20 CAR pt. 579, Appendix A
The DOM-400 cost reporting forms described below must be used by all long-term care Nursing Facilities participating in the Arkansas Medicaid Program. Medicare (Title XVIII) cost reporting forms are not acceptable in lieu of these forms. The forms can be found in Section V of the Arkansas Medicaid Provider Manuals by clicking the hyperlink within this sentence.
These instructions are for use in the preparation and submission of the cost report to the Division of Medical Services by all Nursing Facilities providing care and services under the Medical Assistance Program. All ICF/IID facilities will continue to use the Financial and Statistical Report, DHS-750 and applicable instructions.
Only per diem cost amounts calculated on Form 6, Line 12 and employee beginning hourly rates identified on Form 16, Column 4 will be reported/calculated in cents. All other dollar amounts must be rounded to the nearest dollar (no cents) upon transfer to the cost report.
Cost report forms that are not applicable to a facility must be submitted with the other forms and identified as 'Not Applicable' or 'NA' on the unused form.
Facilities which are combined with or attached to other operations (hospitals, RCF's, etc.) sometimes use one common accounting system and general ledger. For such facilities, adjusting entries must be made to the trial balance before the amounts are posted to the Nursing Facility cost report forms. The trial balance submitted with the cost report must reflect the general ledger amounts, any adjustments necessary to remove amounts applicable to other operations, and the net adjusted trial balance amounts applicable to the Nursing Facility. Copies of workpapers used to make these adjustments must be attached to the submitted trial balance. These workpapers will identify adjustment amounts, descriptions, ledger balances affected, and allocation methods used.
1. I. Provider Facility
all correspondence, desk reviews, audits, etc. should be addressed. Each facility is allowed only one name and address in this section.
Complete this section only if the facility has a home office.
Complete this section if the facility pays management fees. A narrative description of purchased management services or a copy of contracts for managed services must be submitted with the cost report in order for management fees to be allowed. Check the applicable identification as to whether the management company is related party or non-related.
Do not complete this section.
The Certification by Officer or Administrator of Provider is required and must include an original signature (not a copy) by an authorized officer or the administrator of the facility. The cost report will not be deemed received by the Division of Medical Services if this certification has not been completed.
The cost report may be completed by the facility's employees, owners, independent accountants, or other qualified parties. If a Certified Public Accountant prepares the cost report, the cost report must be accompanied by the appropriate compilation, review or audit report. The cost report must be completed in addition to any other items required by the Guidelines for Financial and Compliance Audits of Programs Funded by the Arkansas Department of Human Services.
Check the appropriate blocks that apply to your facility. Check only one block on each of Lines 1 and 3. Line 2 must have a box checked on each of Lines A, B, C and D. Line 2B and/or 2C should be checked 'Yes' if any owner (individual, partnership, corporation, etc.) of this facility with a 5% or greater ownership also owns a 5% or greater share of any other nursing facility/facilities.
Complete the number of actual resident days by type of resident (payment source).
days in the period. Any increase or decrease in the number of beds must be taken into consideration as well as the number of days elapsed during each increase or decrease.
The percentage of occupancy for the cost report period is computed by dividing the total resident days from Line 4.1, Column A by the bed days available on Line 8. The decimal place will be carried out to four places. Example - 92.31%.
The percentage of Medicaid utilization is computed by dividing the total Medicaid days from Line 4.1, Column B by the total resident days from Line 4.1, Column A. The decimal place will be carried out to four places. Example - 92.31%.
A resident day is the period of service for one resident for one day of care. For cost reporting purposes, a day paid is considered a resident day. This means that a paid reserved bed will be counted toward total resident days. Examples of paid reserved beds include resident leave of absences from the facility to the hospital or therapeutic home visit that are paid by any source.
The day of the resident's admission is counted but the day of discharge is not counted as a resident day. When a resident is admitted and discharged on the same day, this period must be counted as one resident day.
List Medicaid resident days for the reporting period by month. The total of this column must agree with Form 3, Line 4.1, Column B.
List Medicare resident days for the reporting period by month. The total of this column must agree with Form 3, Line 4.1, Column C.
List private pay resident days for the reporting period by month. The total of this column must agree with Form 3, Line 4.1, Column D.
List all other types of resident days for the reporting period by month. The total of this column must agree with Form 3, Line 4.1, Column E.
e) Column 6 Total of Columns 2, 3, 4, and 5. The total of this column must agree with Form 3, Line 4.1, Column A.
f) Column 7 List the total number of bed days available for each month. The total of this column must agree with Form 3, Line 8.
g) Column 8 Divide the Total Resident Days in Column 6 by the Bed Days Available in Column 7 for each line. The “Total” Line for this column must agree with Form 3, Line 9. The decimal place will be carried out to four places. Example - 92.31%.
2. Section II.
List the facility's third party daily rates for both private rooms and semi-private rooms that were effective during the reporting period. The list should include all rates that were effective during the reporting period. Also list the number of resident days by level of care by payor source and room type. The resident days by payor source and room type plus Medicaid days by level of care must equal Form 3, Line 4.2.
E. Form 5 Statement of Revenues
All revenue, regardless of source, is to be entered on the appropriate line in Column 1 on this schedule and should agree with the revenue and adjustment account balances recorded on the submitted adjusted trial balance. As described in Section 3-4, adjustments to specific expenses per revenue amounts can be identified in Column 2 in lieu of determining and eliminating the actual cost. Column 3 is to be used to identify which Form 6 line number is being adjusted if the revenue is used to reduce the expense. Provide a separate detailed schedule for Form 6 line number corresponding adjustment amounts when more than one Form 6 line number is to be adjusted.
1. Line 1, Resident Per Diem/Monthly Rate Medicaid, Private, Medicare Part A, and other Third Party amounts received and receivable for services/supplies usually reimbursed on a per diem or monthly basis.
2. Line 2, Medicare Part A Physical Therapy, Occupational Therapy, Speech Therapy, medical supplies and other ancillary services/supplies billed separately to Medicare Part A.
3. Line 3, Medicare Part B Physical Therapy, Occupational Therapy, Speech Therapy and medical supplies amounts received and receivable for Medicare Part B reimbursed services.
4. Line 4, Other Third Party Ancillaries (Schedule) Amounts received and receivable for other ancillary services/supplies/therapies/medical supplies when paid separately from a resident's all inclusive per diem or monthly payment. Amounts received from the sale of other ancillary supplies/services to employees or other non-residents will be included here. Attach a detail schedule of adjustments made for other third party ancillaries.
5. Line 5, Less: Total Contractual Adjustments, Allowances and Discounts on Patients' Accounts.
6. Line 6, Pharmacy Amounts received and receivable for drugs and pharmaceuticals from residents, employees or other non-residents.
7. Line 7, Beauty and Barber Amounts received and receivable for beauty and barber services.
8. Line 8, Contributions, Gifts, Grants, etc. Amounts received from contributions, gifts, grants, etc.
9. Line 9, Guest and Employee Meals Amounts received and receivable for guest and employee meals.
10. Line 10, Interest Interest Income earned per savings accounts, bonds, etc.
11. Line 11, Laundry Amounts received and receivable for laundry services.
12. Line 12, Personal Items Amounts received and receivable from the sale of personal items.
13. Line 13, Nurse Aide Training and Testing Amounts received and receivable for nurse aide training and testing.
14. Line 14, Rental Amounts received and receivable for rental.
15. Line 15, Television (Resident Rooms) Amounts received and receivable for television services.
16. Line 16, Telephone Amounts received and receivable for telephone services.
17. Line 17, Vending Machines Amounts received and receivable from vending machine sales.
1. 18. Line 18, Criminal Records Check Amounts received and receivable for criminal records checks.
2. 19. Line 19, Other (Schedule) Amounts received and receivable for other. Attach a detail schedule of other income items.
3. 20. Line 20, Total Revenue Sum of Lines 1 through 19.
4. 21. Line 21, Less: Total Operating Expenses Amount per Form 6, Line 6, Column 1.
5. 22. Line 22, Net Income (Loss) Per Books Line 20 less Line 21.
6. 23. Line 23, Less: Net Related Party Adjustments Amount per Form 6, Line 6, Column 3.
7. 24. Line 24, Other Adjustments (Schedule) Any other necessary adjustments including excess direct compensation as described in Sections 3-2.B. and 3-2.O.
8. 25. Line 25, Adjusted Net Income (Loss) Line 22 plus/minus Line 23 and 24 adjustments.
Column 1 - Enter the expenses per the adjusted trial balance on the appropriate line. Do not net general ledger expenses by omitting from the first column any non-allowable items. Columns 2 and 5 must be used to reclassify or adjust out any non-allowable items. Line 6, Column 1 must agree with Form 5, Line 21.
Column 2 - This column is for any reclassification that should be made between expenses. The total for Column 2 on Line 6 must be zero.
Column 3 - This column is used to make adjustments for related party expenses. Example - to remove unallowable related party rent included on Line 3-09 or 3-10 and record the actual cost of amortization, depreciation, interest, property insurance and property taxes on Lines 3-01, 3-02, 3-03, 3-04, 3-05, 3-06 and 3-08. This column will include the total net adjustments to allowable cost for related management company/home office expense reported on Line 2-50.
Column 4 - Column 1 plus or minus Column 2 and Column 3.
Column 5 - Adjustments to expenses will be entered in Column 5. These adjustments will include Form 5 revenue adjustments and unallowable expenses, etc. This
column will include adjustments for excess direct facility compensation as described in Section 3-2.B.
Column 6 - Column 4 plus or minus Column 5 adjustments.
Salaries of certified nurse aides and nurse aides in training.
Salaries of Medication Assistants-Certified
Salaries of licensed practical nurses and graduate practical nurses.
Salaries of registered nurses and graduate nurses (excluding the DON and Assistant DON).
Salaries of the Assistant Director of Nursing.
Salaries of Director of Nursing.
Salaries of occupational therapists. Therapy costs which are reimbursed by Medicare Part A, Medicare Part B or a third party payer should be reclassified to Line 5-11.
Salaries of physical therapists. Therapy costs which are reimbursed by Medicare Part A, Medicare Part B or a third party payer should be reclassified to Line 5-11.
Salaries of speech therapists. Therapy costs which are reimbursed by Medicare Part A, Medicare Part B or a third party payer should be reclassified to Line 5-11.
Salaries of therapists other than occupational therapists, physical therapists and speech therapists. Therapy costs which are reimbursed by Medicare Part A, Medicare Part B or a third party payer should be reclassified to Line 5-11.
Line 1-11, Salaries - Rehabilitation Nurse Aides Salaries of rehabilitation nurse aides and/or Health Rehabilitative Nurse Aides.Line 1-12, FICA - Direct Care Cost of employer's portion of Social Security Tax for direct care employees.Line 1-13, Group Health - Direct Care Cost of employer's contribution to employee health insurance for direct care employees.Line 1-14, Pensions - Direct Care Cost of employer's contribution to employee pensions for direct care employees.Line 1-15, Unemployment Taxes - Direct Care Cost of employer's contribution to State and Federal unemployment taxes for direct care employees.Line 1-16, Uniform Allowance - Direct Care Employer's cost of uniform allowance and/or uniforms for direct care employees.Line 1-17, Worker's Compensation - Direct Care Cost of worker's compensation insurance for direct care employees.Line 1-18, Other Fringe Benefits - Direct Care (Schedule) Cost of other fringe benefits not specifically noted on Line 1-11 through 1-16. A schedule must be attached that details the amount on this line.Line 1-19, Contract - Aides Cost of aides hired through contract that are not facility employees.Line 1-20, Contract – Medication Assistants Cost of Medication Assistants-Certified hired through contract that are not facility employees.Line 1-21, Contract - LPN's Cost of LPN's and graduate practical nurses hired through contract that are not facility employees.Line 1-22, Contract - RN's Cost of RN's and graduate nurses hired through contract that are not facility employees.
Cost of occupational therapists hired through contract that are not facility employees. Therapy costs, which are reimbursed by Medicare Part A, Medicare Part B or a third party payer, should be reclassified to Line 5-11.
Cost of physical therapists hired through contract that are not facility employees. Therapy costs, which are reimbursed by Medicare Part A, Medicare Part B or a third party payer, should be reclassified to Line 5-11.
Cost of speech therapists hired through contract that are not facility employees. Therapy costs, which are reimbursed by Medicare Part A, Medicare Part B or a third party payer, should be reclassified to Line 5-11.
Cost of therapists other than occupational therapists, physical therapists and speech therapists hired through contract that are not facility employees. Therapy costs, which are reimbursed by Medicare Part A, Medicare Part B or a third party payer, should be reclassified to Line 5-11.
Fees paid to nursing personnel, not on the facility payroll, for providing advisory and educational services to the facility.
Cost of training related to resident care for RN’s, LPN’s and Certified Nurse Aides. Also includes travel costs associated with this training. Training cost for Nurse Aide certification should be on Line 5-10, non-allowable nurse aide training. A detailed schedule must be submitted that agrees with the amount on this line. The schedule will include for each expenditure the date, description of training, destination, person traveling, expense description, and the cost.
Line 1-29, Over-the-Counter Drugs
Cost of over-the-counter drugs provided by the facility to its residents.
Line 1-30, Oxygen
Cost of oxygen and related supplies.
Line 1-31, Medical Supplies - Direct Care
Cost of providing direct medical care. Includes by illustration:
Cost associated with point of care software applications.
Line 1-32, Therapy Supplies
The cost of supplies used directly by the therapy staff for rendering therapeutic service to the residents of the facility. Costs of therapy supplies for which other third party income is received (Medicare Part A, Medicare Part B, etc.) must be reclassified to Line 5-11 in Column 2 or removed in Column 5 per Form 5 revenue adjustments.
Line 1-33, Raw Food
Cost of food products used to provide meals and snacks to residents.
Cost of food products given in addition to normal meals and snacks under doctor's orders.
Cost of incontinence supplies to include both disposable and linen diapers, and disposable underpads.
Cost of dentist advisory services (not individual resident specific). All other dental expenses must be reclassified to Line 5-11 in Column 2. A schedule must be attached that details the amount on this line.
For Arkansas Health Center Nursing Facility (AHC), all dental services are allowable.
Cost of prescription drugs are allowable only for AHC. Other nursing facilities must reclassify these costs to Line 5-11 in Column 2.
Cost of lab and x-ray services are allowable only for AHC. Other nursing facilities must reclassify these costs to Line 5-11 in Column 2.
Line 1-39, Total Direct Care Costs
Line 1-39 is the sum of Line 1-01 through Line 1-38.
Line 2-01, Salaries - Administrator
Salaries of licensed administrators excluding owners.
Line 2-02, Salaries - Assistant Administrator
Salaries of licensed assistant administrators excluding owners.
Line 2-03, Salaries - Dietary
Salaries of kitchen personnel including dietary supervisor, cooks, helpers and dishwashers.
Line 2-04, Salaries - Housekeeping
Salaries of housekeeping personnel including housekeeping supervisors and staff.
Line 2-05, Salaries - Laundry
Salaries of laundry personnel including laundry supervisor and staff.
Line 2-06, Salaries - Maintenance
Salaries of personnel involved in operating and maintaining the physical plant, including maintenance supervisor and staff.
Line 2-07, Salaries - Medical Records
Salaries of medical records personnel.
Line 2-08, Salaries - Other Administrative
Salaries of other administrative personnel including bookkeeper, receptionist, administrative assistants and other office and clerical personnel.
Line 2-09, Salaries - Activities
Salaries of personnel providing an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interest and the physical, mental, and psychosocial well being of the residents.
Line 2-10, Salaries - Pharmacy
Salaries of pharmacy employees (AHC only).
Line 2-11, Salaries - Social Services
Salaries of personnel providing medically related social services to
attain or maintain the highest practicable physical, mental or psychosocial well being of the residents.
Line 2-12, Salaries - Owner or Owner/Administrator Salaries of all owners of the facility.
Line 2-13, FICA - Indirect, Administrative and Operating Cost of employer's portion of Social Security Tax for administration and operating employees.
Line 2-14, Group Health - Indirect, Administrative and Operating Cost of employer's contribution to employee health insurance for administration and operating employees.
Line 2-15, Pensions - Indirect, Administrative and Operating Cost of employer's contribution to employee pensions for administration and operating employees.
Line 2-16, Unemployment Taxes - Indirect, Administrative and Operating Cost of employer's contribution to State and Federal unemployment taxes for administration and operating employees.
Line 2-17, Uniform Allowance - Indirect, Administrative and Operating Employer's cost of uniform allowance and/or uniforms for administration and operating employees.
Line 2-18, Worker's Comp - Indirect, Administrative and Operating Cost of worker's compensation insurance for administration and operating employees.
Line 2-19, Other Fringe Benefits - Indirect, Administrative & Operating (Schedule) Cost of other fringe benefits not specifically noted on Line 2-13 through 2-18. A schedule must be attached that details the amount on this line.
Line 2-20, Contract - Dietary Cost of dietary services and personnel hired through contract that are not facility employees.
Line 2-21, Contract - Housekeeping Cost of housekeeping services and personnel hired through contract that are not facility employees.
Cost of laundry services and personnel hired through contract that are not facility employees.
Cost of maintenance services and personnel hired through contract that are not facility employees.
Fees paid to consulting registered dietitians.
Fees paid to consulting Accredited Records Technicians or Medical Records Administrators.
Fees paid to activities personnel, not on the facility payroll, for providing advisory services to the facility.
Fees paid to a medical doctor, not on the facility payroll, for providing advisory, educational and emergency medical services to the facility.
Fees paid to a registered pharmacist, not on the facility payroll, for providing advisory and educational services to the facility.
Fees paid to a social worker, not on the facility payroll, for providing advisory and educational services to the facility.
Fees paid to licensed therapists, not on the facility payroll, for providing advisory and educational services to the facility.
The cost of barber and beauty services provided to residents by facility staff.
In lieu of actual costs, the facility may report on this line allowable amounts claimed (rate per mile) for facility owned or other vehicles used in providing residents medical transportation to local “community” providers or used for business related mileage (as described in Section 3-2.K).
This line should also include cost of providing residents medical transportation to local “community” providers when the facility obtains this service from an outside source.
Cost of resident activities should include pastoral services, recreational activities and supplies.
Personal hygiene items such as soaps, deodorants, shampoos, toothbrush, toothpaste, razor, razor blades etc. Includes minor equipment provided by the facility that is not used in providing direct medical care such as water pitchers, wash basin, emesis basin, bedpan, urinal. hot water bottles, heating pads, crutches, walkers, etc. Includes nurse charting forms, admission forms, medication and treatment records, physician order forms.
Fees incurred for the preparation of the cost report, audits of the financial records, bookkeeping services, tax return preparation of the nursing facility and other related services, excluding personal tax planning and personal tax return preparation.
Allowable advertising expense.
Costs incurred for legal and other expenses when organizing a corporation should be amortized over a period of 60 months. Attach a detail amortization schedule for these costs. These costs are not to be included on the For 7 depreciation schedule.
Fees paid to banks for service charges, excluding penalties and insufficient funds charges.
Cost of Criminal Records Checks for employees and job applicants.
Cost of purchased services for data processing systems and services.
Costs of consumable items such as soap, detergent, napkins, paper cups, straws, etc. used in the dietary department.
A detailed schedule of dues must be included. The schedule should include the dates and purpose covered by the charge.
The cost of registration for attending non-direct care related educational seminars and training by employees of the facility and costs incurred in the provision of non-direct care related in-house training for facility staff. The cost of any travel incurred to attend an educational seminar will be included on Line 2-56, Travel.
Costs incurred by members of the facility governing body to attend meetings. Attach a detail schedule of the members' names and costs incurred.
Cost of consumable housekeeping items including waxes, cleaners, soap, brooms and lavatory supplies.
Cost of consumable goods used in the laundry including soap, detergent, starch and bleach.
Fees paid to attorneys in accordance with other provisions of the State Plan. A schedule must be attached that details the amount on this line.
Cost of mattress covers, sheets, blankets, pillows, and gowns.
Costs incurred in providing nursing facility services that cannot be assigned to any other line item on Form 6. A schedule must be attached that details the amount on this line.
The cost of purchased management services or home office costs incurred that are allocable to the provider. See Form 15 for calculation of allowable home office costs.
Cost of consumable goods used in the business office such as pencils, paper, and computer supplies. Cost of printing forms and stationary including accounting and census forms, charge tickets, facility letterhead and billing forms. Cost of subscribing to newspapers, magazines and periodicals.
Cost of postage, including stamps, metered postage, freight charges and courier services.
Supplies and services, including electricians, plumbers, extended service agreements, etc., used to repair the facility building, furniture, equipment, vehicles and vehicle insurance.
The cost of property taxes on automobiles and other taxes paid that are not included on any other line on Form 6. A schedule must be attached to the cost report in order for the costs to be considered in the determination of allowable costs.
Cost of telephone services, WATS lines and FAX services.
Cost of travel (airfare, lodging, meals, etc.) by Administrator and other authorized personnel to attend professional and continuing educational seminars and meetings related to their position within the facility. A detailed schedule must be submitted that agrees with the amount on this line. The schedule will include for each expenditure the date, destination, person traveling, purpose of the trip, expense description, and the cost.
Cost of water, sewer, gas, electric, and garbage collection services. Cost of television and cable services for common use areas in the facility.
Depreciation on the facility’s vehicles and software. Column 6 of Line 2-58 must agree with Form 7, Page 3, Vehicle Depreciation line, Column 5 and Form 7, Page 3, Software Depreciation line, Column 5.
Interest paid on short term borrowing for facility operations. Also, interest paid or accrued on loans, the proceeds of which were used to purchase vehicles or software. The total of Line 2-59, Column 6, must agree with the Form 10, Page 3, Totals Column, Line 12.
Line 2-60 is the sum of Line 2-01 through Line 2-59.
Amounts for depreciation, Rent – Building and Rent – Furniture and Equipment must be identified for historical purposes only. A Fair Market Rental Payment is made in lieu of these expenses.
Legal and other costs incurred when financing the facility should be amortized over the life of the mortgage. Attach a detail amortization schedule for these costs. These costs are not to be included on the Form 7 depreciation schedule.
Depreciation on the facility's buildings, furniture, equipment, leasehold improvements and land improvements. Items costing $2,500 or more will be capitalized.
Depreciation expense associated with point of care software applications must be reclassified to Line 1-29.
Depreciation on generators approved by the Office of Long Term Care under Act 1602 of 2001.
Interest paid or accrued on notes, mortgages and other loans, the proceeds of which were used to finance the fixed assets or major movable equipment. The total of Line 3-04, Column 6 must agree with the Form 10, Page 3, Totals Column, Line 10.
Interest expense associated with point of care software applications must be reclassified to Line 1-29.
Interest paid or accrued on notes the proceeds of which were used to purchase a generator approved by the Office of Long Term Care under Act 1602 of 2001. The total of Line 3-05, Column 6 must agree with the Form 10, Page 3, Totals Column, Line 11.
Cost of fire and casualty insurance on facility buildings and equipment.
Cost of premiums for insuring the facility against injury and malpractice claims. The allowable insurance premium cost for nursing facilities (excluding Arkansas Health Center) is capped at $2,500 per licensed bed as of the end of the cost reporting period.
Taxes levied on the facility's land, buildings, furniture and equipment.
Cost of leasing the facility's real property.
Cost of leasing the facility's furniture, equipment and vehicles.
Rent expense associated with point of care software applications must be reclassified to Line 1-29.
Line 3-11 is the sum of Line 3-01 through Line 3-10.
Cost of the quality assurance fee paid monthly to the Department Human Services.
Costs of unallowable advertising.
Accounts receivable written off as uncollectable.
The cost of barber and beauty services provided by non-facility personnel.
Amounts donated to charitable or other organizations.
Depreciation charged above straight line. Amounts posted to this line should result from reclassifications (Column 2) from Line 3-02. Column 1 should equal zero.
Taxes on net income levied or expected to be levied by the Federal or State government.
Cost of unallowable life insurance on officers and key employees of the facility per Section 3-3.T.
Line 5-08, Non-Working Officer's Salaries Salaries and other compensation paid to non-working officers.
Line 5-09 and 5-10, Nurse Aide Testing and Training Costs incurred in having nurse aides tested or trained in order to meet OBRA 1987 provisions. This includes both the Medicaid and non-Medicaid portion of the expenses. Example - A nursing facility incurs
$1,000 in allowable expenses for nurse aide training. A bill is submitted to the Division of Medical Services for direct reimbursement. Based on the facility's percentage of Medicaid utilization, the facility was eligible for 80% reimbursement. A payment was made to the facility in the amount of $800 ($1,000 X 80%) for the Medicaid portion of the nurse aide training expense. The $1,000 should be included in non-allowable costs and the $800 reimbursement should be included on Form 5, Line 13. The same principles apply to Nurse Aide Testing Costs and reimbursements from the contracted testing company.
Other costs that are considered non-allowable in accordance with other provisions of the State Plan (products sold to residents, etc.).
Includes by way of illustration, penalties and sanctions assessed by the Division of Medical Services, the Internal Revenue Service, the State Tax Commission, or financial institutions (i.e., insufficient funds charges).
Cost of television sets used in the residents' rooms or for providing cable TV to the residents' rooms.
Cost of items sold to employees, residents and the general public including candy bars and soft drinks.
Amortization of Goodwill costs. These costs are not to be included on the Form 7 depreciation schedule.
Line 5-16 is the sum of Line 5-01 through Line 5-15.
Line 6, is the total of 1-39, 2-60, 3-11, 4, and 5-16. Column 1 must agree with the total expenses in the adjusted trial balance.
Enter the number of total resident days from Form 3, Line 4.1, Column A.
Enter in Column A, the cost from Line 1-37, Column 6. Column B (Direct Care cost per day) is calculated by dividing Line 8, Column A by Line 7.
Enter in Column A, the cost from Line 2-60, Column 6. Column B (Indirect, Administrative and Operating cost per day) is calculated by dividing Line 9, Column A by Line 7.
Enter in Column A, the cost from Line 3-11, Column 6. Column B (Property cost per day) is calculated by dividing Line 10, Column A by Line 7.
Enter in Column A, the cost from Line 4, Column 6. Column B (Quality Assurance Fee cost per day) is calculated by dividing Line 11, Column A by Line 7.
Line 12, Column A is the total of Lines 8, 9, 10 and 11, Column A. This total should agree with Line 6, Column 6. Total Per Diem Cost is calculated by dividing Line 12, Column A by Line 7.
Depreciation expense will be reported on Form 7, Pages 1, 2, and 3 by asset category/description. Pages 1 and 2 are to be used to report separately the depreciation expense incurred for facility owned assets (Page 1) and the depreciation expense incurred for related party owned assets (Page 2). All assets must be reported on these two pages. Page 3 is to be completed by adding Page 1 and Page 2 together. A copy of the facility's depreciation schedule must be attached to the cost report and should identify and reconcile with amounts posted to Form 7, Page 1 by asset category. A separate depreciation schedule for the related party assets reported on Page 2 must also be attached and should identify and reconcile with amounts posted to Form 7, Page 2 by asset category. The depreciation schedule(s) must be completed using the straight-line method and will reflect the same period as the cost report and will include the asset description, acquisition date, historical cost, salvage value if used, depreciable base, useful life, cost report period, depreciation expense claimed, and accumulated depreciation to date. Straight-line depreciation is the only method allowable for cost reporting purposes.
Assets purchased (not leased) from related parties will be included on Page 1 but are subject to related party cost limits identified in Section 3-1.F.2. These assets should be included in Column 1 of Page 1, but adjusted to the related party allowable amounts per Column 4 adjustments.
For Nursing Facilities which are combined with/attached to other operations (hospitals, RCF's, etc.), assets used only by these other operations should not be included on Form 7, Columns 1 through 5. Common used assets should be included on Form 7, Columns 1 through 5, but only for the amounts allocated to the Nursing Facility. Copies of workpapers/schedules used to make these allocations must be attached to Form 7 and the depreciation schedules. These workpapers/schedules will identify the common assets used, allocated amounts, descriptions and allocation methods used.
All vehicles and generators approved by the Office of Long Term Care under Act 1602 of 2001 must be listed separately on their designated Form 7 line. Vehicle depreciation is subject to the limits identified in Section 3-2 K.2.
1. Description of Property
a) Historical Cost - Column 1 Enter the actual cost of the assets. The facility owned asset amounts reported on Form 7, Page 1 must agree with the facility's adjusted trial balance recorded asset amounts.
b) Ending Accumulated Depreciation - Column 2 The total accumulated depreciation calculated using the straight-line method will be reported in this column.
c) Depreciation Expense - Column 3 The depreciation expense using the straight-line method will be reported in this column. The total of this column on Form 7, Page 1 plus any amount reclassified to Form 6, Line 5-05 (Depreciation over straight-line), Column 2 will agree with the total depreciation posted to the adjusted trial balance per Form 6, Line 2-58, Column 1, Line 3-02, Column 1 and Line 3-03, Column 1.
d) Other Adjustments (Schedule) – Column 4 Use this column to record adjustments for unallowable vehicles, allocated unallowable vehicles per usage, mobile homes, RV's, etc. Use this column also to record adjustments to depreciation expense for gains or losses from the sale/disposal of assets. The total of the adjustments in this column will agree with adjustments reported on Form 6, Lines 2-58, 3-02, and 3-03 Column 5. A schedule must be attached that details the adjustment amounts.
e) Facility Related Depreciation - Column 5 Column 3 plus or minus Column 4 adjustments.
2. After Form 7, Pages 1, 2, and 3 are complete,
a) Form 7, Page 3, Column 3 (Total) will equal to Form 6, Lines 2-58, 3-02 and 3-03, Column 4.
b) Form 7, Page 3, Column 4 (Total) will equal to Form 6, Lines 2-58, 3-02 and 3-03, Column 5.
c) Form 7, Page 3, Column 5 (Total) will equal to Form 6, Lines 2-58, 3-02 and 3-03, Column 6.
3. Any Assets included on Form 7, Page 1 that are not related to resident care must be identified on the bottom of Form 7, Page 1.
H. Form 8 Facility Transactions with Related Organizations
1. Section I.
All providers must complete this section. If yes, complete Sections II. and III.
2. Section II.
Identify those costs that contain expenditures for services or supplies furnished to the facility by related organizations per Section 3-1.F.2. Indicate the form number and line number to designate the location of the expense. Provide the name of the related organization, the amount of current year transactions, the cost to the related organization, and the amount of the transactions in excess of cost. The amount of transactions in excess of cost must be transferred to the appropriate line on Form 6 as an adjustment in Column 3. For example, if a facility purchased services or supplies from a related organization for $500 and the cost of those services or supplies to the related organization was $300, the excess over cost, or $200, must be transferred to the appropriate line on Form 6 as a Column 3 adjustment to offset the expense.
Adjustments to expenses will be made to the appropriate line on Form 6, Column 3 for all related party expense adjustments. For related party lease agreements, unallowable lease costs should be removed in total on Lines 3-09 and 3-10, and the actual cost of amortization, depreciation, interest, property insurance and property taxes should be posted to Lines 3-01, 3-02, 3-03, 3-04, 3-05, 3-06 and 3-08, Column 3 respectively. See also instructions for reporting related party depreciation and related party interest per Form 7 and Form 10.
Interest income from related organizations will be transferred to Form 5, Line 10, Column 2. Form 6 interest expense can not be reduced to below zero.
3. Section III.
List the name of each owner of the facility and their relationship with organizations described in Section II.
I. Form 9 Rental of Property, Plant, and Equipment
List any leases pertaining to buildings, furniture, and equipment. Identify the lessor, the leased item, the terms of the lease including the amount of the monthly payment, a description of the purchase option, if any, and the amount of rent applicable to the current reporting period.
J. Form 10 Analysis of Interest Bearing Debt and Related Interest Expense
1. All interest bearing debt must be reported on Form 10, Pages 1 and 2. These two forms are to be used to report separately the interest expense incurred by the facility on Page 1 and allowable interest expense incurred by a related party on Page 2. Each note should be listed under the columns for Notes 1-11 with the total listed in Column 12. If the facility had more than eleven notes payable during the reporting period, please attach an additional Form 10. Form 10, Page 3 is to be completed by adding the Total columns from Form 10, Pages 1 and 2, Lines 2, 3, 4, 5, 6, 10, 11, 12 and 13.
a) Line 1, Lender Report the lender's name.
b) Line 2, Original Loan Amount Report the total amount financed at the loan's origination.
c) Line 3, Beginning Balance Balance at the beginning of the cost reporting period. The Page 1 total of the Beginning Balance line must agree with the payable amounts reported in Column 1 of Form 11.
d) Line 4, Ending Balance Balance at the end of the reporting period. The Page 1 total of the Ending Balance line must agree with the payable amounts reported in Column 2 of Form 11.
e) Line 5, Current Portion The current portion of interest bearing debt. The portion due within one year should be reported in this column for all interest bearing debt. The Page 1 total of this line must agree with the amount on Form 11, Line 23, Column 2.
c) Form 10, Page 3, Column 12, Line 10 will agree with Form 6, Line 3-04, Column 6. Form 10, Page 3, Column 12, Line 11 will agree with Form 6, Line 3-05, Column 6. Form 10, Page 3, Column 12, Line 12 will agree with Form 6, Lines 2-59, Column 6.
The balance sheet as of the beginning of the reporting period is reported in Column 1 and the balance sheet as of the end of the reporting period is reported in Column 2. Note: Column 1 of this report must equal Column 2 of the previous cost report.
1. 1. Line 1, Cash on Hand & In Banks Cash on Hand & in Banks includes all funds actually on hand or in bank accounts subject to immediate withdrawal.
2. 2. Line 2, Accounts Receivable Accounts Receivable represent monies due the facility for services rendered to residents as of the balance sheet date. The dollar amount recorded on the schedule represents gross accounts receivable.
3. 3. Line 3, Less Allowance for Uncollectable Accounts Allowance for Uncollectable Accounts includes the estimated loss for accounts receivable that will not be collected.
4. 4. Line 4, Notes Receivable Notes Receivable includes the current portion of notes other than those due from officers, owners, or related organizations.
5. 5. Line 5, Due From Officers, Owners or Related Organizations Due from Officers, Owners or Related Organizations represent amounts owed the facility by officers, owners or related parties as of the balance sheet date.
6. 6. Line 6, Other Receivables Other Receivables include all current receivables which are not appropriately included on another line such as amounts due from a previous owner.
7. 7. Line 7, Inter-Company Receivables Inter-Company Receivables represent amounts owed the facility by a home office or other nursing home facility in a multi-facility operation.
8. 8. Line 8, Inventory Inventory includes those goods awaiting sale or use, and excludes those long-term assets subject to depreciation. Inventories are normally conservatively valued at the lower of 'cost or market'. List the method of inventory valuation in the space provided. Examples of inventory items include dietary supplies, housekeeping supplies and linens.
1. 9. Line 9, Prepaid Expenses Prepaid Expenses represent the portion of the expenditures which will be carried forward into the next accounting period. Examples of prepaid expenses include membership dues, insurance premiums, rent, service contracts, etc.
2. 10. Line 10, Investments Investments are normally permanent or long-term securities with value, but which are normally not available for immediate withdrawal. Investments include stock and bonds, certificates of deposit, etc.
3. 11. Line 11, Other Current Assets Other Current Assets include all current assets which are not appropriately included on any other line of the balance sheet.
4. 12. Line 12, Total Current Assets Total Current Assets is the sum of Line 1 through Line 11.
5. 13. Line 13, Property, Plant and Equipment Property, Plant and Equipment must agree with the total of all assets recorded on Form 7, Page 1, Column 1.
6. 14. Line 14, Less Accumulated Depreciation Less Accumulated Depreciation represents a reduction of the property, plant, and equipment reported on Line 13. The amount entered in the beginning column reports accumulated depreciation at the beginning of the reporting period, and therefore, does not include the depreciation expense for this period.
7. 15. Line 15, Total Fixed Assets Total Fixed Assets is the difference between Line 13 and Line 14.
8. 16. Line 16, Notes Receivable - Noncurrent Notes Receivable - Noncurrent includes the non-current portion of notes other than those due from officers, owners, and related organizations.
9. 17. Line 17, Due From Officers, Owners or Related Organizations Due from Officers, Owners or Related Organizations under Other Assets includes the non-current portion of amounts owed from officers, owners, or related organizations.
10. 18. Line 18, Deposits (Schedule) Deposits include amounts used to secure accounts with utility companies, for workers compensation insurance or with lessors, for example. A schedule must be attached that details the amount on this line.
1. 19. Line 19, Other Noncurrent Assets Other Noncurrent Assets represent those non-current assets which are not appropriately reported on any other line (ex. organization costs).
2. 20. Line 20, Total Other Assets Total Other Assets is the sum of amounts recorded on Lines 16 through 19.
3. 21. Line 21, Total Assets Total Assets represents the sum of amounts recorded on Lines 12, 15, and 20 of the balance sheet.
4. 22. Line 22, Accounts Payable Accounts Payable represent liabilities of daily transactions normally kept on open account for goods and services purchased. Exclude accounts payable owed to related parties.
5. 23. Line 23, Notes Payable and Current Portion of Long Term Debt Notes Payable and Current Portion of Long-Term Debt includes obligations that are scheduled to mature within one year after the balance sheet date and the current portion of long-term debt.
6. 24. Line 24, Accrued Salaries Accrued Salaries represent the salaries and wages earned by employees but not paid during the accounting period. To be recognized as an allowable expense, salaries accrued at the end of the accounting year must be paid within ninety days of the year end.
7. 25. Line 25, Accrued Payroll Taxes Accrued Payroll Taxes include undeposited federal and state income and FICA taxes withheld. It also includes union dues and insurance withheld and the employers' liability for FICA and unemployment taxes.
8. 26. Line 26, Accrued Income Taxes Accrued Income Taxes include any liability the facility has for federal and state income taxes.
9. 27. Line 27, Inter-Company Payables Inter-company Payables represent amounts owed by the facility to a home office or other nursing home facility in a multi-facility operation.
10. 28. Line 28, Other Current Liabilities Other Current Liabilities represent any current obligations not included elsewhere on Form 11, Lines 22-27. A schedule must be included with the cost report.
11. 29. Line 29, Total Current Liabilities Total Current Liabilities represents the sum of amounts reported on Lines 22 through 28 of this form.
30. Line 30, Mortgage Payable Mortgage Payable represents the mortgage obligation that is scheduled to mature after one year from the balance sheet date.
31. Line 31, Notes Payable Notes Payable - Long-Term include obligations that are scheduled to mature after one year from the balance sheet date.
32. Line 32, Notes Payable to Officers, Owners or Related Organizations Notes Payable to Officers, Owners or Related Organizations represent liabilities to officers, owners or related organizations.
33. Line 33, Total Long-Term Liabilities Total Long-Term Liabilities represents the sum of Lines 30 through 32.
34. Line 34, Total Liabilities Total Liabilities is the sum of current liabilities (Line 29) and long-term liabilities (Line 33).
35. Lines 35 - 41, Capital Capital has sections, which apply to proprietorships, partnerships, governmental facilities, and corporations. Only the applicable lines should be completed.
36. Line 42, Total Capital Total Capital is the sum of amounts reported on Lines 35 through 41.
37. Line 43, Total Liabilities and Capital Total Liabilities and Capital is the sum of Total Liabilities (Line 34) and Total Capital (Line 42). Total Liabilities and Capital should agree with Total Assets (Line 21) of the balance sheet.
L. Form 12 Capital Reconciliation
1. Total Capital at Beginning of Period should be obtained from Form 11, Line 42, Column 1.
2. Additions to Capital - All additions to capital must be included in this section.
a) Line 1, Net Income (Loss) for Period Net Income (Loss) for Period is obtained from Form 5, Line 22.
b) Line 2, Contributions to Capital Contributions to capital must be listed together with the date the contribution was made.
c) Lines 3 and 4 List any other additions to capital.
3. Reductions to Capital - All reductions to capital must be included in this section.
a) Line 1, Dividends Paid Dividends include those dividends declared during the cost reporting period.
b) Line 2, Owners' or Partners' Withdrawals Owners' or Partners' Withdrawal must be listed on the lines provided together with the date the withdrawal was made. A schedule must be attached if necessary.
c) Lines 3 and 4 List any other reductions to capital.
4. Ending Capital - Total Capital at End of Reporting Period must equal the amount on Form 11, Line 42, Column 2.
M. Form 13 Owners' Compensation
A separate Form 13 must be completed for each owner, partner or stockholder listed on Form 14. Additional copies of Form 13 should be made as needed. Compensation other than salary should be specified under other compensation. Examples of such compensation are given on Form 13. Each completed Form 13 must be signed by the owner, partner or stockholder.
The Section I "Compensation Paid by Facility" will identify net allowable compensation claimed after adjustments per Column 6 of the applicable Form 6 reported line number.
The Section I "Compensation Paid by Related Management Company/Home Office" will identify net allowable compensation claimed for this facility after adjustments and included on Form 6, Line 2-50, Column 6. This is the allocated/applicable owner's, partner's or stockholder's allowable compensation amount included from Form 15, Line 2-01, Column 6 plus any direct Form 15, Line 2-01, Column 3 compensation.
The Section VII "Analysis of Compensation Paid to Relatives of Owner/Partner/Stockholder" will identify the Form 6 line number in which the compensation is claimed and the total compensation paid to each relative per line number. For relatives of related management company/home office owners, partners or stockholders, the total compensation paid by the related management company/home office to each relative will be identified here per Line 2-50.
Each provider is required to complete the applicable section of this form. All owners, partners, major stockholders, and officers will be identified on this Form.
The “Direct Compensation from Facility” column will identify direct total compensation amounts paid by the facility. This column will include each owner’s, partner’s, major stockholder’s and officer’s total compensation amount as posted from the trial balance to Form 6, Column 1 (do not include Form 6, Line 2-50 amounts for related management company/home office). The “Form 15 Compensation Amount” column will identify the total compensation amount paid to each related management company/home office owner, partner, major stockholder and officer as posted to Form 15, Column 1.
Each provider that reports expense on Form 6, Line 2-50 as a result of home office costs or management fees paid to a related management company must complete Form 15. The form is to be used to report the allocation of indirectly related expenses as well as directly related expenses from the home office or related management company.
This section must include the total revenue of the home office or related management company. Facilities should complete only Columns 1 and 2 in Section 1.
Line 2-01 through 2-30 will be used to report the expenses for the described accounts. All expense accounts that are not listed in Section 2 must be reported on Line 2-28, Other, and a detailed schedule must be attached to the cost report.
This column must agree with the general ledger of the home office or the management company.
This column is for adjustments for expenses not related to resident care or to offset revenues against expenses. This column will also be used to make necessary adjustments for excess compensation to Line 2-01 as described in Section 3-2.E.
c) Column 3 Expenses that are directly related to the management of the facility for which the cost report is being filed must be reported in Column 3.
d) Column 4 Expenses, which are directly related to the management of all other facilities, must be reported in Column 4.
e) Column 5 Column 1, less Column 2, less Column 3, less Column 4 will be reported in Column 5. These are the expenses to be allocated to all facilities managed by the home office or the management company.
f) Column 6 Column 5 multiplied by the allocation percentage related to the facility for which the cost report is being filed will be reported in Column 6.
3. Section 3 - Calculation of Allowable Expenditures
a) Line 3-01, Expenditures Directly Related to the Facility The total of expenses directly related to this facility from Line 2-31, Column 3 are reported here.
b) Line 3-02, Expenditures Allocated to this Facility The total amount of this facility's allocated portion of the indirectly related expenses from Line 2-31, Column 6 are reported here.
c) Line 3-03, Less: Nonallowable Expenses Nonallowable expenses that are included in Section 2 will be listed by the following categories: Bad Debts, Contributions, Income Tax, Vehicles, and Other. Other nonallowable expenses must be listed on a schedule attached to the cost report.
d) Line 3-04, Total Allowable Expenditures Total of Lines 3-01, 3-02, and 3-03.
4. Section 4 - Description of Allocation Methods
This section is to be used to describe the methodology used to allocate home office or related management company expenditures to this facility. See Section 3-2.E for instructions concerning allowable cost allocation methods.
P. Form 16 Staffing and Salary Costs
Form 16 must be completed for each facility.
1. Column 2, Salaries Cost This column must equal the amount on Form 6, Column 1 for the line recorded in column 1.
2. Column 3, Actual Hours This column is used to record the actual hours paid during the report period for each staff classification.
4. Column 4, Beginning Hourly Rate This column is used to record the facility's beginning hourly rate for each staff classification as of the ending date of the report period.
110.00 Cash in Bank - General
111.00 Cash in Bank - Payroll
114.00 Cash in Bank - Savings
116.00 Resident Trust
118.00 Petty Cash
120.00 Private
121.00 Medicare – Part A
122.00 Medicare – Part B
122.10 Medicare Coinsurance/Deductible
123.00 Medicaid
123.10 Medicaid Resident Liability
124.00 Nurse Aide Training & Testing
130.00 Allowance for Doubtful Accounts
135.00 Nursing Supplies
136.00 Food
137.00 Food Supplements
138.00 Linen
Cash on deposit in a checking account at a bank.
Cash on deposit in a checking account used for payroll purposes only. The balance in this account is usually offset by payables for payroll and withholding.
Cash on deposit in bank or Savings and Loan earning interest income.
Funds left with the facility by residents for safekeeping, which is either as cash on hand or in a checking/savings account on deposit.
Amount of cash retained on the premises to meet the daily requirements for small purchases or to make change for residents and visitors.
Amounts due from self-pay residents and other Third Parties.
Amounts billed to the Medicare Title XVIII fiscal intermediary for SNF services.
Amounts billed to the Medicare Title XVIII fiscal intermediary for Part B services.
Amounts billed to the resident or third party for coinsurance or deductible for Medicare services.
Amounts due from the Department of Human Services (DHS) for services provided to Medicaid residents.
Amounts due from the Medicaid resident or third party for his care as established by the local DHS county office.
Amounts due from Medicaid/Medicare/ Private Pay/etc. for Nurse Aide Training and/or Testing.
Estimate of accounts receivable which will not be collected.
The value of supplies on hand used for the professional care of the resident (i.e., medical and nursing supplies).
The value of food and food items on hand.
The value of food supplements such as Ensure, etc. on hand.
The value of sheets, blankets, pillow cases and gowns on hand.
139.00 Incontinence Supplies The value of incontinence supplies such as diapers and underpads on hand.
145.00 Insurance Insurance Premiums paid in a current period that apply to coverage in a future period.
146.00 Real Estate Taxes Real estate taxes paid in advance which apply to future cost reporting periods.
147.00 Personal Property Taxes Taxes levied on furniture and equipment, which are paid and applied to future cost reporting periods.
151.00 Land - Nursing Home Cost of land that is used as the site of the facility building.
152.00 Land Improvements Cost of paving, parking lot improvements, lighting standards, shrubs or other land improvements not attached to the building. These assets will be included with Buildings and Improvements on the Form 7 Depreciation Schedule.
155.00 Buildings The cost of buildings and attached assets (central heat/air, carpeting, etc.) used in providing resident care.
156.00 Building Improvements The cost of remodeling done to building used in providing resident care.
160.00 Equipment Movable equipment costing $2,500 or more, e.g., beds, ovens, freezers, typewriters, computers, desks, etc.
161.00 Software Cost of software owned by the facility.
164.00 Vehicles Cost of automotive vehicles owned by the facility.
166.00 Leasehold Improvements The cost incurred by the facility for improvements on rented or leased property used for resident care.
170.00 Accumulated Depreciation Depreciation expense taken during the current period as well as prior years on the above assets.
181.00 Deposits – Utilities Amounts on deposit as security with utility companies.
182.00 Deposits – Leases Amounts on deposit (or last month’s rent paid at the beginning of a lease with lessor as security. 183.00 Organization Costs Net costs incurred in formation of the business the benefits of which will be received over future periods.
184.00 Goodwill Difference, recorded on the books of the purchaser,
of the excess purchase price over the book value of the net tangible assets of an acquired operating entity. Includes any amounts paid to the seller for the permit of approval licensure, covenants not to compete, etc.
| 201.00 | Accounts Payable | Amounts due to suppliers for services rendered or supplies received. |
|---|---|---|
| 205.00 | Payroll Payable | Payroll amounts due to employees, not yet paid. |
| 206.00 | Current Portion of Long Term Debt | Amounts owed for long term debt for the current period, not yet paid. |
| 207.00 | Resident's Deposits | Amounts owed to residents for funds left with the facility for safekeeping. |
| 221.00 | Federal Income Tax | Amount of Federal Income Tax withheld from employee's gross pay, not yet remitted. |
|---|---|---|
| 222.00 | FICA (Social Security) | FICA withheld from employee's gross pay, not yet remitted. |
| 223.00 | State Income Tax | Amount of State Income Tax withheld from employee's gross pay, not yet remitted. |
| 226.00 | Union Dues | Amount of union dues withheld from employee's gross pay. |
| 227.00 | Insurance | Amount of insurance premiums withheld from employee's gross pay. |
| 230.00 | FICA | Social Security taxes owed by employer in addition to those withheld from employees pay. |
|---|---|---|
| 231.00 | Unemployment Taxes | Unemployment Insurance payroll taxes owed by the employer. |
| 235.00 | Worker's Comp | Worker's Compensation premiums owed by the employer. |
| 241.00 | Real Property Tax | Amount owed for taxes levied upon the real property (land and buildings) owned by the facility. |
|---|---|---|
| 242.00 | Personal Property Tax | Amount owed for taxes levied upon the personal property (furniture and equipment) owned by the facility. |
| 243.00 | Federal Income Tax | Amount due to Federal Government for taxes levied by it on the net income of the facility. |
244.00 State Income Tax
Amount due to the state for taxes levied by it on the net income of the facility.
245.00 Sales Tax
Taxes, passed on to the customers or residents, levied on the retail sale of the facility, which are owed by the facility to state and local governments.
Amount due to a third party, which is usually made as a result of an agreement to accept cost as payment to a contracting agent.
253.00 Medicare
Amount due to Medicare fiscal intermediary based on cost settlement.
255.00 Medicaid
Amount due to the Department of Human Services.
261.00 Mortgage Payable
Amount due on mortgages, against the facility's real property and improvements owned, with term longer than one year.
263.00 Notes Payable
Amount due on secured notes payable with term longer than one year. Note that amount due to owner and/or related organizations should be separated.
301.00 Capital
Owner's capital at balance sheet date.
310.00 Capital Stock
The par or stated value of stock owned at balance sheet date.
320.00 Paid in Capital
The amount of capital in excess of par or stated value of stock at balance sheet date.
392.00 Retained Earnings
Accumulated earnings after income taxes and after dividends have been paid to stockholders.
393.00 Net Profit or (Loss)
Net profit or (loss) from operation for current year to date before provisions for income taxes have been made.
395.00 Proprietor Draw
Amount withdrawn from the business by the owner(s) in cases where the facility is not a corporation.
The gross charges made to residents for room and board services, including general nursing, dietary, housekeeping and all other commonly used services and supplies available to all residents and normally expressed as a daily or monthly rate.
In lieu of recording all charges and contractual adjustments, these accounts may be used to record amounts received (cash basis) during the period
| and applicable accrual adjustments at the beginning and end of the period. | ||
|---|---|---|
| 402.00 | Private, Other Third Party | Amounts billed to self-pay residents and other third parties for services/supplies, which are reimbursed on a per diem or monthly basis. |
| 404.00 | Medicare – Part A | Amounts billed to the Medicare Title XVIII Part A fiscal intermediary for SNF services/supplies, which are reimbursed on a per diem basis. This is the daily amount billed for room & board and does not include the Medicare Part A ancillary services/supplies which are billed separately. |
| 405.00 | Medicaid | Amounts billed to Medicaid for services/supplies, which are reimbursed on a per diem basis. |
| ANCILLARY REVENUE | ||
| In lieu of recording all changes and adjustments, these accounts may be used to record amounts received (cash basis) during the period and applicable accrual adjustments at the beginning and end of the period. | ||
| 410.00 | Medicare Part A Physical Therapy | Amounts billed to Medicare Part A for physical therapy services and supplies. |
| 410.10 | Medicare Part B Physical Therapy | Amounts billed to Medicare Part B for physical therapy services and supplies. |
| 410.20 | Other Physical Therapy | Amounts billed to other Third Parties and non-residents/employees/etc. for physical therapy services and supplies. |
| 411.00 | Medicare Part A Occupational Therapy | Amounts billed to Medicare Part A for occupational therapy services and supplies. |
| 411.10 | Medicare Part B Occupational Therapy | Amounts billed to Medicare Part B for occupational therapy services and supplies. |
| 411.20 | Other Occupational Therapy | Amounts billed to other Third Parties and non-residents/employees/etc. for occupational therapy services and supplies. |
| 412.00 | Medicare Part A Speech Therapy | Amounts billed to Medicare Part A for speech therapy services and supplies. |
| 412.10 | Medicare Part B Speech Therapy | Amounts billed to Medicare Part B for speech therapy services and supplies. |
| 412.20 | Other Speech Therapy | Amounts billed to other Third Parties and non-residents/employees/etc. for speech therapy services and supplies. |
| 413.00 | Medicare Part A Oxygen/Inhalation Therapy | Amounts billed to Medicare Part A for oxygen/inhalation therapy services and supplies. |
| 413.10 | Medicare Part B Oxygen/Inhalation Therapy | Amounts billed to Medicare Part B for oxygen/inhalation therapy services and supplies. |
| 413.20 | Other Oxygen/Inhalation Therapy | Amounts billed to other Third Parties and non-residents/employees/etc. for oxygen/inhalation therapy services and supplies. |
|---|---|---|
| 414.00 | Medicare Part A Intravenous Therapy | Amounts billed to Medicare Part A for intravenous therapy services and supplies. |
| 414.10 | Medicare Part B Intravenous Therapy | Amounts billed to Medicare Part B for intravenous therapy services and supplies. |
| 414.20 | Other Intravenous Therapy | Amounts billed to other Third Parties and non-residents/employees/etc. for intravenous therapy services and supplies. |
| 415.00 | Medicare Part A Pharmacy | Amounts billed to Medicare Part A for drugs and pharmaceuticals. |
| 415.20 | Other Pharmacy | Amounts billed to other Third Parties and non-residents/employees, etc. for drugs and pharmaceuticals. |
| 416.00 | Medicare Part A Nursing/Medical Supplies | Amounts billed to Medicare Part A for nursing and medical supplies. |
| 416.10 | Medicare Part B Nursing/Medical Supplies | Amounts billed to Medicare Part B for nursing and medical supplies. |
| 416.20 | Other Nursing/Medical Supplies | Amounts billed to other Third Parties and non-residents/employees/etc. for nursing and medical supplies. |
| 417.00 | Medicare Part A Laboratory | Amounts billed to Medicare Part A for laboratory services and supplies. |
| 417.10 | Medicare Part B Laboratory | Amounts billed to Medicare Part B for laboratory services and supplies. |
| 417.20 | Other Laboratory | Amounts billed to other Third Parties and non-residents/employees/etc. for laboratory services and supplies. |
| 418.00 | Part A X-Ray/Radiology | Amounts billed to Medicare Part A for X-Ray/Radiology services and supplies. |
| 418.10 | Part B X-Ray/Radiology | Amounts billed to Medicare Part B for X-Ray/Radiology services and supplies. |
| 418.20 | Other X-Ray/Radiology | Amounts billed to other Third Parties and non-residents/employees/etc. for X-Ray/Radiology services and supplies. |
| 419.00 | Part A Other Miscellaneous Ancillary | Amounts billed to Medicare Part A for miscellaneous ancillary services and supplies. |
| 419.10 | Part B Other Miscellaneous Ancillary | Amounts billed to Medicare Part B for miscellaneous ancillary services and supplies. |
| 419.20 | Other Miscellaneous Ancillary | Amounts billed to other Third Parties and non-residents/employees/etc. for miscellaneous ancillary services and supplies. |
| 430.00 | Television | Amounts received and receivable from television rental and cable fees from residents. |
|---|---|---|
| 432.00 | Beauty and Barber | Amounts received and receivable from the provision of beauty and barber services. |
| 434.00 | Personal Items | Amounts received and receivable from the sale of personal items such as toothpaste, razor blades, shaving cream, etc. |
| 436.00 | Vending | Amounts received and receivable from the sale of products in vending machines, such as candy bars and soda pop. |
| 438.00 | Rental | Amounts received and receivable from the rental of space or equipment. |
| 440.00 | Interest | Amounts received and receivable for interest earned on cash deposits or notes and accounts receivable. |
| 442.00 | Arts & Crafts | Amounts received and receivable from the sale of arts and craft items. |
| 444.00 | Meal | Amounts received and receivable from the sale of meals to guests and employees. |
| 446.00 | Laundry | Amounts received and receivable from the sale of laundry services. |
| 448.00 | Contributions, Gifts, Grants | Amounts received and receivable from contributions, gifts and grants. |
| 449.00 | Criminal Records Check | Amounts received and receivable for reimbursement of criminal records check disbursements. |
| 450.00 | Other | Amounts received and receivable for which a specific account is not established. |
| DEDUCTIONS | Contractual adjustments made to resident care revenue to reflect settlements for the difference between the billed amounts as recorded per general ledger revenue accounts and contracted amounts actually paid. These adjustments are usually made as a result of an agreement to accept payment amounts from a contracting third party agent which are less than the billed amounts. | |
| 501.00 | Private Pay & Other Third Party Contractual Adjustment | Contractual adjustments made to Private Pay and Other Third Party covered charges. |
| 503.00 | Medicare Part A Contractual Adjustment | Contractual adjustments made to Medicare Part A covered charges. |
| 504.00 | Medicaid Contractual Adjustment | Contractual adjustments made to Medicaid covered charges. |
| 505.00 | Medicare Part B Contractual Adjustment | Contractual adjustments made to Medicare Part B covered charges. |
| 522.00 | Private Pay & Other Third Party Allowance | Allowance adjustment made to Private Pay and Other Third Party covered charges. |
|---|---|---|
| 524.00 | Medicare Part A Allowance | Allowance adjustment made to Medicare Part A covered charges. |
| 525.00 | Medicaid Allowance | Allowance adjustment made to Medicaid covered charges. |
| 526.00 | Medicare Part B Allowance | Allowance adjustment made to Medicare Part B covered charges. |
| 601.00 | Salaries – RNs | Salaries of Registered Nurses (excluding the DON). |
|---|---|---|
| 602.00 | Salaries – LPNs | Salaries of Licensed Practical Nurses. |
| 603.00 | Salaries – Aides | Salaries of Nurse Aides. |
| 603.10 | Salaries – Medication Assistants | Salaries of Medication Assistants-Certified |
| 604.00 | Salaries – Assistant Director of Nursing | Salaries of the Assistant Director of Nursing. |
| 605.00 | Salaries – Director of Nursing | Salaries of the Director of Nursing who is in a supervisory position. |
| 606.00 | Salaries – Occupational Therapists | Salaries of occupational therapists. |
| 607.00 | Salaries – Physical Therapists | Salaries of physical therapists. |
| 608.00 | Salaries – Speech Therapists | Salaries of speech therapists. |
| 609.00 | Salaries – Other Therapists | Salaries of therapists other than occupational, physical or speech therapists. |
| 610.00 | Salaries – Rehab Nurse Aide | Salaries of rehabilitation nurse aide. Each facility should have a nursing assistant who is designated to be the Rehabilitative nurse aide. This aide should be trained by the therapist to provide the maintenance program for those residents who require these services. |
| 611.00 | FICA – Direct Care | Cost of employer's portion of Social Security Tax for direct care staff. |
| 612.00 | Group Health - Direct Care | Cost of employer's contribution to employee Health Insurance for direct care staff. |
| 613.00 | Pensions – Direct Care | Cost of employer's contribution to employee pension plan for direct care staff. |
| 614.00 | Unemployment Taxes –Direct Care | Cost of employer's contribution to State and Federal unemployment taxes for direct care staff. |
| 615.00 | Uniform Allowance - Direct Care | Cost of uniform allowance or uniforms given to staff as a fringe benefit for direct care staff. |
|---|---|---|
| 616.00 | Worker's Comp - Direct Care | Cost of worker's compensation insurance for direct care staff. |
| 617.00 | Other Fringe Benefits –Direct Care | Cost of other fringe benefits offered to direct care staff not specifically listed in the categories above. These must be included in the facility’s benefits policy. |
|---|---|---|
| 618.00 | Contract – Aides | Cost of Certified Nurse Aides hired through contract that are not on the facility payroll. |
| 618.10 | Contract – Medication Assistants | Cost of Medication Assistants-Certified hired through contract that are not on the facility payroll. |
| 619.00 | Contract - LPN’s | Cost of LPN’s and graduate practical nurses hired through contract that are not on facility payroll. |
| 620.00 | Contract - RN’s | Cost of RN’s and graduate nurses hired through contract that are not on facility payroll. |
| 621.00 | Contract – Occupational Therapists | Cost of occupational therapists hired through contract that are not on the facility payroll. |
| 622.00 | Contract - Physical Therapists | Cost of physical therapists hired through contract that are not on facility payroll. |
| 623.00 | Contract - Speech Therapists | Cost of speech therapists hired through contract that are not on facility payroll. |
| 624.00 | Contract - Other Therapists | Cost of therapists other than occupational, physical, and speech therapists hired through contract that are not facility employees. |
| 625.00 | Consultant Fees – Nursing | Fees paid to nursing personnel, not on the facility payroll, for providing advisory and educational services to the facility. |
| 626.00 | Training – Direct Care | Cost of training related to resident care for RN’s, LPN’s and Certified Nurse Aides. Also includes travel costs associated with this training. Does not include training cost for Nurse Aide certification. |
| 627.00 | Over the Counter Drugs | Cost of over the counter drugs provided to its residents such as pain relievers, cough and cold medications, Rubbing Alcohol, aspirin. |
| 628.00 | Oxygen | Cost of oxygen and related supplies. |
| 629.00 | Medical Supplies - Direct Care | Cost of providing direct medical care, including single use disposable items and consumable supplies that are used in the course of providing direct medical care to a resident, such as catheters, syringes, sterile dressings, prep supplies, alcohol pads, Betadine solution in bulk, tongue depressors, and cotton balls. Includes minor medical equipment used in providing direct medical care such as thermometers, sphygmomanometers, stethoscopes, etc. |
| 629.10 | Medical Supplies – Point of Care | Cost of Point of Care Software Applications that does not require capitalization. |
| 630.00 | Therapy Supplies | Cost of supplies used directly by the therapy staff for rendering therapeutic services to the residents of the facility. |
| 631.00 | Raw Food | Cost of food products used to provide meals and snacks to residents. |
|---|---|---|
| 632.00 | Food Supplements | Cost of food products given in addition to normal meals and snacks under doctor's orders (Ensure, etc.). |
| 633.00 | Incontinence Supplies | Cost of incontinence supplies to include diapers and underpads. |
| 634.00 | Dental | Cost of dental services. |
| 635.00 | Consultant Fees – Dental | Fees paid to a dentist, not on the facility payroll, for providing advisory and educational services to the facility. |
|---|---|---|
| 636.00 | Drugs – Legend | Cost of prescription drugs prescribed by the physician as medically necessary, provided by the facility to its residents. |
| 637.00 | Laboratory | Cost of laboratory procedures such as blood tests and urinalysis provided to it's on residents. |
| 637.10 | X-Ray | Cost of providing radiological services to its residents. |
| 701.00 | Salaries – Administrator | Salaries of licensed administrators excluding owners. |
|---|---|---|
| 702.00 | Salaries - Assistant Administrator | Salaries of licensed assistant administrators excluding owners. |
| 703.00 | Salaries - Dietary Supervisor | Salaries of dietary supervisors. |
| 703.10 | Salaries - Dietary Staff | Salaries of kitchen personnel including cooks, helpers and dishwashers. |
| 704.00 | Salaries – Housekeeping Supervisor | Salaries of housekeeping supervisors. |
| 704.10 | Salaries - Housekeeping Staff | Salaries of housekeeping personnel including maids and janitors. |
| 705.00 | Salaries - Laundry Supervisor | Salaries of laundry supervisor. |
| 705.10 | Salaries - Laundry Staff | Salaries of laundry personnel except supervisors. |
| 706.00 | Salaries – Maintenance Supervisor | Salaries of the maintenance supervisors. |
| 706.10 | Salaries - Maintenance Staff | Salaries of personnel involved in operating and maintaining the physical plant, including maintenance men or plant engineer excluding the maintenance supervisor. |
| 707.00 | Salaries - Medical Records | Salaries of medical records personnel. |
| 708.00 | Salaries - Other Administrative | Salaries of other administrative personnel not included in other accounts. |
| 708.10 | Salaries – Bookkeeper | Salaries of personnel responsible for accumulating and maintaining financial and statistical records. |
| 708.20 | Salaries – Receptionist | Salaries of personnel answering telephones, greeting visitors, answering questions and performing secretarial functions. |
| 709.00 | Salaries – Activities | Salaries of Activities staff. |
| 710.00 | Salaries – Pharmacy | Salaries of pharmacy employees. |
|---|---|---|
| 711.00 | Salaries - Social Services | Salaries of personnel providing an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interest and the physical, mental and psychosocial well being of the residents. |
| 712.00 | Salaries - Owner or Owner/Administrator | Salaries of all owners of the facility. |
| 713.00 | FICA – Indirect, Administrative & Operating | Cost of employer's portion of Social Security Tax for indirect, administrative & operating staff. |
| 714.00 | Group Health – Indirect, Administrative & Operating | Cost of employer's contribution to employee Health Insurance for indirect, administrative & operating staff. |
| 715.00 | Pensions – Indirect, Administrative & Operating | Cost of employer's contribution to employee pension plan for indirect, administrative & operating staff. |
| 716.00 | Unemployment Taxes – Indirect, Administrative & Operating | Cost of employer's contribution to State and Federal unemployment taxes for indirect, administrative & operating staff. |
| 717.00 | Uniform Allowance – Indirect, Administrative & Operating | Cost of uniform allowance or uniforms given to staff as a fringe benefit for indirect, administrative & operating staff. |
| 718.00 | Worker's Comp – Indirect, Administrative & Operating | Cost of worker's compensation insurance for indirect, administrative & operating staff. |
| 719.00 | Other Fringe Benefits – Indirect, Administrative & Operating | Cost of other fringe benefits offered to administrative staff not specifically listed in the categories above. These should be included in the facilities benefits policy. |
| 720.00 | Contract – Dietary | Cost of dietary services and personnel hired through contract that are not facility employees. |
| 721.00 | Contract - Housekeeping | Cost of housekeeping services and personnel hired through contract that are not facility employees. |
| 722.00 | Contract – Laundry | Cost of laundry services and personnel hired through contract that are not facility employees. |
| 723.00 | Contract - Maintenance | Cost of maintenance services and personnel hired through contract that are not facility employees, includes electricians, plumbers, locksmiths, etc. |
| 724.00 | Consultant Fees - Dietitian | Fees paid to consulting registered dietitians for advisory and educational services. |
| 725.00 | Consultant Fees - Medical Records | Fees paid to consulting medical records Accredited Records Technicians or Medical Records Administrator for advisory and educational services. |
| 726.00 | Consultant Fees – Activities | Fees paid to activities personnel, not on the facility payroll, for providing advisory services to the facility. |
| 727.00 | Consultant Fees – Medical Director | Fees paid to a medical doctor, not on the facility payroll, for providing advisory and educational services to the facility. |
|---|---|---|
| 728.00 | Consultant Fees – Pharmacy | Fees paid to a registered pharmacist, not on the facility payroll, for providing advisory and educational services to the facility. |
| 729.00 | Consultant Fees - Social Worker | Fees paid to a social worker, not on the facility payroll, for providing advisory and educational services to the facility. |
| 730.00 | Consultant Fees – Therapists | Fees paid to licensed therapists, not on the facility payroll, for providing advisory and educational services to the facility. |
| 731.00 | Barber & Beauty Expense – Allowable | The cost of barber and beauty services provided to residents by facility staff. |
| 732.00 | Medical Transportation | Cost of providing residents medical transportation to local community providers when the facility does not use facility vehicles. |
| 732.10 | Business Related Mileage | Amounts claimed (rate per mile) for facility owned or other vehicles used in providing residents medical transportation to local “community” providers or used for business related mileage. |
| 733.00 | Resident Activities | Cost of resident activities should include pastoral services, recreational activities and supplies (games, puzzles, art supplies). |
| 733.10 | Supplies - Care Related | Personal hygiene items. Soaps, deodorants, shampoos, toothbrush, toothpaste, razor, razor blades etc. Includes minor equipment provided by the facility that is not used in providing direct medical care such as water pitchers, wash basin, emesis basin, bedpan, urinal, hot water bottles, heating pads, crutches, walkers, etc. Includes nurse charting forms, admission forms, medication and treatment records, physician order forms. |
| 735.00 | Accounting Fees | Fees paid for the preparation of the cost report, audits of the financial records, bookkeeping services, tax return preparation of the nursing facility and other related services, excluding personal tax planning and personal tax return preparation. |
| 735.10 | Payroll Processing | Fees paid to banks, data processing companies, or accounting firms for preparing the facility payroll. |
| 736.00 | Advertising for Labor/Supplies | Advertising expense limited to classified advertisements for the purpose of procurement of resident care related labor or supplies. Advertisements, including yellow page listings, designed to promote the facility or to solicit residents are not allowable. |
| 737.00 | Amortization Exp. - Non-Capital | Costs incurred for legal and other expenses when organizing a corporation should be amortized over a period of 60 months. |
|---|---|---|
| 738.00 | Bank Service Charges | Fees paid to banks for service charges, excluding |
| penalties and insufficient funds charges. | ||
|---|---|---|
| 739.00 | Criminal Records Check | Costs incurred for criminal records checks for employee and job applicants. |
| 740.00 | Data Processing Fees | Cost of purchased services for data processing systems and services. |
| 741.00 | Dietary Supplies | Cost of consumable items such as soap, detergent, napkins, paper cups, straws, etc. used in the dietary department. |
| 741.10 | Dietary Non-Expendable Supplies | Cost of non-expendable dietary supplies such as forks, spoons, trays, plates, cups, bowls, glasses, etc. |
| 742.00 | Dues | Cost of dues paid for membership in industry associations. |
| 743.00 | Educational Seminars & Training | The cost of registration for attending educational seminars and training by employees of the facility and costs incurred in the provision of in-house training for facility staff. Do not include travel. |
| 744.00 | Governing Body | Cost of Governing Body. |
| 745.00 | Housekeeping Supplies | Cost of consumable housekeeping items including waxes, cleaners, soap, brooms and lavatory supplies. |
| 746.00 | Interest Expense - Non-Capital | Interest paid on short term borrowing for facility operations. |
| 747.00 | Laundry Supplies | Cost of consumable goods used in the laundry including soap, detergent, starch and bleach. |
| 748.00 | Legal Fees | Fees paid to attorneys. |
| 749.00 | Linen & Laundry | Cost of sheets, blankets, pillows and gowns. |
| 750.00 | Miscellaneous | Cost incurred in providing nursing facility services that cannot be assigned to any other account. |
| 750.10 | License Fees | Fees for licenses including state, county and local business licenses as well as nursing facility and administrator licensing fees. |
| 750.20 | Printing | Cost of printing forms and stationary including accounting and census forms, charge tickets, facility letterhead, etc. |
| 752.00 | Management Fees & Home Office | The cost of purchased management services or home office costs incurred that are allowable to the provider. |
| 753.00 | Office Supplies | Cost of consumable items used in the business office (pencils, erasers, paper, staples, computer paper, ribbons). |
| 753.10 | Subscriptions | Cost of subscribing to newspapers, magazines and periodicals for facility use. |
| 754.00 | Postage | Cost of postage including stamps, metered postage, freight charges and courier services. |
| 755.00 | Repairs & Maintenance | Cost of supplies and services used to repair the facility building, furniture and equipment (include light bulbs, nails, lumber, glass). |
|---|---|---|
| 755.10 | Vehicle Maintenance | Costs of maintaining facility vehicles including gas, oil, tires and auto insurance. |
| 755.20 | Painting | Supplies and services. |
| 755.30 | Gardening | Supplies and services for lawn care. |
| 756.00 | Taxes, Other | The cost of taxes paid that are not included in any other account. |
| 757.00 | Telephone & Communications | Cost the telephone services, WATTS lines and FAX services. |
| 758.00 | Travel | Cost of travel (airfare, mileage, lodging, meals, etc.) by Administrator and other authorized personnel to attend professional and continuing educational seminars and meetings related to their position within the facility. |
| 759.00 | Utilities | Cost of utility services not specified in other accounts such as cable TV for common areas. . |
| 759.10 | Utilities - Heating | Cost of gas, or other heating fuel services. |
| 759.20 | Utilities - Electricity | Cost of electric services. |
| 759.30 | Utilities - Water, Sewer & Garbage | Cost of water, sewer and garbage collection. |
| 760.00 | Depreciation – Vehicles | Depreciation on vehicles. |
| 760.10 | Depreciation – Software | Depreciation on software. |
| 761.00 | Interest – Vehicles | Interest paid or accrued on notes, mortgages, and other loans, the proceeds of which were used to purchase facility vehicles. |
| 801.00 | Amortization Expense - Capital | Legal and other costs incurred when financing the facility which are amortized over the life of the mortgage. |
|---|---|---|
| 802.10 | Depreciation - Land Improvements | Depreciation on improvements having a limited life made to the land of the facility (paving, landscaping). |
| 802.20 | Depreciation - Building | Depreciation on the facility’s building and attached assets. |
| 802.30 | Depreciation - Building Improvements | Depreciation on major additions or improvements to the facility. For example a new laundry or dining room. |
| 802.40 | Depreciation - Equipment | Depreciation on items of movable equipment costing $2,500 or more such as beds, floor polishers, stoves, washing machines, computers, etc. |
|---|---|---|
| 802.41 | Depreciation – Point of Care | Depreciation expense associated with point of care software applications. |
| 802.50 | Depreciation - Leasehold | Depreciation on major additions or improvements |
| Improvements | to building or plant where the facility is leased and the cost of the changes are incurred by the lessee. | |
|---|---|---|
| 802.60 | Depreciation - Generator | Depreciation on generators approved by the Office of Long Term Care under Act 1602 of 2001. |
| 803.10 | Interest - Land/Building | Interest paid or accrued on notes, mortgages and other loans, the proceeds of which were used to purchase the facilities real property (land and building). |
| 803.20 | Interest -Furniture/Equipment | Interest paid or accrued on notes, mortgages, and other loans, the proceeds of which were used to purchase the facility's furniture and equipment. |
| 803.30 | Interest - Generator | Interest paid or accrued on notes the proceeds of which were used to purchase generators approved by the Office of Long Term Care under Act 1602 of 2001. |
| 803.40 | Interest – Point of Care | Interest expense associated with point of care software applications. |
| 804.00 | Property Insurance | Cost of fire and casualty insurance on facility buildings and equipment. |
| 805.00 | Insurance - Professional Liability | Cost of premiums for insuring the facility against injury and malpractice claims. The allowable insurance premium cost for nursing facilities (excluding Arkansas Health Center) is capped at $2,500 per licensed bed as of the end of the cost reporting period. |
| 806.00 | Property Taxes | Cost of taxes levied on the facility's land and buildings. |
| 807.00 | Rent - Building | Cost of leasing the facility's real property (land and building). |
| 808.00 | Rent - Furniture & Equipment | Cost of leased or rented furniture and equipment for the facility. |
| 809.00 | Rent – Point of Care | Rent expense associated with point of care software applications. |
| 820.00 | Quality Assurance Fee | Cost of the quality assurance fee paid monthly to the Department of Human Services. |
|---|---|---|
| 831.00 | Advertising | Cost of advertisements in magazines, newspapers, trade publications, radio, TV and yellow pages which seeks to increase resident utilization of the nursing facility. |
|---|---|---|
| 832.00 | Bad Debts | Accounts receivable written off as uncollectable. |
| 833.00 | Barber & Beauty | Cost directly related to the provision of beauty and barber services to residents. The cost of beauty and barber services provided by facility staff are considered allowable costs and should be recorded in account 731.00. |
| 834.00 | Contributions | Amounts donated to charitable, political or other organizations. |
|---|---|---|
| 836.00 | Income Taxes - State & Federal | Taxes on net income levied or expected to be levied by the federal or state government. |
| 837.00 | Insurance - Officers | Cost of life insurance on officers and/or key |
| 839.00 | Non-Working Officer's Salaries | employees of the facility. Salaries and other compensation paid to non-working officers. |
|---|---|---|
| 840.00 | Nurse Aide Testing | Costs incurred in having nurse aides tested in order to meet OBRA 1987 provisions that have been or will be submitted to the Division of Medical Services for direct reimbursement. This includes both the Medicaid and non-Medicaid portion of the expenses. |
| 841.00 | Nurse Aide Training | Costs incurred in having nurse aide training in order to meet OBRA 1987 provisions that have been or will be submitted to the Division of Medical Services for direct reimbursement. This includes both the Medicaid and non-Medicaid portion of the expenses. |
| 842.00 | Other Non-Allowable Cost | Other costs that are considered non-allowable in accordance with other provisions of the state plan that does not have a specific account established. |
| 842.10 | Gift Shop | Cost of products sold in the gift shop and other costs that are directly associated with the sale of those products. |
| 843.00 | Penalties & Sanctions | Penalties and sanctions assessed by the Division of Medical Services, the Internal Revenue Service or the State Tax Commission, insufficient funds charges, etc.. |
| 844.00 | Television | Cost of television sets used in the residents' rooms or for providing cable TV to the residents' rooms.. |
| 845.00 | Vending Machines | Cost of items sold to employees, residents and the general public including candy bars and soft drinks. |
| 846.00 | Goodwill Amortization | Amortization of amount paid for a facility in excess of the book value of its tangible assets. |