08-97 FORM CMS-2552-96 3690 (Cont.) 08-97 FORM CMS-2552-96 3690 (Cont.) 08-97 FORM CMS-2552-96 3690 (Cont.) ALLOCATION OF GENERAL SERVICE PROVIDER NO.: ______________ PERIOD: "WORKSHEET H-5," ALLOCATION OF GENERAL SERVICE PROVIDER NO.: ______________ PERIOD: "WORKSHEET H-5," ALLOCATION OF GENERAL SERVICE PROVIDER NO.: ______________ PERIOD: "WORKSHEET H-5," COSTS TO HHA COST CENTERS HHA NO.: _____________ FROM__________________ PART I COSTS TO HHA COST CENTERS HHA NO.: _____________ FROM__________________ PART I (CONT.) COSTS TO HHA COST CENTERS HHA NO.: _____________ FROM ______________ PART I (CONT.) TO ___________________ TO ___________________ TO _________________ OLD CAPITAL NEW CAPITAL INTERN & From HHA RELATED COSTS RELATED COSTS NON- RESIDENT ALLOCATED HHA COST CENTER Wkst. H-4 TRIAL ADMINIS- MAIN- LAUNDRY CORF COST CENTER MAIN- NURSING CENTRAL MEDICAL OTHER PHYSICIAN HHA COST CENTER INTERNS & RESIDENTS PARAMEDICAL SUBTOTAL COST & POST HHA (omit cents) "Part I," BALANCE BLDGS. & MOVABLE BLDGS. & MOVABLE EMPLOYEE SUBTOTAL TRATIVE & TENANCE & OPERATION & LINEN (omit cents) HOUSE TENANCE OF ADMINIS- SERVICES & RECORDS & SOCIAL GENERAL ANES- (omit cents) NURSING SALARY AND PROGRAM EDUCATION (sum of cols. STEPDOWN SUBTOTAL A&G (see TOTAL "col. 6," (1) FIXTURES EQUIPMENT FIXTURES EQUIPMENT BENEFITS (cols. 0-5) GENERAL REPAIRS OF PLANT SERVICE KEEPING DIETARY CAFETERIA PERSONNEL TRATION SUPPLY PHARMACY LIBRARY SERVICE SERVICE THETISTS SCHOOL FRINGES COSTS (SPECIFY) 5a-24) ADJUSTMENTS (cols. 25 ± 26) Part II) HHA COSTS line 0 1 2 3 4 5 5A 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 1 Administrative and General 5 1 1 Administrative and General X X X X X X X X X X X 1 1 Administrative and General X X X X X X X 1 2 Skilled Nursing Care 6 X X X X X X X X X X 2 2 Skilled Nursing Care X X X X X X X X X X X 2 2 Skilled Nursing Care X X X X X X X X 2 3 Physical Therapy 7 X X X X X X X X X X X 3 3 Physical Therapy X X X X X X X X X X X 3 3 Physical Therapy X X X X X X X X 3 4 Occupational Therapy 8 X X X X X X X X X X X 4 4 Occupational Therapy X X X X X X X X X X X 4 4 Occupational Therapy X X X X X X X X 4 5 Speech Pathology 9 X X X X X X X X X X X 5 5 Speech Pathology X X X X X X X X X X X 5 5 Speech Pathology X X X X X X X X 5 6 Medical Social Services 10 X X X X X X X X X X X 6 6 Medical Social Services X X X X X X X X X X X 6 6 Medical Social Services X X X X X X X X 6 7 Home Health Aide 11 X X X X X X X X X X X 7 7 Home Health Aide X X X X X X X X X X X 7 7 Home Health Aide X X X X X X X X 7 8 Supplies 12 X X X X X X X X X X X 8 8 Supplies X X X X X X X X X X X 8 8 Supplies X X X X X X X X 8 9 Drugs 13 X X X X X X X X X X X 9 9 Drugs X X X X X X X X X X X 9 9 Drugs X X X X X X X X 9 10 DME 14 X X X X X X X X X X X 10 10 DME X X X X X X X X X X X 10 10 DME X X X X X X X X 10 11 Home Dialysis Aide Services 15 X X X X X X X X X X X 11 11 Home Dialysis Aide Services X X X X X X X X X X X 11 11 Home Dialysis Aide Services X X X X X X X X 11 12 Respiratory Therapy 16 X X X X X X X X X X X 12 12 Respiratory Therapy X X X X X X X X X X X 12 12 Respiratory Therapy X X X X X X X X 12 13 Private Duty Nursing 17 X X X X X X X X X X X 13 13 Private Duty Nursing X X X X X X X X X X X 13 13 Private Duty Nursing X X X X X X X X 13 14 Clinic 18 X X X X X X X X X X X 14 14 Clinic X X X X X X X X X X X 14 14 Clinic X X X X X X X X 14 15 Health Promotion Activities 19 X X X X X X X X X X X 15 15 Health Promotion Activities X X X X X X X X X X X 15 15 Health Promotion Activities X X X X X X X X 15 16 Day Care Program 20 X X X X X X X X X X X 16 16 Day Care Program X X X X X X X X X X X 16 16 Day Care Program X X X X X X X X 16 17 Home Delivered Meals Program 21 X X X X X X X X X X X 17 17 Home Delivered Meals Program X X X X X X X X X X X 17 17 Home Delivered Meals Program X X X X X X X X 17 18 Homemaker Service 22 X X X X X X X X X X X 18 18 Homemaker Service X X X X X X X X X X X 18 18 Homemaker Service X X X X X X X X 18 19 All Others 23 X X X X X X X X X X X 19 19 All Others X X X X X X X X X X X 19 19 All Others X X X X X X X X 19 20 Totals (sum of lines 1-19) (2) X X X X X X X X X X X 20 20 Totals (sum of lines 1-19) (2) X X X X X X X X X X X 20 20 Totals (sum of lines 1-19) (2) X X X X X X X X 20 21 "Unit Cost Multiplier: column 27, line 1 divided by the sum of column 27, line 20 " 21 21 "Unit Cost Multiplier: column 27, line 1 divided by the sum of column 27, line 20 " 21 21 "Unit Cost Multiplier: column 27, line 1 divided by the sum of column 27, line 20 " 21 "minus column 27, line 1, rounded to 6 decimal places." "minus column 27, line 1, rounded to 6 decimal places." "minus column 27, line 1, rounded to 6 decimal places." "(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." "(2) Columns 0 through 27, line 20 must agree with the corresponding columns of Wkst. B, Part I, line 71." "(2) Columns 0 through 27, line 20 must agree with the corresponding columns of Wkst. B, Part I, line 71." "FORM CMS-2552-96 (9/97) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3646.1)" "FORM CMS-2552-96 (9/97) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3646.1)" "FORM CMS-2552-96 (9/97) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3646.1)" Rev. 3 36-611 Rev. 3 36-612 Rev. 3 36-613