,867,420



COMPUTATION OF TOTAL RPCH INPATIENT ANCILLARY COSTS I 15-1327 I FROM 1/ 1/2008 I WORKSHEET C


TOTAL COST TOTAL TOTAL CHARGE TO TOTAL

WKST A COST CENTER DESCRIPTION WKST B, PT I ANCILLARY INP ANCILLARY CHARGE INPATIENT

LINE NO. COL. 27 CHARGES CHARGES RATIO COST

1 2 3 4 5


37 OPERATING ROOM 1,392,825 3,735,483

39 DELIVERY ROOM & LABOR ROO 44,257 159,498

40 ANESTHESIOLOGY 4,556 337,471

41 RADIOLOGY-DIAGNOSTIC 1,342,592 8,857,127

41 01 ULTRASOUND 270,664 1,847,134

43 RADIOISOTOPE 182,122 499,301

44 LABORATORY 1,369,180 7,341,362

47 BLOOD STORING, PROCESSING 142,300 434,528

48 INTRAVENOUS THERAPY 42,468 615,046

49 RESPIRATORY THERAPY 684,209 2,370,957

50 PHYSICAL THERAPY 739,963 1,414,278

50 01 SPORTS THERAPY

51 OCCUPATIONAL THERAPY 160,612 190,152

52 SPEECH PATHOLOGY 170,525 324,670


54 ELECTROENCEPHALOGRAPHY 11,779 53,354

54 01 CARDIOPULMONARY 89,985 200,370

55 MEDICAL SUPPLIES CHARGED 825,193 3,842,741

56 DRUGS CHARGED TO PATIENTS 1,235,714 2,719,656



61 EMERGENCY 1,741,568 6,512,092

62 OBSERVATION BEDS (NON-DIS 1,374,817 2,139,226


101 TOTAL 11,825,329 43,594,446



COMPUTATION OF OUTPATIENT COST PER VISIT - I 15-1327 I FROM 1/ 1/2008 I WORKSHEET C

RURAL PRIMARY CARE HOSPITAL I I TO 12/31/2008 I PART V

TOTAL COST PROVIDER-BASED TOTAL TOTAL TOTAL RATIO OF OUT- TOTAL OUT-

WKST A COST CENTER DESCRIPTION WKST B, PT I PHYSICIAN COSTS ANCILLARY OUTPATIENT PATIENT CHRGS PATIENT

LINE NO. COL. 27 ADJUSTMENT CHARGES CHARGES TO TTL CHARGES COSTS

1 2 3 4 5 6 7


37 OPERATING ROOM 1,392,825 1,392,825 3,735,483


40 ANESTHESIOLOGY 4,556 424,360 428,916 337,471


41 01 ULTRASOUND 270,664 270,664 1,847,134

43 RADIOISOTOPE 182,122 182,122 499,301

44 LABORATORY 1,369,180 1,369,180 7,341,362



49 RESPIRATORY THERAPY 684,209 684,209 2,370,957

50 PHYSICAL THERAPY 739,963 739,963 1,414,278







55 MEDICAL SUPPLIES CHARGED 825,193 825,193 3,842,741




61 EMERGENCY 1,741,568 1,741,568 6,512,092



101 TOTAL 11,825,329 424,360 12,249,689 43,594,446

102 TOTAL OUTPATIENT VISITS

103 AGGREGATE COST PER VISIT

104 TITLE V OUTPATIENT VISITS

105 TITLE XVIII OUTPAT VISITS

106 TITLE XIX OUTPAT VISITS

107 TITLE V OUTPAT COSTS

108 TITLE XVIII OUTPAT COSTS

109 TITLE XIX OUTPAT COSTS



APPORTIONMENT OF MEDICAL, OTHER HEALTH SERVICES & VACCINE COSTS I 15-1327 I FROM 1/ 1/2008 I WORKSHEET D

I COMPONENT NO: I TO 12/31/2008 I PART V

I 15-1327 I I

TITLE XVIII, PART B HOSPITAL

Cost/Charge Cost/Charge Cost/Charge Outpatient Outpatient

Ratio (C, Pt I, Ratio (C, Pt I, Ratio (C, Pt Ambulatory Radialogy

col. 9) col. 9) II, col. 9) Surgical Ctr

Cost Center Description 1 1.01 1.02 2 3

(A) ANCILLARY SRVC COST CNTRS

37 OPERATING ROOM .434338 .434338

39 DELIVERY ROOM & LABOR ROOM .321880 .321880

40 ANESTHESIOLOGY .013797 .013797

41 RADIOLOGY-DIAGNOSTIC .164343 .164343

41 01 ULTRASOUND .156933 .156933

43 RADIOISOTOPE .391720 .391720

44 LABORATORY .201961 .201961

47 BLOOD STORING, PROCESSING & TRANS. .364734 .364734

48 INTRAVENOUS THERAPY .073286 .073286

49 RESPIRATORY THERAPY .406196 .406196

50 PHYSICAL THERAPY .556618 .556618

50 01 SPORTS THERAPY .396596 .396596

51 OCCUPATIONAL THERAPY 1.173065 1.173065

52 SPEECH PATHOLOGY 1.226709 1.226709


54 ELECTROENCEPHALOGRAPHY .198748 .198748

54 01 CARDIOPULMONARY .561333 .561333

55 MEDICAL SUPPLIES CHARGED TO PATIENTS .209968 .209968

56 DRUGS CHARGED TO PATIENTS .484226 .484226



61 EMERGENCY .281701 .281701

62 OBSERVATION BEDS (NON-DISTINCT PART) .696891 .696891

101 SUBTOTAL

102 CRNA CHARGES

103 LESS PBP CLINIC LAB SVCS-

PROGRAM ONLY CHARGES

104 NET CHARGES

____________________________________________________________________________________________________________________________________

(A) WORKSHEET A LINE NUMBERS

(1) REPORT NON HOSPITAL AND NON SUBPROVIDER COMPONENTS COST FOR THE PERIOD HERE (SEE INSTRUCTIONS)

Health Financial Systems MCRIF32 FOR SULLIVAN COUNTY COMMUNITY HOSPITAL IN LIEU OF FORM CMS-2552-96(05/2004) CONTD




I 15-1327 I I


Other All Other (1) Outpatient Outpatient Other

Outpatient Ambulatory Radialogy Outpatient

Diagnostic Surgical Ctr Diagnostic

Cost Center Description 4 5 6 7 8


37 OPERATING ROOM 1,030,381

39 DELIVERY ROOM & LABOR ROOM


41 RADIOLOGY-DIAGNOSTIC 2,746,360

41 01 ULTRASOUND 504,672


44 LABORATORY 2,364,165

47 BLOOD STORING, PROCESSING & TRANS. 132,620


49 RESPIRATORY THERAPY 761,450

50 PHYSICAL THERAPY 523,308


51 OCCUPATIONAL THERAPY 64,210

52 SPEECH PATHOLOGY 12,706


54 ELECTROENCEPHALOGRAPHY 12,978


55 MEDICAL SUPPLIES CHARGED TO PATIENTS 902,247

56 DRUGS CHARGED TO PATIENTS 558,020



61 EMERGENCY 2,158,147

62 OBSERVATION BEDS (NON-DISTINCT PART) 926,739

101 SUBTOTAL 13,148,471

102 CRNA CHARGES



104 NET CHARGES 13,148,471

____________________________________________________________________________________________________________________________________







I 15-1327 I I


All Other Hospital I/P Hospital I/P

Part B Charges Part B Costs

Cost Center Description 9 10 11


37 OPERATING ROOM 447,534



41 RADIOLOGY-DIAGNOSTIC 451,345



44 LABORATORY 477,469

47 BLOOD STORING, PROCESSING & TRANS. 48,371














61 EMERGENCY 607,952


101 SUBTOTAL 4,047,698

102 CRNA CHARGES



104 NET CHARGES 4,047,698

____________________________________________________________________________________________________________________________________





APPORTIONMENT OF MEDICAL, OTHER HEALTH SERVICES & VACCINE COST I 15-1327 I FROM 1/ 1/2008 I WORKSHEET D

I COMPONENT NO: I TO 12/31/2008 I PART VI

I 15-1327 I I


PART VI - VACCINE COST APPORTIONMENT

1

1 DRUGS CHARGED TO PATIENTS-RATIO OF COST TO CHARGES .484226

2 PROGRAM VACCINE CHARGES 2,412

3 PROGRAM COSTS 1,168





I 15-1327 I I

TITLE XIX - O/P HOSPITAL

Cost/Charge Outpatient Outpatient Other All Other (1)

Ratio (C, Pt I, Ambulatory Radialogy Outpatient

col. 9) Surgical Ctr Diagnostic

Cost Center Description 1 2 3 4 5


37 OPERATING ROOM .434338 391,801

39 DELIVERY ROOM & LABOR ROOM .321880 28,139

40 ANESTHESIOLOGY .013797 98,834

41 RADIOLOGY-DIAGNOSTIC .164343 1,001,966

41 01 ULTRASOUND .156933 237,968

43 RADIOISOTOPE .391720 35,682

44 LABORATORY .201961 893,954

47 BLOOD STORING, PROCESSING & TRANS. .364734

48 INTRAVENOUS THERAPY .073286 44,245

49 RESPIRATORY THERAPY .406196 132,864

50 PHYSICAL THERAPY .556618 107,243

50 01 SPORTS THERAPY .396596

51 OCCUPATIONAL THERAPY 1.173065 21,362

52 SPEECH PATHOLOGY 1.226709 22,671


54 ELECTROENCEPHALOGRAPHY .198748 12,978

54 01 CARDIOPULMONARY .561333 4,263

55 MEDICAL SUPPLIES CHARGED TO PATIENTS .209968 395,906

56 DRUGS CHARGED TO PATIENTS .484226 159,412



61 EMERGENCY .281701 984,404

62 OBSERVATION BEDS (NON-DISTINCT PART) .696891 321,831

101 SUBTOTAL 4,895,523

102 CRNA CHARGES




____________________________________________________________________________________________________________________________________







I 15-1327 I I


PPS Services Non-PPS PPS Services Outpatient Outpatient

FYB to 12/31 Services 1/1 to FYE Ambulatory Radialogy

Surgical Ctr

Cost Center Description 5.01 5.02 5.03 6 7


37 OPERATING ROOM


40 ANESTHESIOLOGY

41 RADIOLOGY-DIAGNOSTIC

41 01 ULTRASOUND

43 RADIOISOTOPE

44 LABORATORY

47 BLOOD STORING, PROCESSING & TRANS.

48 INTRAVENOUS THERAPY

49 RESPIRATORY THERAPY

50 PHYSICAL THERAPY


51 OCCUPATIONAL THERAPY

52 SPEECH PATHOLOGY


54 ELECTROENCEPHALOGRAPHY

54 01 CARDIOPULMONARY

55 MEDICAL SUPPLIES CHARGED TO PATIENTS




61 EMERGENCY

62 OBSERVATION BEDS (NON-DISTINCT PART)

101 SUBTOTAL

102 CRNA CHARGES



104 NET CHARGES

____________________________________________________________________________________________________________________________________







I 15-1327 I I


Other All Other PPS Services Non-PPS PPS Services

Outpatient FYB to 12/31 Services 1/1 to FYE

Diagnostic

Cost Center Description 8 9 9.01 9.02 9.03


37 OPERATING ROOM 170,174

39 DELIVERY ROOM & LABOR ROOM 9,057


41 RADIOLOGY-DIAGNOSTIC 164,666



44 LABORATORY 180,544

47 BLOOD STORING, PROCESSING & TRANS.














61 EMERGENCY 277,308


101 SUBTOTAL 1,413,782

102 CRNA CHARGES




____________________________________________________________________________________________________________________________________





COMPUTATION OF INPATIENT OPERATING COST I 15-1327 I FROM 1/ 1/2008 I WORKSHEET D-1

I COMPONENT NO: I TO 12/31/2008 I PART I

I 15-1327 I I

TITLE XVIII PART A HOSPITAL OTHER

PART I - ALL PROVIDER COMPONENTS

1

INPATIENT DAYS

1 INPATIENT DAYS (INCLUDING PRIVATE ROOM AND SWING BED DAYS, EXCLUDING NEWBORN) 5,232

2 INPATIENT DAYS (INCLUDING PRIVATE ROOM, EXCLUDING SWING-BED AND NEWBORN DAYS) 4,830

3 PRIVATE ROOM DAYS (EXCLUDING SWING-BED PRIVATE ROOM DAYS)

4 SEMI-PRIVATE ROOM DAYS (EXCLUDING SWING-BED PRIVATE ROOM DAYS) 4,830

5 TOTAL SWING-BED SNF-TYPE INPATIENT DAYS (INCLUDING PRIVATE ROOM DAYS) 380

THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD

6 TOTAL SWING-BED SNF-TYPE INPATIENT DAYS (INCLUDING PRIVATE ROOM DAYS) AFTER

DECEMBER 31 OF COST REPORTING PERIOD (IF CALENDAR YEAR, ENTER 0 ON THIS LINE)

7 TOTAL SWING-BED NF TYPE INPATIENT DAYS (INCLUDING PRIVATE ROOM DAYS) 22


8 TOTAL SWING-BED NF TYPE INPATIENT DAYS (INCLUDING PRIVATE ROOM DAYS) AFTER


9 TOTAL INPATIENT DAYS INCLUDING PRIVATE ROOM DAYS APPLICABLE TO THE PROGRAM 1,751

(EXCLUDING SWING-BED AND NEWBORN DAYS)

10 SWING-BED SNF-TYPE INPATIENT DAYS APPLICABLE TO TITLE XVIII ONLY (INCLUDING 380

PRIVATE ROOM DAYS) THROUGH DECEMBER 31 OF THE COST REPORTING PERIOD

11 SWING-BED SNF-TYPE INPATIENT DAYS APPLICABLE TO TITLE XVIII ONLY (INCLUDING

PRIVATE ROOM DAYS) AFTER DECEMBER 31 OF THE COST REPORTING PERIOD (IF CALENDAR

YEAR, ENTER 0 ON THIS LINE)

12 SWING-BED NF-TYPE INPATIENT DAYS APPLICABLE TO TITLES V & XIX ONLY (INCLUDING


13 SWING-BED NF-TYPE INPATIENT DAYS APPLICABLE TO TITLE V & XIX ONLY (INCLUDING



14 MEDICALLY NECESSARY PRIVATE ROOM DAYS APPLICABLE TO THE PROGRAM

(EXCLUDING SWING-BED DAYS)

15 TOTAL NURSERY DAYS (TITLE V OR XIX ONLY)

16 NURSERY DAYS (TITLE V OR XIX ONLY)

SWING-BED ADJUSTMENT

17 MEDICARE RATE FOR SWING-BED SNF SERVICES APPLICABLE TO SERVICES THROUGH

DECEMBER 31 OF THE COST REPORTING PERIOD

18 MEDICARE RATE FOR SWING-BED SNF SERVICES APPLICABLE TO SERVICES AFTER


19 MEDICAID RATE FOR SWING-BED NF SERVICES APPLICABLE TO SERVICES THROUGH 163.85


20 MEDICAID RATE FOR SWING-BED NF SERVICES APPLICABLE TO SERVICES AFTER


21 TOTAL GENERAL INPATIENT ROUTINE SERVICE COST 4,011,385

22 SWING-BED COST APPLICABLE TO SNF-TYPE SERVICES THROUGH DECEMBER 31 OF THE COST

REPORTING PERIOD

23 SWING-BED COST APPLICABLE TO SNF-TYPE SERVICES AFTER DECEMBER 31 OF THE COST

REPORTING PERIOD

24 SWING-BED COST APPLICABLE TO NF-TYPE SERVICES THROUGH DECEMBER 31 OF THE COST 3,605

REPORTING PERIOD

25 SWING-BED COST APPLICABLE TO NF-TYPE SERVICES AFTER DECEMBER 31 OF THE COST

REPORTING PERIOD

26 TOTAL SWING-BED COST (SEE INSTRUCTIONS) 295,920

27 GENERAL INPATIENT ROUTINE SERVICE COST NET OF SWING-BED COST 3,715,465

PRIVATE ROOM DIFFERENTIAL ADJUSTMENT

28 GENERAL INPATIENT ROUTINE SERVICE CHARGES (EXCLUDING SWING-BED CHARGES) 3,160,910

29 PRIVATE ROOM CHARGES (EXCLUDING SWING-BED CHARGES)

30 SEMI-PRIVATE ROOM CHARGES (EXCLUDING SWING-BED CHARGES) 3,160,910

31 GENERAL INPATIENT ROUTINE SERVICE COST/CHARGE RATIO 1.175442

32 AVERAGE PRIVATE ROOM PER DIEM CHARGE

33 AVERAGE SEMI-PRIVATE ROOM PER DIEM CHARGE 654.43

34 AVERAGE PER DIEM PRIVATE ROOM CHARGE DIFFERENTIAL

35 AVERAGE PER DIEM PRIVATE ROOM COST DIFFERENTIAL

36 PRIVATE ROOM COST DIFFERENTIAL ADJUSTMENT

37 GENERAL INPATIENT ROUTINE SERVICE COST NET OF SWING-BED COST AND PRIVATE ROOM 3,715,465

COST DIFFERENTIAL




I COMPONENT NO: I TO 12/31/2008 I PART II

I 15-1327 I I


PART II - HOSPITAL AND SUBPROVIDERS ONLY

1

PROGRAM INPATIENT OPERATING COST BEFORE

PASS THROUGH COST ADJUSTMENTS

38 ADJUSTED GENERAL INPATIENT ROUTINE SERVICE COST PER DIEM 769.25

39 PROGRAM GENERAL INPATIENT ROUTINE SERVICE COST 1,346,957

40 MEDICALLY NECESSARY PRIVATE ROOM COST APPLICABLE TO THE PROGRAM

41 TOTAL PROGRAM GENERAL INPATIENT ROUTINE SERVICE COST 1,346,957

TOTAL TOTAL AVERAGE PROGRAM PROGRAM

I/P COST I/P DAYS PER DIEM DAYS COST

1 2 3 4 5

42 NURSERY (TITLE V & XIX ONLY)

INTENSIVE CARE TYPE INPATIENT

HOSPITAL UNITS

43 INTENSIVE CARE UNIT 914,203 405 2,257.29 251 566,580

44 CORONARY CARE UNIT

45 BURN INTENSIVE CARE UNIT

46 SURGICAL INTENSIVE CARE UNIT

47 OTHER SPECIAL CARE

1

48 PROGRAM INPATIENT ANCILLARY SERVICE COST 1,107,702

49 TOTAL PROGRAM INPATIENT COSTS 3,021,239


50 PASS THROUGH COSTS APPLICABLE TO PROGRAM INPATIENT ROUTINE SERVICES

51 PASS THROUGH COSTS APPLICABLE TO PROGRAM INPATIENT ANCILLARY SERVICES

52 TOTAL PROGRAM EXCLUDABLE COST

53 TOTAL PROGRAM INPATIENT OPERATING COST EXCLUDING CAPITAL RELATED, NONPHYSICIAN

ANESTHETIST, AND MEDICAL EDUCATION COSTS

TARGET AMOUNT AND LIMIT COMPUTATION

54 PROGRAM DISCHARGES

55 TARGET AMOUNT PER DISCHARGE

56 TARGET AMOUNT

57 DIFFERENCE BETWEEN ADJUSTED INPATIENT OPERATING COST AND TARGET AMOUNT

58 BONUS PAYMENT

58.01 LESSER OF LINES 53/54 OR 55 FROM THE COST REPORTING PERIOD ENDING 1996, UPDATED

AND COMPOUNDED BY THE MARKET BASKET

58.02 LESSER OF LINES 53/54 OR 55 FROM PRIOR YEAR COST REPORT, UPDATED BY THE MARKET

BASKET

58.03 IF LINES 53/54 IS LESS THAN THE LOWER OF LINES 55, 58.01 OR 58.02 ENTER THE

LESSER OF 50% OF THE AMOUNT BY WHICH OPERATING COSTS (LINE 53) ARE LESS THAN

EXPECTED COSTS (LINES 54 x 58.02), OR 1 PERCENT OF THE TARGET AMOUNT (LINE 56)

OTHERWISE ENTER ZERO.

58.04 RELIEF PAYMENT

59 ALLOWABLE INPATIENT COST PLUS INCENTIVE PAYMENT

59.01 ALLOWABLE INPATIENT COST PER DISCHARGE (LINE 59 / LINE 54) (LTCH ONLY)

59.02 PROGRAM DISCHARGES PRIOR TO JULY 1

59.03 PROGRAM DISCHARGES AFTER JULY 1

59.04 PROGRAM DISCHARGES (SEE INSTRUCTIONS)

59.05 REDUCED INPATIENT COST PER DISCHARGE FOR DISCHARGES PRIOR TO JULY 1

(SEE INSTRUCTIONS) (LTCH ONLY)

59.06 REDUCED INPATIENT COST PER DISCHARGE FOR DISCHARGES AFTER JULY 1


59.07 REDUCED INPATIENT COST PER DISCHARGE (SEE INSTRUCTIONS) (LTCH ONLY)

59.08 REDUCED INPATIENT COST PLUS INCENTIVE PAYMENT (SEE INSTRUCTIONS)

PROGRAM INPATIENT ROUTINE SWING BED COST

60 MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS THROUGH DECEMBER 31 OF THE COST 292,315

REPORTING PERIOD (SEE INSTRUCTIONS)

61 MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS AFTER DECEMBER 31 OF THE COST


62 TOTAL MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS 292,315

63 TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS THROUGH DECEMBER 31 OF THE

COST REPORTING PERIOD

64 TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS AFTER DECEMBER 31 OF THE


65 TOTAL TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS




I COMPONENT NO: I TO 12/31/2008 I PART III

I 15-1327 I I


PART III - SKILLED NURSING FACILITY, NURSINGFACILITY & ICF/MR ONLY

1

66 SKILLED NURSING FACILITY/OTHER NURSING FACILITY/ICF/MR ROUTINE

SERVICE COST

67 ADJUSTED GENERAL INPATIENT ROUTINE SERVICE COST PER DIEM

68 PROGRAM ROUTINE SERVICE COST

69 MEDICALLY NECESSARY PRIVATE ROOM COST APPLICABLE TO PROGRAM

70 TOTAL PROGRAM GENERAL INPATIENT ROUTINE SERVICE COSTS

71 CAPITAL-RELATED COST ALLOCATED TO INPATIENT ROUTINE SERVICE COSTS

72 PER DIEM CAPITAL-RELATED COSTS

73 PROGRAM CAPITAL-RELATED COSTS

74 INPATIENT ROUTINE SERVICE COST

75 AGGREGATE CHARGES TO BENEFICIARIES FOR EXCESS COSTS

76 TOTAL PROGRAM ROUTINE SERVICE COSTS FOR COMPARISON TO THE COST LIMITATION

77 INPATIENT ROUTINE SERVICE COST PER DIEM LIMITATION

78 INPATIENT ROUTINE SERVICE COST LIMITATION

79 REASONABLE INPATIENT ROUTINE SERVICE COSTS

80 PROGRAM INPATIENT ANCILLARY SERVICES

81 UTILIZATION REVIEW - PHYSICIAN COMPENSATION

82 TOTAL PROGRAM INPATIENT OPERATING COSTS

PART IV - COMPUTATION OF OBSERVATION BED COST

83 TOTAL OBSERVATION BED DAYS 1,938

84 ADJUSTED GENERAL INPATIENT ROUTINE COST PER DIEM 769.25

85 OBSERVATION BED COST 1,490,807

COMPUTATION OF OBSERVATION BED PASS THROUGH COST

COLUMN 1 TOTAL OBSERVATION BED

ROUTINE DIVIDED BY OBSERVATION PASS THROUGH

COST COST COLUMN 2 BED COST COST

1 2 3 4 5

86 OLD CAPITAL-RELATED COST

87 NEW CAPITAL-RELATED COST

88 NON PHYSICIAN ANESTHETIST

89 MEDICAL EDUCATION

89.01 MEDICAL EDUCATION - ALLIED HEA

89.02 MEDICAL EDUCATION - ALL OTHER




I COMPONENT NO: I TO 12/31/2008 I PART I

I 15-1327 I I

TITLE XIX - I/P HOSPITAL OTHER

PART I - ALL PROVIDER COMPONENTS

1

INPATIENT DAYS

1 INPATIENT DAYS (INCLUDING PRIVATE ROOM AND SWING BED DAYS, EXCLUDING NEWBORN) 5,232

2 INPATIENT DAYS (INCLUDING PRIVATE ROOM, EXCLUDING SWING-BED AND NEWBORN DAYS) 4,830

3 PRIVATE ROOM DAYS (EXCLUDING SWING-BED PRIVATE ROOM DAYS)

4 SEMI-PRIVATE ROOM DAYS (EXCLUDING SWING-BED PRIVATE ROOM DAYS) 4,830

5 TOTAL SWING-BED SNF-TYPE INPATIENT DAYS (INCLUDING PRIVATE ROOM DAYS) 380


6 TOTAL SWING-BED SNF-TYPE INPATIENT DAYS (INCLUDING PRIVATE ROOM DAYS) AFTER


7 TOTAL SWING-BED NF TYPE INPATIENT DAYS (INCLUDING PRIVATE ROOM DAYS) 22


8 TOTAL SWING-BED NF TYPE INPATIENT DAYS (INCLUDING PRIVATE ROOM DAYS) AFTER


9 TOTAL INPATIENT DAYS INCLUDING PRIVATE ROOM DAYS APPLICABLE TO THE PROGRAM 461

(EXCLUDING SWING-BED AND NEWBORN DAYS)






12 SWING-BED NF-TYPE INPATIENT DAYS APPLICABLE TO TITLES V & XIX ONLY (INCLUDING 22


13 SWING-BED NF-TYPE INPATIENT DAYS APPLICABLE TO TITLE V & XIX ONLY (INCLUDING



14 MEDICALLY NECESSARY PRIVATE ROOM DAYS APPLICABLE TO THE PROGRAM

(EXCLUDING SWING-BED DAYS)

15 TOTAL NURSERY DAYS (TITLE V OR XIX ONLY) 243

16 NURSERY DAYS (TITLE V OR XIX ONLY) 148

SWING-BED ADJUSTMENT

17 MEDICARE RATE FOR SWING-BED SNF SERVICES APPLICABLE TO SERVICES THROUGH 163.85


18 MEDICARE RATE FOR SWING-BED SNF SERVICES APPLICABLE TO SERVICES AFTER


19 MEDICAID RATE FOR SWING-BED NF SERVICES APPLICABLE TO SERVICES THROUGH 163.85


20 MEDICAID RATE FOR SWING-BED NF SERVICES APPLICABLE TO SERVICES AFTER


21 TOTAL GENERAL INPATIENT ROUTINE SERVICE COST

22 SWING-BED COST APPLICABLE TO SNF-TYPE SERVICES THROUGH DECEMBER 31 OF THE COST 62,263

REPORTING PERIOD

23 SWING-BED COST APPLICABLE TO SNF-TYPE SERVICES AFTER DECEMBER 31 OF THE COST

REPORTING PERIOD

24 SWING-BED COST APPLICABLE TO NF-TYPE SERVICES THROUGH DECEMBER 31 OF THE COST 3,605

REPORTING PERIOD

25 SWING-BED COST APPLICABLE TO NF-TYPE SERVICES AFTER DECEMBER 31 OF THE COST

REPORTING PERIOD

26 TOTAL SWING-BED COST (SEE INSTRUCTIONS) 3,343

27 GENERAL INPATIENT ROUTINE SERVICE COST NET OF SWING-BED COST -3,343

PRIVATE ROOM DIFFERENTIAL ADJUSTMENT

28 GENERAL INPATIENT ROUTINE SERVICE CHARGES (EXCLUDING SWING-BED CHARGES) 3,160,910

29 PRIVATE ROOM CHARGES (EXCLUDING SWING-BED CHARGES)

30 SEMI-PRIVATE ROOM CHARGES (EXCLUDING SWING-BED CHARGES) 3,160,910

31 GENERAL INPATIENT ROUTINE SERVICE COST/CHARGE RATIO - .001058

32 AVERAGE PRIVATE ROOM PER DIEM CHARGE

33 AVERAGE SEMI-PRIVATE ROOM PER DIEM CHARGE 654.43

34 AVERAGE PER DIEM PRIVATE ROOM CHARGE DIFFERENTIAL

35 AVERAGE PER DIEM PRIVATE ROOM COST DIFFERENTIAL

36 PRIVATE ROOM COST DIFFERENTIAL ADJUSTMENT

37 GENERAL INPATIENT ROUTINE SERVICE COST NET OF SWING-BED COST AND PRIVATE ROOM -3,343

COST DIFFERENTIAL





I 15-1327 I I


PART II - HOSPITAL AND SUBPROVIDERS ONLY

1

PROGRAM INPATIENT OPERATING COST BEFORE


38 ADJUSTED GENERAL INPATIENT ROUTINE SERVICE COST PER DIEM - .69

39 PROGRAM GENERAL INPATIENT ROUTINE SERVICE COST -318

40 MEDICALLY NECESSARY PRIVATE ROOM COST APPLICABLE TO THE PROGRAM

41 TOTAL PROGRAM GENERAL INPATIENT ROUTINE SERVICE COST -318

TOTAL TOTAL AVERAGE PROGRAM PROGRAM

I/P COST I/P DAYS PER DIEM DAYS COST

1 2 3 4 5

42 NURSERY (TITLE V & XIX ONLY) 243 148

INTENSIVE CARE TYPE INPATIENT

HOSPITAL UNITS

43 INTENSIVE CARE UNIT 405 38

44 CORONARY CARE UNIT

45 BURN INTENSIVE CARE UNIT

46 SURGICAL INTENSIVE CARE UNIT

47 OTHER SPECIAL CARE

1

48 PROGRAM INPATIENT ANCILLARY SERVICE COST 407,140

49 TOTAL PROGRAM INPATIENT COSTS 406,822


50 PASS THROUGH COSTS APPLICABLE TO PROGRAM INPATIENT ROUTINE SERVICES

51 PASS THROUGH COSTS APPLICABLE TO PROGRAM INPATIENT ANCILLARY SERVICES

52 TOTAL PROGRAM EXCLUDABLE COST

53 TOTAL PROGRAM INPATIENT OPERATING COST EXCLUDING CAPITAL RELATED, NONPHYSICIAN 406,822

ANESTHETIST, AND MEDICAL EDUCATION COSTS

TARGET AMOUNT AND LIMIT COMPUTATION

54 PROGRAM DISCHARGES 164

55 TARGET AMOUNT PER DISCHARGE

56 TARGET AMOUNT

57 DIFFERENCE BETWEEN ADJUSTED INPATIENT OPERATING COST AND TARGET AMOUNT

58 BONUS PAYMENT

58.01 LESSER OF LINES 53/54 OR 55 FROM THE COST REPORTING PERIOD ENDING 1996, UPDATED

AND COMPOUNDED BY THE MARKET BASKET

58.02 LESSER OF LINES 53/54 OR 55 FROM PRIOR YEAR COST REPORT, UPDATED BY THE MARKET

BASKET

58.03 IF LINES 53/54 IS LESS THAN THE LOWER OF LINES 55, 58.01 OR 58.02 ENTER THE

LESSER OF 50% OF THE AMOUNT BY WHICH OPERATING COSTS (LINE 53) ARE LESS THAN

EXPECTED COSTS (LINES 54 x 58.02), OR 1 PERCENT OF THE TARGET AMOUNT (LINE 56)

OTHERWISE ENTER ZERO.

58.04 RELIEF PAYMENT

59 ALLOWABLE INPATIENT COST PLUS INCENTIVE PAYMENT

59.01 ALLOWABLE INPATIENT COST PER DISCHARGE (LINE 59 / LINE 54) (LTCH ONLY)

59.02 PROGRAM DISCHARGES PRIOR TO JULY 1

59.03 PROGRAM DISCHARGES AFTER JULY 1

59.04 PROGRAM DISCHARGES (SEE INSTRUCTIONS)

59.05 REDUCED INPATIENT COST PER DISCHARGE FOR DISCHARGES PRIOR TO JULY 1


59.06 REDUCED INPATIENT COST PER DISCHARGE FOR DISCHARGES AFTER JULY 1


59.07 REDUCED INPATIENT COST PER DISCHARGE (SEE INSTRUCTIONS) (LTCH ONLY)

59.08 REDUCED INPATIENT COST PLUS INCENTIVE PAYMENT (SEE INSTRUCTIONS)

PROGRAM INPATIENT ROUTINE SWING BED COST

60 MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS THROUGH DECEMBER 31 OF THE COST


61 MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS AFTER DECEMBER 31 OF THE COST


62 TOTAL MEDICARE SWING-BED SNF INPATIENT ROUTINE COSTS

63 TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS THROUGH DECEMBER 31 OF THE 3,605


64 TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS AFTER DECEMBER 31 OF THE


65 TOTAL TITLE V OR XIX SWING-BED NF INPATIENT ROUTINE COSTS 3,605





I 15-1327 I I


PART III - SKILLED NURSING FACILITY, NURSINGFACILITY & ICF/MR ONLY

1

66 SKILLED NURSING FACILITY/OTHER NURSING FACILITY/ICF/MR ROUTINE

SERVICE COST

67 ADJUSTED GENERAL INPATIENT ROUTINE SERVICE COST PER DIEM

68 PROGRAM ROUTINE SERVICE COST

69 MEDICALLY NECESSARY PRIVATE ROOM COST APPLICABLE TO PROGRAM

70 TOTAL PROGRAM GENERAL INPATIENT ROUTINE SERVICE COSTS

71 CAPITAL-RELATED COST ALLOCATED TO INPATIENT ROUTINE SERVICE COSTS

72 PER DIEM CAPITAL-RELATED COSTS

73 PROGRAM CAPITAL-RELATED COSTS


75 AGGREGATE CHARGES TO BENEFICIARIES FOR EXCESS COSTS

76 TOTAL PROGRAM ROUTINE SERVICE COSTS FOR COMPARISON TO THE COST LIMITATION

77 INPATIENT ROUTINE SERVICE COST PER DIEM LIMITATION

78 INPATIENT ROUTINE SERVICE COST LIMITATION

79 REASONABLE INPATIENT ROUTINE SERVICE COSTS

80 PROGRAM INPATIENT ANCILLARY SERVICES

81 UTILIZATION REVIEW - PHYSICIAN COMPENSATION

82 TOTAL PROGRAM INPATIENT OPERATING COSTS

PART IV - COMPUTATION OF OBSERVATION BED COST

83 TOTAL OBSERVATION BED DAYS 1,938

84 ADJUSTED GENERAL INPATIENT ROUTINE COST PER DIEM - .69

85 OBSERVATION BED COST -1,337

COMPUTATION OF OBSERVATION BED PASS THROUGH COST

COLUMN 1 TOTAL OBSERVATION BED

ROUTINE DIVIDED BY OBSERVATION PASS THROUGH

COST COST COLUMN 2 BED COST COST

1 2 3 4 5

86 OLD CAPITAL-RELATED COST

87 NEW CAPITAL-RELATED COST

88 NON PHYSICIAN ANESTHETIST

89 MEDICAL EDUCATION

89.01 MEDICAL EDUCATION - ALLIED HEA

89.02 MEDICAL EDUCATION - ALL OTHER



INPATIENT ANCILLARY SERVICE COST APPORTIONMENT I 15-1327 I FROM 1/ 1/2008 I WORKSHEET D-4

I COMPONENT NO: I TO 12/31/2008 I

I 15-1327 I I

TITLE XVIII, PART A HOSPITAL OTHER

WKST A COST CENTER DESCRIPTION RATIO COST INPATIENT INPATIENT

LINE NO. TO CHARGES CHARGES COST

1 2 3


25 ADULTS & PEDIATRICS 1,923,511

26 INTENSIVE CARE UNIT 430,214


37 OPERATING ROOM .434338 259,293 112,621

39 DELIVERY ROOM & LABOR ROOM .321880

40 ANESTHESIOLOGY .013797 36,316 501

41 RADIOLOGY-DIAGNOSTIC .164343 322,520 53,004

41 01 ULTRASOUND .156933 262,174 41,144

43 RADIOISOTOPE .391720 26,460 10,365

44 LABORATORY .201961 682,488 137,836

47 BLOOD STORING, PROCESSING & TRANS. .364734 111,812 40,782

48 INTRAVENOUS THERAPY .073286 118,764 8,704

49 RESPIRATORY THERAPY .406196 410,532 166,756

50 PHYSICAL THERAPY .556618 24,970 13,899


51 OCCUPATIONAL THERAPY 1.173065 7,078 8,303

52 SPEECH PATHOLOGY 1.226709 10,117 12,411


54 ELECTROENCEPHALOGRAPHY .198748 5,768 1,146

54 01 CARDIOPULMONARY .561333

55 MEDICAL SUPPLIES CHARGED TO PATIENTS .209968 756,413 158,823

56 DRUGS CHARGED TO PATIENTS .484226 699,091 338,518



61 EMERGENCY .281701 5,072 1,429

62 OBSERVATION BEDS (NON-DISTINCT PART) .696891 2,095 1,460


101 TOTAL 3,740,963 1,107,702

102 LESS PBP CLINIC LABORATORY SERVICES -







I 15-Z327 I I

TITLE XVIII, PART A SWING BED SNF OTHER



1 2 3


25 ADULTS & PEDIATRICS

26 INTENSIVE CARE UNIT


37 OPERATING ROOM .434338 3,031 1,316

39 DELIVERY ROOM & LABOR ROOM .321880

40 ANESTHESIOLOGY .013797 602 8


41 01 ULTRASOUND .156933 1,310 206

43 RADIOISOTOPE .391720

44 LABORATORY .201961 67,582 13,649

47 BLOOD STORING, PROCESSING & TRANS. .364734 3,938 1,436





51 OCCUPATIONAL THERAPY 1.173065 9,971 11,697



54 ELECTROENCEPHALOGRAPHY .198748






61 EMERGENCY .281701

62 OBSERVATION BEDS (NON-DISTINCT PART) .696891


101 TOTAL 371,814 130,530



103 NET CHARGES 371,814





I 15-1327 I I

TITLE XIX HOSPITAL OTHER



1 2 3


25 ADULTS & PEDIATRICS 626,930

26 INTENSIVE CARE UNIT 70,324


37 OPERATING ROOM .434338 151,885 65,969

39 DELIVERY ROOM & LABOR ROOM .321880 76,846 24,735

40 ANESTHESIOLOGY .013797 90,205 1,245


41 01 ULTRASOUND .156933 27,275 4,280

43 RADIOISOTOPE .391720 1,351 529

44 LABORATORY .201961 175,363 35,416

47 BLOOD STORING, PROCESSING & TRANS. .364734





51 OCCUPATIONAL THERAPY 1.173065



54 ELECTROENCEPHALOGRAPHY .198748 721 143






61 EMERGENCY .281701 75,365 21,230

62 OBSERVATION BEDS (NON-DISTINCT PART) .696891 44,058 30,704


101 TOTAL 1,401,597 407,140






CALCULATION OF REIMBURSEMENT SETTLEMENT I 15-1327 I FROM 1/ 1/2008 I WORKSHEET E

I COMPONENT NO: I TO 12/31/2008 I PART B

I 15-1327 I I

PART B - MEDICAL AND OTHER HEALTH SERVICES

HOSPITAL

1 MEDICAL AND OTHER SERVICES (SEE INSTRUCTIONS) 4,048,866

1.01 MEDICAL AND OTHER SERVICES RENDERED ON OR AFTER APRIL 1,

2001 (SEE INSTRUCTIONS).

1.02 PPS PAYMENTS RECEIVED INCLUDING OUTLIERS.

1.03 ENTER THE HOSPITAL SPECIFIC PAYMENT TO COST RATIO.

1.04 LINE 1.01 TIMES LINE 1.03.

1.05 LINE 1.02 DIVIDED BY LINE 1.04.

1.06 TRANSITIONAL CORRIDOR PAYMENT (SEE INSTRUCTIONS)

1.07 ENTER THE AMOUNT FROM WORKSHEET D, PART IV, (COLS 9,

9.01, 9,02) LINE 101.

2 INTERNS AND RESIDENTS

3 ORGAN ACQUISITIONS

4 COST OF TEACHING PHYSICIANS

5 TOTAL COST (SEE INSTRUCTIONS) 4,048,866

COMPUTATION OF LESSER OF COST OR CHARGES

REASONABLE CHARGES

6 ANCILLARY SERVICE CHARGES

7 INTERNS AND RESIDENTS SERVICE CHARGES

8 ORGAN ACQUISITION CHARGES

9 CHARGES OF PROFESSIONAL SERVICES OF TEACHING PHYSICIANS.

10 TOTAL REASONABLE CHARGES

CUSTOMARY CHARGES

11 AGGREGATE AMOUNT ACTUALLY COLLECTED FROM PATIENTS LIABLE FOR

PAYMENT FOR SERVICES ON A CHARGE BASIS

12 AMOUNTS THAT WOULD HAVE BEEN REALIZED FROM PATIENTS LIABLE

FOR PAYMENT FOR SERVICES ON A CHARGE BASIS HAD SUCH PAYMENT

BEEN MADE IN ACCORDANCE WITH 42 CFR 413.13(e).

13 RATIO OF LINE 11 TO LINE 12

14 TOTAL CUSTOMARY CHARGES (SEE INSTRUCTIONS)

15 EXCESS OF CUSTOMARY CHARGES OVER REASONABLE COST

16 EXCESS OF REASONABLE COST OVER CUSTOMARY CHARGES

17 LESSER OF COST OR CHARGES (FOR CAH SEE INSTRUC) 4,089,355

17.01 TOTAL PROSPECTIVE PAYMENT (SUM OF LINES 1.02, 1.06 AND 1.07)

COMPUTATION OF REIMBURSEMENT SETTLEMENT

18 CAH DEDUCTIBLES 29,629

18.01 CAH ACTUAL BILLED COINSURANCE 2,156,058

LINE 17.01 (SEE INSTRUCTIONS)

19 SUBTOTAL (SEE INSTRUCTIONS) 1,903,668

20 SUM OF AMOUNTS FROM WORKSHEET E PARTS C, D & E (SEE INSTR.)

21 DIRECT GRADUATE MEDICAL EDUCATION PAYMENTS

22 ESRD DIRECT MEDICAL EDUCATION COSTS

23 SUBTOTAL 1,903,668

24 PRIMARY PAYER PAYMENTS 1,037

25 SUBTOTAL 1,902,631

REIMBURSABLE BAD DEBTS (EXCLUDE BAD DEBTS FOR PROFESSIONAL SERVICES)

26 COMPOSITE RATE ESRD

27 BAD DEBTS (SEE INSTRUCTIONS) 471,599

27.01 ADJUSTED REIMBURSABLE BAD DEBTS (SEE INSTRUCTIONS) 471,599

27.02 REIMBURSABLE BAD DEBTS FOR DUAL ELIGIBLE BENEFICIARIES 371,647

28 SUBTOTAL 2,374,230

29 RECOVERY OF EXCESS DEPRECIATION RESULTING FROM PROVIDER

TERMINATION OR A DECREASE IN PROGRAM UTILIZATION.

30 OTHER ADJUSTMENTS (SPECIFY)

30.99 OTHER ADJUSTMENTS (MSP-LCC RECONCILIATION AMOUNT)

31 AMOUNTS APPLICABLE TO PRIOR COST REPORTING PERIODS RESULTING

FROM DISPOSITION OF DEPRECIABLE ASSETS.

32 SUBTOTAL 2,374,230

33 SEQUESTRATION ADJUSTMENT (SEE INSTRUCTIONS)

34 INTERIM PAYMENTS 2,433,863

34.01 TENTATIVE SETTLEMENT (FOR FISCAL INTERMEDIARY USE ONLY)

35 BALANCE DUE PROVIDER/PROGRAM -59,633

36 PROTESTED AMOUNTS (NONALLOWABLE COST REPORT ITEMS)

IN ACCORDANCE WITH CMS PUB. 15-II, SECTION 115.2



ANALYSIS OF PAYMENTS TO PROVIDERS FOR SERVICES RENDERED I 15-1327 I FROM 1/ 1/2008 I WORKSHEET E-1


I 15-1327 I I

TITLE XVIII HOSPITAL

DESCRIPTION INPATIENT-PART A P A R T B

MM/DD/YYYY AMOUNT MM/DD/YYYY AMOUNT

1 2 3 4

1 TOTAL INTERIM PAYMENTS PAID TO PROVIDER 2,604,379 2,519,153

2 INTERIM PAYMENTS PAYABLE ON INDIVIDUAL BILLS, NONE NONE

EITHER SUBMITTED OR TO BE SUBMITTED TO THE

INTERMEDIARY, FOR SERVICES RENDERED IN THE COST

REPORTING PERIOD. IF NONE, WRITE "NONE" OR

ENTER A ZERO.

3 LIST SEPARATELY EACH RETROACTIVE LUMP SUM ADJUSTMENT

AMOUNT BASED ON SUBSEQUENT REVISION OF THE INTERIM

RATE FOR THE COST REPORTING PERIOD. ALSO SHOW DATE

OF EACH PAYMENT. IF NONE, WRITE "NONE" OR ENTER A

ZERO. (1)

ADJUSTMENTS TO PROVIDER .01 8/15/2008 215,189 8/11/2008 156,243

ADJUSTMENTS TO PROVIDER .02 12/18/2008 134,994


ADJUSTMENTS TO PROVIDER .04


ADJUSTMENTS TO PROGRAM .50 8/11/2008 8,917 8/15/2008 54,730

ADJUSTMENTS TO PROGRAM .51 12/18/2008 186,803

ADJUSTMENTS TO PROGRAM .52



SUBTOTAL .99 408,860 -85,290

4 TOTAL INTERIM PAYMENTS 3,013,239 2,433,863

TO BE COMPLETED BY INTERMEDIARY

5 LIST SEPARATELY EACH TENTATIVE SETTLEMENT PAYMENT

AFTER DESK REVIEW. ALSO SHOW DATE OF EACH PAYMENT.

IF NONE, WRITE "NONE" OR ENTER A ZERO. (1)

TENTATIVE TO PROVIDER .01



TENTATIVE TO PROGRAM .50



SUBTOTAL .99 NONE NONE

6 DETERMINED NET SETTLEMENT SETTLEMENT TO PROVIDER .01

AMOUNT (BALANCE DUE) SETTLEMENT TO PROGRAM .02 318,220 59,633

BASED ON COST REPORT (1)

7 TOTAL MEDICARE PROGRAM LIABILITY 2,695,019 2,374,230

NAME OF INTERMEDIARY:

INTERMEDIARY NO:

SIGNATURE OF AUTHORIZED PERSON: ___________________________________________________

DATE: ___/___/___

____________________________________________________________________________________________________________________________________

(1) ON LINES 3, 5 AND 6, WHERE AN AMOUNT IS DUE PROVIDER TO PROGRAM, SHOW THE AMOUNT AND DATE ON WHICH THE PROVIDER

AGREES TO THE AMOUNT OF REPAYMENT, EVEN THOUGH TOTAL REPAYMENT IS NOT ACCOMPLISHED UNTIL A LATER DATE.



ANALYSIS OF PAYMENTS TO PROVIDERS FOR SERVICES RENDERED I 15-1327 I FROM 1/ 1/2008 I WORKSHEET E-1


I 15-Z327 I I

TITLE XVIII SWING BED SNF

DESCRIPTION INPATIENT-PART A P A R T B


1 2 3 4

1 TOTAL INTERIM PAYMENTS PAID TO PROVIDER 394,709





ENTER A ZERO.





ZERO. (1)






ADJUSTMENTS TO PROGRAM .50 12/18/2008 1,689





SUBTOTAL .99 15,797 NONE

4 TOTAL INTERIM PAYMENTS 410,506












6 DETERMINED NET SETTLEMENT SETTLEMENT TO PROVIDER .01 14,263

AMOUNT (BALANCE DUE) SETTLEMENT TO PROGRAM .02


7 TOTAL MEDICARE PROGRAM LIABILITY 424,769


INTERMEDIARY NO:


DATE: ___/___/___

____________________________________________________________________________________________________________________________________



Health Financial Systems MCRIF32 FOR SULLIVAN COUNTY COMMUNITY HOSPITAL IN LIEU OF FORM CMS-2552-96-E-2 (05/2004)


CALCULATION OF REIMBURSEMENT SETTLEMENT I 15-1327 I FROM 1/ 1/2008 I

SWING BEDS I COMPONENT NO: I TO 12/31/2008 I WORKSHEET E-2

I 15-Z327 I I

TITLE XVIII SWING BED SNF

PART A PART B

COMPUTATION OF NET COST OF COVERED SERVICES 1 2

1 INPATIENT ROUTINE SERVICES - SWING BED-SNF (SEE INSTR) 295,238

2 INPATIENT ROUTINE SERVICES - SWING BED-NF (SEE INSTR)

3 ANCILLARY SERVICES (SEE INSTRUCTIONS) 131,835

4 PER DIEM COST FOR INTERNS AND RESIDENTS NOT IN APPROVED

TEACHING PROGRAM (SEE INSTRUCTIONS)

5 PROGRAM DAYS 380

6 INTERNS AND RESIDENTS NOT IN APPROVED TEACHING PROGRAM

(SEE INSTRUCTIONS)

7 UTILIZATION REVIEW - PHYSICIAN COMPENSATION - SNF OPTIONAL

METHOD ONLY

8 SUBTOTAL 427,073

9 PRIMARY PAYER PAYMENTS (SEE INSTRUCTIONS)

10 SUBTOTAL 427,073

11 DEDUCTIBLES BILLED TO PROGRAM PATIENTS (EXCLUDE AMOUNTS

APPLICABLE TO PHYSICIAN PROFESSIONAL SERVICES)

12 SUBTOTAL 427,073

13 COINSURANCE BILLED TO PROGRAM PATIENTS (FROM PROVIDER 2,304

RECORDS)(EXCLUDE COINSURANCE FOR PHYSICIAN

PROFESSIONAL SERVICES)

14 80% OF PART B COSTS

15 SUBTOTAL 424,769


17 REIMBURSABLE BAD DEBTS

17.01 REIMBURSABLE BAD DEBTS FOR DUAL ELIGIBLE BENEFICIARIES

(SEE INSTRUCTIONS)

18 TOTAL 424,769


20 INTERIM PAYMENTS 410,506


21 BALANCE DUE PROVIDER/PROGRAM 14,263


IN ACCORDANCE WITH CMS PUB. 15-II, SECTION 115.2.



CALCULATION OF REIMBURSEMENT SETTLEMENT I 15-1327 I FROM 1/ 1/2008 I WORKSHEET E-3


I 15-1327 I I

PART II - MEDICARE PART A SERVICES - COST REIMBURSEMENT

HOSPITAL

1 INPATIENT SERVICES 3,021,239

1.01 NURSING AND ALLIED HEALTH MANAGED CARE PAYMENT

2 ORGAN ACQUISITION

3 COST OF TEACHING PHYSICIANS

4 SUBTOTAL 3,021,239

5 PRIMARY PAYER PAYMENTS 2,871

6 TOTAL COST. FOR CAH (SEE INSTRUCTIONS) 3,048,552


REASONABLE CHARGES

7 ROUTINE SERVICE CHARGES

8 ANCILLARY SERVICE CHARGES

9 ORGAN ACQUISITION CHARGES, NET OF REVENUE

10 TEACHING PHYSICIANS

11 TOTAL REASONABLE CHARGES

CUSTOMARY CHARGES

12 AGGREGATE AMOUNT ACTUALLY COLLECTED FROM PATIENTS LIA BLE

FOR PAYMENT FOR SERVICES ON A CHARGE BASIS



BEEN MADE IN ACCORDANCE WITH 42 CFR 413.13(e)

14 RATIO OF LINE 12 TO LINE 13 (NOT TO EXCEED 1.000000)

15 TOTAL CUSTOMARY CHARGES (SEE INSTRUCTIONS)





19 COST OF COVERED SERVICES 3,048,552

20 DEDUCTIBLES (EXCLUDE PROFESSIONAL COMPONENT) 415,680

21 EXCESS REASONABLE COST

22 SUBTOTAL 2,632,872

23 COINSURANCE

24 SUBTOTAL 2,632,872

25 REIMBURSABLE BAD DEBTS (EXCLUDE BAD DEBTS FOR PROFESS IONAL 62,147

SERVICES (SEE INSTRUCTIONS)

25.01 ADJUSTED REIMBURSABLE BAD DEBTS (SEE INSTRUCTIONS) 62,147

25.02 REIMBURSABLE BAD DEBTS FOR DUAL ELIGIBLE BENEFICIARIES 38,388

26 SUBTOTAL 2,695,019

27 RECOVERY OF EXCESS DEPRECIATION RESULTING FROM PROVID ER

TERMINATION OR A DECREASE IN PROGRAM UTILIZATION


29 AMOUNTS APPLICABLE TO PRIOR COST REPORTING PERIODS

RESULTING FROM DISPOSITION OF DEPRECIABLE ASSETS

30 SUBTOTAL 2,695,019

31 SEQUESTRATION ADJUSTMENT



33 BALANCE DUE PROVIDER/PROGRAM -318,220







I - I I

PART III - TITLE V OR TITLE XIX SERVICES OR TITLE XVIII SNF PPS ONLY

TITLE XIX HOSPITAL

TITLE V OR TITLE XVIII

TITLE XIX SNF PPS

1 2

COMPUTATION OF NET COST OF COVERED SERVICE

1 INPATIENT HOSPITAL/SNF/NF SERVICES 406,822

2 MEDICAL AND OTHER SERVICES 1,413,782

3 INTERNS AND RESIDENTS (SEE INSTRUCTIONS)

4 ORGAN ACQUISITION (CERT TRANSPLANT CENTERS ONLY)

5 COST OF TEACHING PHYSICIANS (SEE INSTRUCTIONS)


7 INPATIENT PRIMARY PAYER PAYMENTS

8 OUTPATIENT PRIMARY PAYER PAYMENTS



REASONABLE CHARGES

10 ROUTINE SERVICE CHARGES

11 ANCILLARY SERVICE CHARGES 6,297,120

12 INTERNS AND RESIDENTS SERVICE CHARGES

13 ORGAN ACQUISITION CHARGES, NET OF REVENUE

14 TEACHING PHYSICIANS

15 INCENTIVE FROM TARGET AMOUNT COMPUTATION

16 TOTAL REASONABLE CHARGES 6,297,120

CUSTOMARY CHARGES

17 AMOUNT ACTUALLY COLLECTED FROM PATIENTS LIABLE FOR




BEEN MADE IN ACCORDANCE WITH 42 CFR 413.13(e)

19 RATIO OF LINE 17 TO LINE 18

20 TOTAL CUSTOMARY CHARGES (SEE INSTRUCTIONS) 6,297,120

21 EXCESS OF CUSTOMARY CHARGES OVER REASONABLE COST 4,476,516


23 COST OF COVERED SERVICES 1,820,604

PROSPECTIVE PAYMENT AMOUNT

24 OTHER THAN OUTLIER PAYMENTS

25 OUTLIER PAYMENTS

26 PROGRAM CAPITAL PAYMENTS

27 CAPITAL EXCEPTION PAYMENTS (SEE INSTRUCTIONS)

28 ROUTINE SERVICE OTHER PASS THROUGH COSTS

29 ANCILLARY SERVICE OTHER PASS THROUGH COSTS

30 SUBTOTAL 1,820,604

31 CUSTOMARY CHARGES (TITLE XIX PPS COVERED SERVICES ONLY)

32 TITLES V OR XIX PPS, LESSER OF LNS 30 OR 31; NON PPS & TITLE 1,820,604

XVIII ENTER AMOUNT FROM LINE 30

33 DEDUCTIBLES (EXCLUDE PROFESSIONAL COMPONENT)


34 EXCESS OF REASONABLE COST

35 SUBTOTAL 1,820,604

36 COINSURANCE

37 SUM OF AMOUNTS FROM WKST. E, PARTS C, D & E, LN 19

38 REIMBURSABLE BAD DEBTS (SEE INSTRUCTIONS)

38.01 ADJUSTED REIMBURSABLE BAD DEBTS FOR PERIODS ENDING

BEFORE 10/01/05 (SEE INSTRUCTIONS)

38.02 REIMBURSABLE BAD DEBTS FOR DUAL ELIGIBLE BENEFICIARIES

38.03 ADJUSTED REIMBURSABLE BAD DEBTS FOR PERIODS BEGINNING

ON OR AFTER 10/01/05 (SEE INSTRUCTIONS)

39 UTILIZATION REVIEW

40 SUBTOTAL (SEE INSTRUCTIONS) 1,820,604


42 MEDICARE INPATIENT ROUTINE CHARGES




FOR PAYMENT OF PART A SERVICES

45 RATIO OF LINE 43 TO 44

46 TOTAL CUSTOMARY CHARGES



49 RECOVERY OF EXCESS DEPRECIATION RESULTING FROM PROVIDER

TERMINATION OR A DECREASE IN PROGRAM UTILIZATION




52 SUBTOTAL 1,820,604

53 INDIRECT MEDICAL EDUCATION ADJUSTMENT (PPS ONLY)


55 TOTAL AMOUNT PAYABLE TO THE PROVIDER 1,820,604




58 BALANCE DUE PROVIDER/PROGRAM






I - I I

PART III - TITLE V OR TITLE XIX SERVICES OR TITLE XVIII SNF PPS ONLY

TITLE XIX HOSPITAL

TITLE V OR TITLE XVIII

TITLE XIX SNF PPS

1 2




BALANCE SHEET I 15-1327 I FROM 1/ 1/2008 I

I I TO 12/31/2008 I WORKSHEET G

GENERAL SPECIFIC ENDOWMENT PLANT

FUND PURPOSE FUND FUND

ASSETS FUND

1 2 3 4

CURRENT ASSETS

1 CASH ON HAND AND IN BANKS 4,245,212

2 TEMPORARY INVESTMENTS 11,331,342

3 NOTES RECEIVABLE

4 ACCOUNTS RECEIVABLE 6,620,391

5 OTHER RECEIVABLES 50,227

6 LESS: ALLOWANCE FOR UNCOLLECTIBLE NOTES & ACCOUNTS -4,160,660

RECEIVABLE

7 INVENTORY 341,419

8 PREPAID EXPENSES 1,481,042

9 OTHER CURRENT ASSETS

10 DUE FROM OTHER FUNDS

11 TOTAL CURRENT ASSETS 19,908,973

FIXED ASSETS

12 LAND 1,197,839

12.01

13 LAND IMPROVEMENTS 52,640

13.01 LESS ACCUMULATED DEPRECIATION

14 BUILDINGS 16,699,250

14.01 LESS ACCUMULATED DEPRECIATION -13,601,337

15 LEASEHOLD IMPROVEMENTS


16 FIXED EQUIPMENT 788,899


17 AUTOMOBILES AND TRUCKS


18 MAJOR MOVABLE EQUIPMENT 9,343,523


19 MINOR EQUIPMENT DEPRECIABLE


20 MINOR EQUIPMENT-NONDEPRECIABLE

21 TOTAL FIXED ASSETS 14,480,814

OTHER ASSETS

22 INVESTMENTS

23 DEPOSITS ON LEASES

24 DUE FROM OWNERS/OFFICERS

25 OTHER ASSETS

26 TOTAL OTHER ASSETS

27 TOTAL ASSETS 34,389,787



BALANCE SHEET I 15-1327 I FROM 1/ 1/2008 I

I I TO 12/31/2008 I WORKSHEET G

GENERAL SPECIFIC ENDOWMENT PLANT

FUND PURPOSE FUND FUND

LIABILITIES AND FUND BALANCE FUND

1 2 3 4

CURRENT LIABILITIES

28 ACCOUNTS PAYABLE 384,553

29 SALARIES, WAGES & FEES PAYABLE 238,955

30 PAYROLL TAXES PAYABLE 364,506

31 NOTES AND LOANS PAYABLE (SHORT TERM)

32 DEFERRED INCOME

33 ACCELERATED PAYMENTS

34 DUE TO OTHER FUNDS

35 OTHER CURRENT LIABILITIES 1,557,065

36 TOTAL CURRENT LIABILITIES 2,545,079

LONG TERM LIABILITIES

37 MORTGAGE PAYABLE

38 NOTES PAYABLE

39 UNSECURED LOANS

40.01 LOANS PRIOR TO 7/1/66

40.02 ON OR AFTER 7/1/66

41 OTHER LONG TERM LIABILITIES 6,255,000

42 TOTAL LONG-TERM LIABILITIES 6,255,000

43 TOTAL LIABILITIES 8,800,079

CAPITAL ACCOUNTS

44 GENERAL FUND BALANCE 25,589,708

45 SPECIFIC PURPOSE FUND

46 DONOR CREATED- ENDOWMENT FUND BALANCE- RESTRICTED

47 DONOR CREATED- ENDOWMENT FUND BALANCE- UNRESTRICT

48 GOVERNING BODY CREATED- ENDOWMENT FUND BALANCE

49 PLANT FUND BALANCE-INVESTED IN PLANT

50 PLANT FUND BALANCE- RESERVE FOR PLANT IMPROVEMENT,

REPLACEMENT AND EXPANSION

51 TOTAL FUND BALANCES 25,589,708

52 TOTAL LIABILITIES AND FUND BALANCES 34,389,787



STATEMENT OF CHANGES IN FUND BALANCES I 15-1327 I FROM 1/ 1/2008 I WORKSHEET G-1

I I TO 12/31/2008 I

GENERAL FUND SPECIFIC PURPOSE FUND

1 2 3 4

1 FUND BALANCE AT BEGINNING 21,293,311

OF PERIOD

2 NET INCOME (LOSS) 4,299,462

3 TOTAL 25,592,773

ADDITIONS (CREDIT ADJUSTMENTS) (SPECIFY)

4 ADDITIONS (CREDIT ADJUSTM

5

6

7

8

9

10 TOTAL ADDITIONS

11 SUBTOTAL 25,592,773

DEDUCTIONS (DEBIT ADJUSTMENTS) (SPECIFY)

12 DEDUCTIONS (DEBIT ADJUSTM 3,065

13

14

15

16

17

18 TOTAL DEDUCTIONS 3,065

19 FUND BALANCE AT END OF 25,589,708

PERIOD PER BALANCE SHEET

ENDOWMENT FUND PLANT FUND

5 6 7 8

1 FUND BALANCE AT BEGINNING

OF PERIOD

2 NET INCOME (LOSS)

3 TOTAL

ADDITIONS (CREDIT ADJUSTMENTS) (SPECIFY)

4 ADDITIONS (CREDIT ADJUSTM

5

6

7

8

9

10 TOTAL ADDITIONS

11 SUBTOTAL

DEDUCTIONS (DEBIT ADJUSTMENTS) (SPECIFY)

12 DEDUCTIONS (DEBIT ADJUSTM

13

14

15

16

17

18 TOTAL DEDUCTIONS

19 FUND BALANCE AT END OF

PERIOD PER BALANCE SHEET



STATEMENT OF PATIENT REVENUES AND OPERATING EXPENSES I 15-1327 I FROM 1/ 1/2008 I WORKSHEET G-2

I I TO 12/31/2008 I PARTS I & II

PART I - PATIENT REVENUES

REVENUE CENTER INPATIENT OUTPATIENT TOTAL

1 2 3

GENERAL INPATIENT ROUTINE CARE SERVICES

1 00 HOSPITAL 3,160,910 3,160,910

4 00 SWING BED - SNF 178,836 178,836

5 00 SWING BED - NF

9 00 TOTAL GENERAL INPATIENT ROUTINE CARE 3,339,746 3,339,746

INTENSIVE CARE TYPE INPATIENT HOSPITAL SVCS

10 00 INTENSIVE CARE UNIT 694,690 694,690

15 00 TOTAL INTENSIVE CARE TYPE INPAT HOSP 694,690 694,690

16 00 TOTAL INPATIENT ROUTINE CARE SERVICE 4,034,436 4,034,436

17 00 ANCILLARY SERVICES 7,387,618 36,436,848 43,824,466

18 00 OUTPATIENT SERVICES

19 00 HOME HEALTH AGENCY

23 00 HOSPICE

24 00 IDENTIFIED ON TRIAL BALANCE 189,514 967,827 1,157,341

25 00 TOTAL PATIENT REVENUES 11,611,568 37,404,675 49,016,243

PART II-OPERATING EXPENSES

26 00 OPERATING EXPENSES 19,620,325

ADD (SPECIFY)

27 00 ADD (SPECIFY)

28 00

29 00

30 00

31 00

32 00

33 00 TOTAL ADDITIONS

DEDUCT (SPECIFY)

34 00 DEDUCT (SPECIFY)

35 00

36 00

37 00

38 00

39 00 TOTAL DEDUCTIONS

40 00 TOTAL OPERATING EXPENSES 19,620,325



STATEMENT OF REVENUES AND EXPENSES I 15-1327 I FROM 1/ 1/2008 I WORKSHEET G-3

I I TO 12/31/2008 I

DESCRIPTION

1 TOTAL PATIENT REVENUES 49,016,243

2 LESS: ALLOWANCES AND DISCOUNTS ON PATIENT'S ACCTS 25,733,007

3 NET PATIENT REVENUES 23,283,236

4 LESS: TOTAL OPERATING EXPENSES 19,620,325

5 NET INCOME FROM SERVICE TO PATIENTS 3,662,911

OTHER INCOME

6 CONTRIBUTIONS, DONATIONS, BEQUESTS, ETC. 29,300

7 INCOME FROM INVESTMENTS 431,889

8 REVENUE FROM TELEPHONE AND TELEGRAPH SERVICE

9 REVENUE FROM TELEVISION AND RADIO SERVICE

10 PURCHASE DISCOUNTS

11 REBATES AND REFUNDS OF EXPENSES

12 PARKING LOT RECEIPTS

13 REVENUE FROM LAUNDRY AND LINEN SERVICE

14 REVENUE FROM MEALS SOLD TO EMPLOYEES AND GUESTS 124,114

15 REVENUE FROM RENTAL OF LIVING QUARTERS

16 REVENUE FROM SALE OF MEDICAL & SURGICAL SUPPLIES 271

TO OTHER THAN PATIENTS

17 REVENUE FROM SALE OF DRUGS TO OTHR THAN PATIENTS 9,946

18 REVENUE FROM SALE OF MEDICAL RECORDS & ABSTRACTS 4,704

19 TUITION (FEES, SALE OF TEXTBOOKS, UNIFORMS, ETC)

20 REVENUE FROM GIFTS,FLOWER, COFFEE SHOP & CANTEEN

21 RENTAL OF VENDING MACHINES 1,884

22 RENTAL OF HOSPITAL SPACE 4,500

23 GOVERNMENTAL APPROPRIATIONS

24 IDENTIFIED ON TRIAL BALANCE 29,943

25 TOTAL OTHER INCOME 636,551

26 TOTAL 4,299,462

OTHER EXPENSES

27 OTHER EXPENSES (SPECIFY)

28

29

30 TOTAL OTHER EXPENSES

31 NET INCOME (OR LOSS) FOR THE PERIOD 4,299,462


ANALYSIS OF PROVIDER-BASED I PROVIDER NO: I PERIOD: I PREPARED 5/15/2009

HOME HEALTH AGENCY COSTS I 15-1327 I FROM 1/ 1/2008 I WORKSHEET H

I HHA NO: I TO 12/31/2008 I

I 15-7542 I I

HHA 1

SALARIES EMPLOYEE TRANSPORTATION CONTRACTED/ OTHER COSTS TOTAL

BENEFITS PURCHASED SVCS

1 2 3 4 5 6

GENERAL SERVICE COST CENTERS

1 CAP-REL COST-BLDG & FIX

2 CAP-REL COST-MOV EQUIP

3 PLANT OPER & MAINT

4 TRANSPORTATION

5 ADMIN & GENERAL 113,983 8,278 24,244 146,505

HHA REIMBURSABLE SERVICES

6 SKILLED NURSING CARE 154,553 11,223 165,776



9 SPEECH PATHOLOGY 3,508 255 3,763

10 MEDICAL SOCIAL SERVICES 3,537 257 3,794

11 HOME HEALTH AIDE 28,269 2,053 30,322

12 SUPPLIES

13 DRUGS

13.20 COST ADMINISTERING DRUGS

14 DME

HHA NONREIMBURSABLE SERVICES

15 HOME DIALYSIS AIDE SVCS


17 PRIVATE DUTY NURSING

18 CLINIC

19 HEALTH PROM ACTIVITIES

20 DAY CARE PROGRAM

21 HOME DEL MEALS PROGRAM

22 HOMEMAKER SERVICE

23 ALL OTHER

23.50 TELEMEDICINE

24 TOTAL (SUM OF LINES 1-23) 417,080 30,289 24,244 471,613

RECLASSIFI- RECLASSIFIED NET EXPENSES

CATIONS TRIAL BALANCE ADJUSTMENTS FOR ALLOCATION

7 8 9 10





4 TRANSPORTATION

5 ADMIN & GENERAL 146,505 146,505


6 SKILLED NURSING CARE 165,776 165,776

7 PHYSICAL THERAPY 101,290 101,290


9 SPEECH PATHOLOGY 3,763 3,763

10 MEDICAL SOCIAL SERVICES 3,794 3,794

11 HOME HEALTH AIDE 30,322 30,322

12 SUPPLIES

13 DRUGS


14 DME





18 CLINIC


20 DAY CARE PROGRAM



23 ALL OTHER

23.50 TELEMEDICINE

24 TOTAL (SUM OF LINES 1-23) 471,613 471,613


COST ALLOCATION - I PROVIDER NO: I PERIOD: I PREPARED 5/15/2009

HHA GENERAL SERVICE COST I 15-1327 I FROM 1/ 1/2008 I WORKSHEET H-4

I HHA NO: I TO 12/31/2008 I PART I

I 15-7542 I I

HHA 1

NET EXPENSES CAP-REL CAP-REL PLANT OPER & TRANSPORTATIO SUBTOTAL ADMINISTRATIV

FOR COST COST-BLDG & COST-MOV MAINT N E & GENERAL

ALLOCATION FIX EQUIP

0 1 2 3 4 4A 5





4 TRANSPORTATION

5 ADMINISTRATIVE & GENERAL 146,505 146,505 146,505






10 MEDICAL SOCIAL SERVICES 3,794 3,794 1,710

11 HOME HEALTH AIDE 30,322 30,322 13,664

12 SUPPLIES

13 DRUGS


14 DME





18 CLINIC


20 DAY CARE PROGRAM



23 ALL OTHERS

23.50 TELEMEDICINE

24 TOTAL (SUM OF LINES 1-23) 471,613 471,613

TOTAL

6





4 TRANSPORTATION

5 ADMINISTRATIVE & GENERAL


6 SKILLED NURSING CARE 240,480




10 MEDICAL SOCIAL SERVICES 5,504

11 HOME HEALTH AIDE 43,986

12 SUPPLIES

13 DRUGS


14 DME





18 CLINIC


20 DAY CARE PROGRAM



23 ALL OTHERS

23.50 TELEMEDICINE

24 TOTAL (SUM OF LINES 1-23) 471,613


COST ALLOCATION - I PROVIDER NO: I PERIOD: I PREPARED 5/15/2009

HHA STATISTICAL BASIS I 15-1327 I FROM 1/ 1/2008 I WORKSHEET H-4

I HHA NO: I TO 12/31/2008 I PART II

I 15-7542 I I

HHA 1

CAP-REL CAP-REL PLANT OPER & TRANSPORTATIO RECONCILIATIO ADMINISTRATIV

COST-BLDG & COST-MOV MAINT N N E & GENERAL

FIX EQUIP

( SQUARE ( DOLLAR ( SQUARE ( MILEAGE ( ACCUM.

FEET ) VALUE ) FEET ) ) ( COST )

1 2 3 4 5A 5





4 TRANSPORTATION

5 ADMINISTRATIVE & GENERAL -146,505 325,108


6 SKILLED NURSING CARE 165,776




10 MEDICAL SOCIAL SERVICES 3,794

11 HOME HEALTH AIDE 30,322

12 SUPPLIES

13 DRUGS


14 DME





18 CLINIC


20 DAY CARE PROGRAM



23 ALL OTHERS

23.50 TELEMEDICINE

24 TOTAL (SUM OF LINES 1-23) -146,505 325,108

25 COST TO BE ALLOCATED 146,505

26 UNIT COST MULIPLIER .450635


ALLOCATION OF GENERAL SERVICE I PROVIDER NO: I PERIOD: I PREPARED 5/15/2009

COSTS TO HHA COST CENTERS I 15-1327 I FROM 1/ 1/2008 I WORKSHEET H-5


I 15-7542 I I

HHA 1

HHA TRIAL NEW CAP REL NEW CAP REL EMPLOYEE BEN IS/ACCOUNTIN BUSINESS OFF

BALANCE (1) COSTS-BLDG & COSTS-MVBLE EFITS G/MARKETING ICE & ADMITT

HHA COST CENTER 0 3 4 5 6.01 6.02

1 ADMIN & GENERAL 10,811 13,288 27,390 1,843 3,336

2 SKILLED NURSING CARE 240,480 37,138 7,613 13,779


4 OCCUPATIONAL THERAPY 29,249 4,517 926 1,676

5 SPEECH PATHOLOGY 5,459 843 173 313

6 MEDICAL SOCIAL SERVICES 5,504 850 174 315

7 HOME HEALTH AIDE 43,986 6,793 1,392 2,520

8 SUPPLIES

9 DRUGS


10 DME




14 CLINIC


16 DAY CARE PROGRAM



19 ALL OTHER

19.50 TELEMEDICINE

20 TOTAL (SUM OF 1-19) (2) 471,613 10,811 13,288 100,223 16,772 30,358

21 UNIT COST MULIPLIER

(1) COLUMN 0, LINE 20 MUST AGREE WITH WKST. A, COLUMN 7, LINE 71.

(2) COLUMNS 0 THROUGH 27, LINE 20 MUST AGREE WITH THE CORRESPONDING COLUMNS OF WKST. B, PART I, LINE 71.

SUBTOTAL OTHER ADMINI OPERATION OF LAUNDRY & LI HOUSEKEEPING DIETARY

STRATIVE AND PLANT NEN SERVICE

HHA COST CENTER 6A.02 6.03 8 9 10 11

1 ADMIN & GENERAL 56,668 4,056 20,351 7,245


3 PHYSICAL THERAPY 182,697 13,077


5 SPEECH PATHOLOGY 6,788 486

6 MEDICAL SOCIAL SERVICES 6,843 490


8 SUPPLIES

9 DRUGS


10 DME




14 CLINIC


16 DAY CARE PROGRAM



19 ALL OTHER

19.50 TELEMEDICINE

20 TOTAL (SUM OF 1-19) (2) 643,065 46,029 20,351 7,245








I 15-7542 I I

HHA 1

CAFETERIA NURSING ADMI CENTRAL SERV PHARMACY MEDICAL RECO SUBTOTAL

NISTRATION ICES & SUPPL RDS & LIBRAR

HHA COST CENTER 12 14 15 16 17 25

1 ADMIN & GENERAL 6,198 37,535 937 132,990


3 PHYSICAL THERAPY 763 196,537

4 OCCUPATIONAL THERAPY 149 39,120

5 SPEECH PATHOLOGY 149 7,423

6 MEDICAL SOCIAL SERVICES 1,136 8,469


8 SUPPLIES

9 DRUGS


10 DME




14 CLINIC


16 DAY CARE PROGRAM



19 ALL OTHER

19.50 TELEMEDICINE

20 TOTAL (SUM OF 1-19) (2) 16,754 37,535 937 771,916




POST STEP SUBTOTAL ALLOCATED TOTAL HHA

DOWN ADJUST HHA A & G COSTS

HHA COST CENTER 26 27 28 29

1 ADMIN & GENERAL 132,990






7 HOME HEALTH AIDE 63,167 13,148 76,315

8 SUPPLIES

9 DRUGS


10 DME




14 CLINIC


16 DAY CARE PROGRAM



19 ALL OTHER

19.50 TELEMEDICINE

20 TOTAL (SUM OF 1-19) (2) 771,916 132,990 771,916

21 UNIT COST MULIPLIER 0.208146






STATISTICAL BASIS I HHA NO: I TO 12/31/2008 I PART II

I 15-7542 I I

HHA 1

NEW CAP REL NEW CAP REL EMPLOYEE BEN IS/ACCOUNTIN BUSINESS OFF RECONCILIATI

COSTS-BLDG & COSTS-MVBLE EFITS G/MARKETING ICE & ADMITT ON

(SQUARE (SQUARE ( GROSS (ACCUM. COS (ACCUM. COS

FEET ) FEET ) SALARIES ) T ) T )

HHA COST CENTER 3 4 5 6.01 6.02 6A.03

1 ADMIN & GENERAL 1,231 1,231 113,983 65,647 67,494






7 HOME HEALTH AIDE 28,269 49,588 50,982

8 SUPPLIES

9 DRUGS


10 DME




14 CLINIC


16 DAY CARE PROGRAM



19 ALL OTHER

19.50 TELEMEDICINE

20 TOTAL (SUM OF 1-19) 1,231 1,231 417,080 597,319 614,120

21 COST TO BE ALLOCATED 10,811 13,288 100,223 16,772 30,358

22 UNIT COST MULIPLIER 8.782291 10.794476 0.240297 0.028079 0.049433

OTHER ADMINI OPERATION OF LAUNDRY & LI HOUSEKEEPING DIETARY CAFETERIA

STRATIVE AND PLANT NEN SERVICE

( ACCUM. (SQUARE (POUNDS OF (SQUARE (MEALS S (FTE'S

COST ) FEET ) LAUNDRY ) FEET ) ERVED ) )

HHA COST CENTER 6.03 8 9 10 11 12

1 ADMIN & GENERAL 56,668 1,231 1,231 333

2 SKILLED NURSING CARE 299,010 204

3 PHYSICAL THERAPY 182,697 41

4 OCCUPATIONAL THERAPY 36,368 8

5 SPEECH PATHOLOGY 6,788 8

6 MEDICAL SOCIAL SERVICES 6,843 61

7 HOME HEALTH AIDE 54,691 245

8 SUPPLIES

9 DRUGS


10 DME




14 CLINIC


16 DAY CARE PROGRAM



19 ALL OTHER

19.50 TELEMEDICINE

20 TOTAL (SUM OF 1-19) 643,065 1,231 1,231 900

21 COST TO BE ALLOCATED 46,029 20,351 7,245 16,754

22 UNIT COST MULIPLIER 0.071578 16.532088 5.885459 18.615556




STATISTICAL BASIS I HHA NO: I TO 12/31/2008 I PART II

I 15-7542 I I

HHA 1

NURSING ADMI CENTRAL SERV PHARMACY MEDICAL RECO

NISTRATION ICES & SUPPL RDS & LIBRAR

(DIRECT NR (COSTED R (COSTED R ( GROSS

SING HRS ) EQUIS. ) EQUIS. ) CHARGES )

HHA COST CENTER 14 15 16 17

1 ADMIN & GENERAL 18,726 2,635

2 SKILLED NURSING CARE

3 PHYSICAL THERAPY


5 SPEECH PATHOLOGY

6 MEDICAL SOCIAL SERVICES

7 HOME HEALTH AIDE

8 SUPPLIES

9 DRUGS


10 DME




14 CLINIC


16 DAY CARE PROGRAM



19 ALL OTHER

19.50 TELEMEDICINE

20 TOTAL (SUM OF 1-19) 18,726 2,635

21 COST TO BE ALLOCATED 37,535 937

22 UNIT COST MULIPLIER 2.004432 0.355598


APPORTIONMENT OF PATIENT SERVICE COSTS I PROVIDER NO: I PERIOD: I PREPARED 5/15/2009

I 15-1327 I FROM 1/ 1/2008 I WORKSHEET H-6

I HHA NO: I TO 12/31/2008 I PARTS I II & III

I 15-7542 I I HHA 1

[ ] TITLE V [X] TITLE XVIII [ ] TITLE XIX

PART I - APPORTIONMENT OF HHA COST CENTERS:

COMPUTATION OF THE LESSER OF AGGREGATE MEDICARE COST OR THE AGGREGATE OF THE MEDICARE LIMITATION

FROM FACILITY SHARED

COST PER VISIT WKST H-5 COSTS ANCILLARY PROGRAM

COMPUTATION PART I (FROM COSTS AVERAGE VISITS

COL. 29, WKST H-5 (FROM TOTAL HHA TOTAL COST

PATIENT SERVICES LINE: PART I) PART II) COSTS VISITS PER VISIT PART A

1 2 3 4 5 6

1 SKILLED NURSING 2 391,693 391,693 1,683 232.73 537

2 PHYSICAL THERAPY 3 237,445 237,445 1,455 163.19 295

3 OCCUPATIONAL THERAPY 4 47,263 47,263 406 116.41 85

4 SPEECH PATHOLOGY 5 8,968 8,968 163 55.02 5

5 MEDICAL SOCIAL SERVICES 6 10,232 10,232 17 601.88 6

6 HOME HEALTH AIDE SERVICE 7 76,315 76,315 1,044 73.10 192

7 TOTAL 771,916 771,916 4,768 1,120

-----PROGRAM VISITS----- -------------COST OF SERVICES--------

---------PART B--------- ---------PART B---------

NOT SUBJECT SUBJECT NOT SUBJECT SUBJECT TOTAL

TO DEDUCT TO DEDUCT TO DEDUCT TO DEDUCT PROGRAM

& COINSUR & COINSUR PART A & COINSUR & COINSUR COST

7 8 9 10 11 12

1 SKILLED NURSING 636 124,976 148,016 272,992


3 OCCUPATIONAL THERAPY 112 9,895 13,038 22,933

4 SPEECH PATHOLOGY 10 275 550 825

5 MEDICAL SOCIAL SERVICES 9 3,611 5,417 9,028

6 HOME HEALTH AIDE SERVICES 517 14,035 37,793 51,828

7 TOTAL 1,674 200,933 268,458 469,391

LIMITATION COST PROGRAM

COMPUTATION PROGRAM VISITS

COST

PATIENT SERVICES LIMITS PART A

1 2 3 4 5 6

8 SKILLED NURSING

9 PHYSICAL THERAPY


11 SPEECH PATHOLOGY


13 HOME HEALTH AIDE SERVICE

14 TOTAL

-----PROGRAM VISITS----- -------------COST OF SERVICES--------

---------PART B--------- ---------PART B---------

NOT SUBJECT SUBJECT NOT SUBJECT SUBJECT TOTAL

TO DEDUCT TO DEDUCT TO DEDUCT TO DEDUCT PROGRAM

& COINSUR & COINSUR PART A & COINSUR & COINSUR COST

7 8 9 10 11 12

8 SKILLED NURSING

9 PHYSICAL THERAPY


11 SPEECH PATHOLOGY


13 HOME HEALTH AIDE SERVICE

14 TOTAL


APPORTIONMENT OF PATIENT SERVICE COSTS I PROVIDER NO: I PERIOD: I PREPARED 5/15/2009

I 15-1327 I FROM 1/ 1/2008 I WORKSHEET H-6

I HHA NO: I TO 12/31/2008 I PARTS I II & III

I 15-7542 I I HHA 1

[ ] TITLE V [X] TITLE XVIII [ ] TITLE XIX

PART I - APPORTIONMENT OF HHA COST CENTERS:

COMPUTATION OF THE LESSER OF AGGREGATE MEDICARE COST OR THE AGGREGATE OF THE MEDICARE LIMITATION

FROM FACILITY SHARED

SUPPLIES AND EQUIPMENT WKST H-5 COSTS ANCILLARY PROGRAM

COST COMPUTATION PART I (FROM COSTS COVERED

COL. 29, WKST H-5 (FROM TOTAL HHA TOTAL CHARGES

OTHER PATIENT SERVICES LINE: PART I) PART II) COSTS CHARGES RATIO PART A

1 2 3 4 5 6

15 COST OF MEDICAL SUPPLIES 8.00 9,055 3,794

16 COST OF DRUGS 9.00

16.20 COST OF DRUGS 9.20

PROGRAM COVERED CHARGES -------------COST OF SERVICES--------

---------PART B--------- ---------PART B---------

NOT SUBJECT SUBJECT NOT SUBJECT SUBJECT

TO DEDUCT TO DEDUCT TO DEDUCT TO DEDUCT

& COINSUR & COINSUR PART A & COINSUR & COINSUR

7 8 9 10 11

15 COST OF MEDICAL SUPPLIES 5,261

16 COST OF DRUGS

16.20 COST OF DRUGS

PER BENEFICIARY COST MSA

LIMITATION: NUMBER AMOUNT

1 2

162 PROGRAM UNDUP CENSUS FROM WRKST S-4

17 PER BENE COST LIMITATION (FRM FI)

18 PER BENE COST LIMITATION (LN 17*18)

PART II - APPORTIONMENT OF COST OF HHA SERVICES FURNISHED BY SHARED HOSPITAL DEPARTMENTS

FROM COST TO TOTAL HHA SHARED TRANSFER TO

WKST C CHARGE HHA ANCILLARY PART I

PT I, COL 9 RATIO CHARGES COSTS AS INDICATED

1 2 3 4

1 PHYSICAL THERAPY 50 .556618 COL 2, LN 2

1.01 SPORTS THERAPY 50.01 .396596

2 OCCUPATIONAL THERAPY 51 1.173065 COL 2, LN 3

3 SPEECH PATHOLOGY 52 1.226709 COL 2, LN 4

4 MEDICAL SUPPLIES CHARGED TO PATIENT 55 .209968 COL 2, LN 15

5 DRUGS CHARGED TO PATIENTS 56 .484226 COL 2, LN 16

PART III - OUTPATIENT THERAPY REDUCTION COMPUATION

----------- PART B SERVICES SUBJECT TO DEDUCTIBLES AND COINSURANCE -----------

FROM COST ---- PROGRAM VISITS -----|----- PROGRAM COSTS ---| PROG VISITS

PART I, PER PRIOR 1/1/1998 TO PRIOR 1/1/1998 TO ON OR AFTER

COL 5 VISIT 1/1/1998 12/31/1998 1/1/1998 12/31/1998 1/1/1999

1 2 2.01 3 3.01 4 5

1 PHYSICAL THERAPY 2 163.19

2 OCCUPATIONAL THERAPY 3 116.41

3 SPEECH PATHOLOGY 4 55.02

4 TOTAL (SUM OF LINES 1-3)

Health Financial Systems MCRIF32 FOR SULLIVAN COUNTY COMMUNITY HOSPITAL IN LIEU OF FORM CMS-2552-96 H-7 (5/2004)


CALCULATION OF HHA REIMBURSEMENT I 15-1327 I FROM 1/ 1/2008 I WORKSHEET H-7

SETTLEMENT I HHA NO: I TO 12/31/2008 I PARTS I & II

I 15-7542 I I

TITLE XVIII HHA 1

PART I - COMPUTATION OF THE LESSER OF REASONABLE COST OR CUSTOMARY CHARGES

PART A PART B PART B

NOT SUBJECT TO SUBJECT TO

DED & COINS DED & COINS

1 2 3

1 REASONABLE COST OF SERVICES

2 TOTAL CHARGES

CUSTOMARY CHARGES



4 AMOUNT THAT WOULD HAVE BEEN REALIZED FROM PATIENTS

LIABLE FOR PAYMENT FOR SERVICES ON A CHARGE

BASIS HAD SUCH PAYMENT BEEN MADE IN ACCORDANCE

WITH 42 CFR 413.13(B)

5 RATIO OF LINE 3 TO 4 (NOT TO EXCEED 1.000000)

6 TOTAL CUSTOMARY CHARGES

7 EXCESS OF TOTAL CUSTOMARY CHARGES OVER TOTAL

REASONABLE COST


9 PRIMARY PAYOR AMOUNTS

PART II - COMPUTATION OF HHA REIMBURSEMENT SETTLEMENT

PART A PART B

SERVICES SERVICES

1 2

10 TOTAL REASONABLE COST

10.01 TOTAL PPS REIMBURSEMENT-FULL EPISODES WITHOUT 179,167 237,112

OUTLIERS

10.02 TOTAL PPS REIMBURSEMENT-FULL EPISODES WITH

OUTLIERS

10.03 TOTAL PPS REIMBURSEMENT-LUPA EPISODES 2,418 1,696

10.04 TOTAL PPS REIMBURSEMENT-PEP EPISODES 1,554

10.05 TOTAL PPS REIMBURSEMENT-SCIC WITHIN A PEP EPISODE

10.06 TOTAL PPS REIMBURSEMENT-SCIC EPISODES 3,531

10.07 TOTAL PPS OUTLIER REIMBURSEMENT-FULL EPISODES WITH

OUTLIERS

10.08 TOTAL PPS OUTLIER REIMBURSEMENT-PEP EPISODES

10.09 TOTAL PPS OUTLIER REIMBURSEMENT-SCIC WITHIN A PEP

EPISODE

10.10 TOTAL PPS OUTLIER REIMBURSEMENT-SCIC EPISODES

10.11 TOTAL OTHER PAYMENTS

10.12 DME PAYMENTS

10.13 OXYGEN PAYMENTS

10.14 PROSTHETIC AND ORTHOTIC PAYMENTS

11 PART B DEDUCTIBLES BILLED TO MEDICARE PATIENTS

(EXCLUDE COINSURANCE)

12 SUBTOTAL 183,139 242,339

13 EXCESS REASONABLE COST

14 SUBTOTAL 183,139 242,339

15 COINSURANCE BILLED TO PROGRAM PATIENTS

16 NET COST 183,139 242,339

17 REIMBURSABLE BAD DEBTS

17.01 REIMBURSABLE BAD DEBTS FOR DUAL ELIGIBLE

BENEFICIARIES (SEE INSTRUCTIONS)

18 TOTAL COSTS - CURRENT COST REPORTING PERIOD 183,139 242,339



20 RECOVERY OF EXCESS DEPRECIATION RESULTING FROM

AGENCIES' TERMINATION OR DECREASE IN MEDICARE

UTILIZATION


22 SUBTOTAL 183,139 242,339

23 SEQUESTRATION ADJUSTMENT

24 SUBTOTAL 183,139 242,339

25 INTERIM PAYMENTS 183,139 242,339

25.01 TENTATIVE SETTLEMENT (FOR FISCAL INTERMEDIARY USE

ONLY)

26 BALANCE DUE PROVIDER/PROGRAM


IN ACCORDANCE WITH CMS PUB. 15-II SECTION 115.2



ANALYSIS OF PAYMENTS TO PROVIDER-BASED HHAS FOR SERVICES RENDERED TO I 15-1327 I FROM 1/ 1/2008 I WORKSHEET H-8

PROGRAM BENEFICIARIES I HHA NO: I TO 12/31/2008 I

I 15-7542 I I

TITLE XVIII HHA 1

DESCRIPTION P A R T A P A R T B


1 2 3 4

1 TOTAL INTERIM PAYMENTS PAID TO PROVIDER 183,139 242,339





ENTER A ZERO.





ZERO. (1)












4 TOTAL INTERIM PAYMENTS 183,139 242,339












6 DETERMINED NET SETTLEMENT SETTLEMENT TO PROVIDER .01

AMOUNT (BALANCE DUE) SETTLEMENT TO PROGRAM .02


7 TOTAL MEDICARE PROGRAM LIABILITY 183,139 242,339


INTERMEDIARY NO:


DATE: ___/___/___

____________________________________________________________________________________________________________________________________



Documents

Health Financial Systems MCRIF32 FOR SULLIVAN COUNTY ... · health financial systems mcrif32 for sullivan county community hospital in lieu of form cms-2552-96 (12/2008) contd i provider