09-01					FORM CMS-2552-96							   3690 (Cont.)																																																																												
ANALYSIS OF PROVIDER-BASED							PROVIDER NO.: ___________		PERIOD:		WORKSHEET K																																																																													
HOSPICE COSTS									FROM ____________																																																																															
							HOSPICE NO.: ____________		TO _______________																																																																															
					CON-																																																																																			
			EMPLOYEE		TRACTED																																																																																			
		SALARIES	BENEFITS	TRANSPOR-	SERVICES				SUBTOTAL		TOTAL																																																																													
	COST CENTER DESCRIPTIONS	(from	(from	TATION	(from		TOTAL	RECLASSI-	(col. 6	ADJUST-	(col. 8																																																																													
		Wkst. K-1)	Wkst. K-2)	(see inst.)	Wkst. K-3)	OTHER	(cols. 1-5)	FICATION	± col. 7)	MENTS	± col. 9)																																																																													
		1	2	3	4	5	6	7 	8	9	10																																																																													
	GENERAL SERVICE COST CENTERS																																																																																							
1 	Capital Related Costs-Bldg and Fixt.			X		X				X		1 																																																																												
2 	Capital Related Costs-Movable Equip.			X		X				X		2 																																																																												
3 	Plant Operation and Maintenance			X		X				X		3 																																																																												
4 	Transportation - Staff			X		X				X		4 																																																																												
5 	Volunteer Service Coordination			X		X				X		5 																																																																												
6 	Administrative and General			X		X				X		6 																																																																												
	INPATIENT CARE SERVICE																																																																																							
7 	Inpatient - General Care			X		X				X		7 																																																																												
8 	Inpatient - Respite Care			X		X				X		8 																																																																												
	VISITING SERVICES																																																																																							
9 	Physician Services			X		X				X		9 																																																																												
10 	Nursing Care			X		X				X		10 																																																																												
11 	Physical Therapy			X		X				X		11 																																																																												
12 	Occupational Therapy			X		X				X		12 																																																																												
13 	Speech/ Language Pathology			X		X				X		13 																																																																												
14 	Medical Social Services 			X		X				X		14 																																																																												
15 	Spiritual Counseling		 	X	 	X				X		15 																																																																												
16 	Dietary Counseling			X		X				X		16 																																																																												
17 	Counseling - Other			X		X				X		17 																																																																												
18 	Home Health Aide and Homemaker			X		X				X		18 																																																																												
19 	Other			X		X				X		19 																																																																												
	OTHER HOSPICE SERVICE COSTS																																																																																							
20 	"Drugs, Biological and Infusion Therapy"			X		X				X		20 																																																																												
21 	Durable Medical Equipment/Oxygen			X		X				X		21 																																																																												
22 	Patient Transportation			X		X				X		22 																																																																												
23 	Imaging Services			X		X				X		23 																																																																												
24 	Labs and Diagnostics			X		X				X		24 																																																																												
25 	Medical Supplies			X		X				X		25 																																																																												
26 	Outpatient Services (including E/R Dept.)			X		X				X		26 																																																																												
27 	Radiation Therapy			X		X				X		27 																																																																												
28 	Chemotherapy			X		X				X		28 																																																																												
29 	Other			X		X				X		29 																																																																												
	HOSPICE NONREIMBURSABLE SERVICE																																																																																							
30 	Bereavement Program Costs			X		X				X		30 																																																																												
31 	Volunteer Program Costs			X		X				X		31 																																																																												
32 	Fundraising			X		X				X		32 																																																																												
33 	Other Program Costs			X		X				X		33 																																																																												
34 	Total (sum of lines 1 thru 33)			X		X				X		34 																																																																												
"FORM CMS-2552-96  (9/2000) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3634)"																																																																																								
Rev. 8												36-634.1