Tenn. Comp. R. & Regs. 1200-13-06-.08 – Cost Report for the Nursing Facility Level I Program

STATE OF TENNESSEE COMPTROLLER OF THE TREASURY DEPARTMENT OF AUDIT DIVISION OF STATE AUDIT SUITE 1500 JAMES K. POLK STATE OFFICE BUILDING NASHVILLE, TENNESSEE 37243-0264 IMPORTANT: Read Footnotes and Instructions and Accounting Principles before completing this form. Any form not properly completed may be rejected. DO NOT CHANGE THE EXISTING NOMENCLATURE. If the provider has accounts or descriptions that do not fit the existing categories, report the amounts in “Other” and attach a schedule with the desired nomenclature. This will keep information comparable among cost reports. Provider Numbers:1 Level I _________________________Date Submitted ______________________, 19______ Level II _________________________ Name of Facility 2 _____________________________________________________________________________________________ Mailing Address ______________________________________________________________________________ Street, P.O. Box, RFD City State Zip Code Physical Address _____________________________________________________________________________ Street, P.O. Box, RFD City State Zip Code Name of Present Administrator _______________________________________________( )_________________ Telephone Number Name of Home Office/Management Company_________________________________________________________ Mailing Address________________________________________________________________________ Street, P.O. Box, RFD City State Zip Code Contact Person _____________________________________ ____________( )___________________________ Telephone Number Accounting Period Covered by this Report: From ________________, 19____ thru ______________, 19_______ Fiscal Year End ______________________________________________ ACCRUAL ACCOUNTING MUST BE USED FOR THIS REPORT 3,4 ENTER ALL AMOUNTS IN WHOLE DOLLARS ___________________________________________________________________________________________

A. Type of Facility (Check only one)
1. 1. For Profit: __________ Sole Proprietor __________ Partnership __________ Corporation
2. 2. Nonprofit: __________ Church __________ Corporation __________ Other
3. 3. Government: __________ State __________ County __________ Other ____________________________________________________________________________________________
  1. B. Statistical and Other Data 5 (a) (b) (c) (d) (e) Skilled (a + b) (c + d) Certified Other NF TOTAL NF Non-NF TOTAL Beds Beds BEDS Beds BEDS
    1. 1. Licensed beds - beginning of the accounting period _______ _______ _______ _______ _______
      1. a. Bed change - date_______ _______ _______ _______ _______ _______
      2. b. Bed change - date_______ _______ _______ _______ _______ _______
    2. 2. Licensed beds - end of the accounting period _______ _______ _______ _______ _______
    3. 3. Possible bed days for the period 6 _______ _______ _______ _______ _______
    4. 4. Inpatient days for the period 7
      1. a. Medicare - Skilled ____________________ g. Private ICF/MR ___________________
      2. b. Medicaid - NF2 ____________________ h. Other NF1 ___________________
      3. c. Medicaid - NF1 ____________________ i. Other NF2 ___________________
      4. d. Private - NF1 ____________________ j. TOTAL NURSING FACILITY DAYS
      5. e. Private - NF2 ____________________ (Add items a - i ) ___________________
      6. f. Medicaid ICF/MR ____________________ k. Non-nursing facility days ___________________
      7. l. TOTAL DAYS - Add items j and k ___________________
    5. 5. Percent Occupancy (4.j. divided by 3.c.)
    6. 6. Meals served during the period 8
      1. a. Patients _______
      2. b. Employees _______
    7. (1) Considered part of compensation (Provided free of charge) _______
    8. (2) Paid for by employees _______
      1. c. Guests _______
    9. (1) Provided free of charge _______
    10. (2) Paid for by guests _______
      1. d. Owners _______
    11. (1) Provided free of charge _______
    12. (2) Paid for by owners _______
      1. e. Total Meals _______
        B. Statistical and Other Data (continued)
        7. List names of all persons living in the home that are not patients and their position or relationship to the home, such as owners, employees, etc. (If none, so state). Name / Title, Position, or Relationship / Amount of Salary / Where in Section F is salary shown? __________________ _____________________ ___________ _________________________ __________________ _____________________ ___________ _________________________
        8. List changes in ownership during this reporting period and those changes anticipated during the next reporting period. Type of Type of From Control To Control Date of Change __________________ ___________________ _____________________________ __________________ ___________________ _____________________________ __________________ ___________________ _____________________________
        C. Balance Sheet (Date ____________________, 19___)
        1. Assets
        a. Current Assets:
        (1) Cash on hand and in bank $______
        (2) Accounts receivable $______ Less allowance ______ ______
        (3) Other accounts receivable ______ Less allowance ______ ______
        (4) Notes receivable ______
        (5) Due from officers/owners ______
        (6) Inventory of supplies on hand ______
        (7) Prepaid expenses ______
        (8) Investments ______
        (9) Intercompany receivables ______
        (10) Other current assets (Specify) ___________________________ _______ ___________________________ _______
        C. Balance Sheet (continued)
        (11) Total Current Asset - Add items (1) through (10) $_______
        b. Fixed Assets: Accumulated Cost Depreciation Book Value
        (1) Land $_____ _____ $_____
        (2) Land Improvements $_____ _____ $_____
        (3) Buildings _____ _____ _____
        (4) Leasehold or building improvements _____ _____ _____
        (5) Fixed Equipment _____ _____ _____
        (6) Movable Equipment _____ _____ _____
        (7) Motor vehicles _____ _____ _____
        (8) Construction in progress _____ _____ _____
        (9) Other depreciable assets (Specify) ____________________________ _____ _____ _____ ____________________________ _____ _____ _____ ____________________________ _____ _____ _____
        (10) Total Fixed Assets Add items (1) through (9) $_____ $_____ $_____
        c. Other Assets (if any):
        (1) Deposits on loan $______
        (2) Long term investments ______
        (3) Special funds ______
        (4) Patient trust funds ______
        (5) Unamortized pre-opening expenses ______
        (6) Unamortized organization expenses ______
        (7) Other (Specify) _________________________ ______ _________________________ ______ _________________________ ______
        C. Balance Sheet (continued)
        (8) Total Other Assets - Add items (1) through (7) $______
        d. Total Assets - Add items a(11), b(9), and c(8) $______
        2. Liabilities
        a. Current Liabilities:
        (1) Accounts payable $______
        (2) Mortgages payable within one year ______
        (3) Notes and loans payable within one year ______
        (4) Salaries and wages payable ______
        (5) Payroll taxes payable ______
        (6) Accrued taxes ______
        (7) Deferred income ______
        (8) Patient trust funds due to patients ______
        (9) Intercompany payables ______
        (10) Other current liabilities (specify) _______________________ ______ _______________________ ______ _______________________ ______
        (11) Total Current Liabilities - Add items (1) through (10) $______
        b. Long Term Liabilities
        (1) Mortgages payable beyond one year $______
        (2) Notes payable beyond one year ______
        (3) Unsecured loans ______
        (4) Loans from owners ______
        (5) Other long term liabilities (Specify) _______________________ ______ _______________________ ______
        C. Balance Sheet (continued)
        (6) Total Long Term Liabilities Add items (1) through (5) $______
        c. Total Liabilities - Add items a(11) and b(6) $______
        3. Capital (Owner’s Equity or Fund Balance)
        a. Net Worth:
        (1) Individual $_______
        (2) Partnership _______
        (3) Corporation
        (a) Capital stock (at par or stated value) ________
        (b) Paid in capital ________
        (c) Treasury stock ________
        (d) Retained earnings ________
        (4) Fund Balance (Nonprofit) ________
        b. Total Capital - Add items a(1) through a(4) $________
        4. Total Liabilities and Capital (Section C, item 2c plus item 3b) $________
        D. Summary Statement of Income, Expense, and Retained Earnings
        1. Income 28
        a. Gross Routine Service Charges
        (1) (2) (3) Other Covered (1) + (2) Room & Board Services Total
        (1) Medicare Skilled $________ $________ $________
        (2) Medicaid - NF2 $________ ________ ________
        (3) Medicaid - NF1 $________ ________ ________
        (4) Private - NF1 $________ ________ ________
        (5) Private - NF2 $________ ________ ________
        (6) Medicaid - ICF/MR $________ ________ ________
        (7) Private - ICF/MR $________ ________ ________
        D. Summary Statement of Income, Expense, and Retained Earnings (continued)
        (8) Other NF1 ________ ________ _________
        (9) Other NF2 ________ ________ _________
        (10) TOTAL ROUTINE NF CHARGES Add items
        (1) through (9) $________ $________ $_________
        (11) Non-NF routine charges $_________
        (12) TOTAL ROUTINE CHARGES - Add items (10) and (11) $_________
        b. Other Income
        (1) Pharmacy $_________
        (2) Laboratory _________
        (3) X-ray _________
        (4) All therapies _________
        (5) Other ancillaries (Specify) ______________________________ _________ ______________________________ _________
        (6) Cable TV income _________
        (7) Rental income from non-routine nursing _________ home operations
        (8) Rental income from non-nursing home facilities _________
        (9) Non-routine barber/beauty shop income _________
        (10) Employee, owner, and guest meals _________
        (11) Vending machine income _________
        (12) Non-routine laundry income _________
        (13) Interest and investment income on other than funded depreciation accounts (Attach Itemized Schedule) _________
        (14) Interest on funded depreciation deposits _________
        (15) Contributions, donations, and grants _________
        D. Summary Statement of Income, Expense, and Retained Earnings (continued)
        (16) Miscellaneous income Attach Itemized Schedule) _________
        (17) Total Other Income Add items (1) through (16) $_________
        c. Total Income Add items a(12) and b(17) $_________
        2. Deductions from Revenue:
        a. Bad Debt Expenses
        (1) Applicable to Medicaid NF1 patients $_________
        (2) Applicable to other patients _________
        (3) Other bad debts (Specify) ____________________ _________
        b. Contractual Allowance and Other Adjustments
        (1) Applicable to Medicaid NF1 patients $_________
        (2) Applicable to other patients _________
        (3) Other (Specify) ____________________ _________
        c. Deductions from Revenue Add items 2a through 2b _________
        3. Net Revenue Item 1c minus 2c _________
        4. Operating Expense (Item F.21.) _________
        5. Profit or (Loss) Item 3 minus 4 $_________
        6. Additions and Deductions:
        a. Additions other than revenue (Specify)
        (1) _______________________ $_________
        (2) _______________________ _________
        (3) Total Additions $_________
        b. Deductions
        (1) Dividends _________
        (2) Withdrawal of earnings _________
        (3) Other (Specify) _______________ _________
        (4) Total Deductions _________
        D. Summary Statement of Income, Expense, and Retained Earnings (continued)
        c. Net Additions Over Deductions Item a(3) minus b(4) $_________
        7. Increase or (Decrease) in Balance of Retained Earnings for the Period - Add items 5 and 6c $_________
        8. Beginning Balance (If different from prior year ending balance, explain) $_________
        9. Retained Earnings (or Fund Balance) at the end of the reporting period - Add items 7 and 8 $__________
        E. Information concerning Ownership of the Facility; Compensation of Owners, Administrators, and Relatives of Owners and Administrators; Related Party Transactions, including Home Office Costs; Charge Rates; and Patient Transportation.9,10,11
        1. Statement of Compensation to Owners 13 Proprietors & Partners Corporate Shareholders Percent Share of Operating Percent of Providers Name Title Profit or (Loss) Stock Owned _____(1)______ ____(2)______ _________(3)________________ ___________(4)______________
        a. _____________ ____________ ___________________________ ____________________________
        b. _____________ ____________ ___________________________ ____________________________
        c. _____________ ____________ ___________________________ ____________________________
        d. _____________ ____________ ___________________________ ____________________________ Lines a through d continued below. Percentage of Customary Inclusive Dates of Amount of Compensation Where in Section F Work Week Devoted to this Employment at this Included in Operating is the Compensation Facility Facility Costs for the Period included? _________(5)____________ ______(6)_________ _________(7)__________ _________(8)________
        a. _______________________ _________________ _____________________ ___________________
        b. _______________________ _________________ _____________________ ___________________
        c. _______________________ _________________ _____________________ ___________________
        d. _______________________ _________________ _____________________ ___________________ *Attach a statement describing actual duties performed by each individual listed.
        E. Information concerning Ownership of the Facility; Compensation of Owners, Administrators, and Relatives of Owners and Administrators; Related Party Transactions, including Home Office Costs; Charge Rates; and Patient Transportation. 9,10,11 (continued)
        2. Statement of Compensation Paid to Administrators (Other than Owners) and Relatives of Owners and Administrators 13,14 Relationship to Owners, Percentage of Customary Administrators, or Assistant Work Week Devoted to this Name Title Administrators Facility ___(1)______ ____(2)________ _________(3)____________ ____________(4)_____________ a.___________ ______________ _______________________ ____________________________ b.___________ ______________ _______________________ ____________________________ c.___________ ______________ _______________________ ____________________________ d.___________ ______________ _______________________ ____________________________ Lines a through d continued below. Where in Section F Inclusive Dates of Employment Amount of Compensation Included in is the Compensation at this Facility Operating Costs for the Period included? _________(5)____________ ___________(6)_________________ ___________(7)______________ a._______________________ _______________________________ ____________________________ b._______________________ _______________________________ ____________________________ c._______________________ _______________________________ ____________________________ d._______________________ _______________________________ ____________________________ *Attach a statement describing actual duties performed by each individual listed.
        3. Intercompany Transfers and Transactions with Related Organizations, Including Home Office and Parent Companies 15,16,17 Note: A Home Office cost report and attached apportionment schedules must be filed before these costs can be considered allowable.
        E. Information concerning Ownership of the Facility; Compensation of Owners, Administrators, and Relatives of Owners and Administrators; Related Party Transactions, including Home Office Costs; Charge Rates; and Patient Transportation. 9,10,11 (continued)
        a. List all expenses included in Section F which were paid or accrued to a Related Organization: Department or Account in Name of Organization_______ _____Amount____ _____Section F_______________ _____________________________ ________________ ____________________________ _____________________________ ________________ ____________________________ _____________________________ ________________ ____________________________ _____________________________ ________________ ____________________________
        b. Attach a schedule listing
        (1) All intercompany transfers and transactions between the facility and any Related Organization.
        (2) The names of all business entities
        (a) that are related organizations, and
        (b) with whom the provider, during the reporting period, had more than $25,000 in business transactions or transacted 5 percent or more of the total operating expenses of the provider, whichever is less. (See footnote 12)
        (3) Names, titles, positions, duties, and total compensation received by all members of Boards of Directors, Corporation Officers, Administrators, Owners, and any other key employees and their relatives, who constructively own 5 percent or more, of any of the organizations in (2) above, and the percentage of constructive ownership by each person listed. If none, so indicate.
        4. List the name(s) and address(es) of the owner(s) of the land and buildings. 9,10,11 _______________________________________________________________________________________ _______________________________________________________________________________________
        5. If the land and buildings are rented, state the relationships (family and business) of the operator(s) of the nursing home to the owner(s) of the land and building, if any. If not related, so state. 9,10,11 _____________________________ __________________________________________________ _____________________________ __________________________________________________
        E. Information concerning Ownership of the Facility; Compensation of Owners, Administrators, and Relatives of Owners and Administrators; Related Party Transactions, including Home Office Costs; Charge Rates; and Patient Transportation. 9,10,11 (continued)
        6. Daily Room & Board Charge Rates NF1 NF2 ICF/MR Private Room Rate: effective date _______________ _______________ _____________ _______________ effective date _______________ _______________ _____________ _______________ effective date _______________ _______________ _____________ _______________ Semi-Private Room Rate: effective date _______________ _______________ _____________ _______________ effective date _______________ _______________ _____________ _______________ effective date _______________ _______________ _____________ _______________ Other Room Rates (Specify): effective date _______________ _______________ _____________ _______________ effective date _______________ _______________ _____________ _______________ effective date _______________ _______________ _____________ _______________ ______________________________ effective date _______________ _______________ _____________ _______________ effective date _______________ _______________ _____________ _______________ effective date _______________ _______________ _____________ _______________ Note: Any rate or charge change made during the year should be listed. Please do not include a charge range. If charges have changed since the close of the accounting period, explain: ________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________
        7. Patient NonEmergency Transportation
        a. Does your facility provide or arrange to provide for non-emergency patient transportation? _______________________________________________________________________________ _______________________________________________________________________________
        E. Information concerning Ownership of the Facility; Compensation of Owners, Administrators, and Relatives of Owners and Administrators; Related Party Transactions, including Home Office Costs; Charge Rates; and Patient Transportation. 9,10,11 (continued)
        b. If you arrange for the transportation, provide the name of the organization and the amount of expense included in Section F that was paid for the service. ________________________________________________________________________________ ________________________________________________________________________________
        c. If your facility provides the transportation, do you bill Medicaid separately for the service? ________________________________________________________________________________ If yes, what is the amount of income and where is it included in Section D? ________________________________________________________________________________ ________________________________________________________________________________
        F. Operating Expenses: (Expenses per General Ledger) 4,18,19 *Enter all amounts in whole dollars. Amount of Department or Account Expense Totals FTEs 18 ________(1)________ ___(2)____ __(3)___ __(4)__
        1. Administration and General
        a. Salary of administrator $_________ ________
        b. Other compensation to administrator _________
        c. Other administrative salaries _________ ________
        d. Office supplies and printing _________
        e. Communications _________
        f. Travel (Motor Vehicle) _________
        g. Travel (Other) _________
        h. Advertising 18 _________
        i. Licenses, dues, and subscriptions _________
        j. Professional training and education _________
        F. Operating Expenses: (Expenses per General Ledger) 4,18,19 (continued) *Enter all amounts in whole dollars. Amount of Department or Account Expense Totals FTEs 18 ________(1)________ ___(2)____ __(3)___ __(4)__
        k. Conference registration and fees _________
        l. Accounting and auditing _________
        m. Legal services _________
        n. Pharmacy consultant services _________
        o. Other professional services _________
        p. Management fees _________
        q. Franchise tax and filing fees _________
        r. Public relations 18 _________
        s. Excise taxes _________
        t. Insurance (excluding amounts properly included in item 18d) _________
        u. Utilization review fees _________
        v. Other 18 ______________________ _________
        w. Total Add items a through v $_________
        2. Employee Benefits
        a. Social Security and Unemployment Insurance _________
        b. Other employee benefits (Attach Itemized Schedule) _________
        c. Total - Add items a and b __________
        3. Dietary
        a. Dietary salaries __________ _________
        b. Raw food __________
        F. Operating Expenses: (Expenses per General Ledger) 4,18,19 (continued) *Enter all amounts in whole dollars. Amount of Department or Account Expense Totals FTEs 18 ________(1)________ ___(2)____ __(3)___ __(4)__
        c. Supplies _________
        d. Purchased services (Attach Itemized Schedule) _________
        e. Other 18 _________________________ _________
        f. Total Add items a through e ________
        4. Housekeeping
        a. Housekeeping salaries $_________ _________
        b. Supplies _________
        c. Purchased services (Attach Itemized Schedule) _________
        d. Other 18 ________________________ _________
        e. Total - Add items a through d _________
        5. Laundry and Linen
        a. Laundry and linen salaries _________ _________
        b. Linen and bedding _________
        c. Supplies _________
        d. Purchased services (Attach Itemized Schedule) _________
        e. Other 18 ________________________ _________
        f. Total - Add items a through e _________
        6. Plant Operation and Maintenance
        a. Operation and maintenance salaries ________ ________
        b. Fuel (Heating) _________
        F. Operating Expenses: (Expenses per General Ledger) 4,18,19 (continued) *Enter all amounts in whole dollars. Amount of Department or Account Expense Totals FTEs 18 ________(1)________ ___(2)____ __(3)___ __(4)__
        c. Gas _________
        d. Electricity _________
        e. Water and sewage _________
        f. Supplies _________
        g. Purchased services (Attach Itemized Schedule) _________
        h. Repairs _________
        i. Other 18 _______________________ _________
        j. Total Add items a through i ________
        7. Medical and Nursing
        a. Salaries Medical Director _________ ________
        b. Salaries Registered Professional Nurses (RNs) _________ ________
        c. Salaries Licensed Practical Nurses (LPNs) _________ ________
        d. Salaries Attendants, orderlies, and aides _________ ________
        e. Salaries Other nursing personnel _________ ________
        f. Supplies _________
        g. Purchased services (Attach Itemized Schedule) _________
        h. Routine medical supplies 20 _________
        i. Other 18 ________________________ _________
        j. Total Add items a through i _________
        8. Physicians Care (Excluding Medical Director)
        a. Physicians salaries or fees $_________ ________
        F. Operating Expenses: (Expenses per General Ledger) 4,18,19 (continued) *Enter all amounts in whole dollars. Amount of Department or Account Expense Totals FTEs 18 ________(1)________ ___(2)____ __(3)___ __(4)__
        b. Other salaries or fees _________ _______
        c. Other 18 ______________________ _________
        d. Total Add items a through c $_______
        9. Pharmacy (Excluding consultant fees)
        a. Pharmacy salaries or fees _________ _______
        b. Drugs and pharmaceuticals _________
        c. Supplies _________
        d. Purchased services (Attach Itemized Schedule) _________
        e. Other 18 ________________________ _________
        f. Total Add items a through e ________
        10. Laboratory
        a. Laboratory salaries or fees __________ _______
        b. Supplies _________
        c. Purchased services (Attach Itemized Schedule) _________
        d. Other 18 ________________________ _________
        e. Total Add items a through d _________
        11. X-ray
        a. X-ray salaries or fees _________ ________
        b. Supplies _________
        c. Purchased services (Attach Itemized Schedule) _________
        F. Operating Expenses: (Expenses per General Ledger) 4,18,19 (continued) *Enter all amounts in whole dollars. Amount of Department or Account Expense Totals FTEs 18 ________(1)________ ___(2)____ __(3)___ __(4)__
        d. Other 18 ________________________ _________
        e. Total Add items a through d ________
        12. Recreational Activities
        a. Recreational salaries _________ ________
        b. Supplies _________
        c. Purchased services (Attach Itemized Schedule) _________
        d. Other 18 _______________________ _________
        e. Total Add items a through d ________
        13. Social Service
        a. Social service salaries _________ ________
        b. Other 18 ________________________ _________
        c. Total Add items a and b ________
        14. Physical Therapy
        a. Salaries $_________ ________
        b. Supplies _________
        c. Purchased services (Attach Itemized Schedule) _________
        d. Other 18 ________________________ _________
        e. Total Add items a through d $________
        15. Psychiatric Services 21
        a. Salaries _________ _______
        b. Purchased services (Attach Itemized Schedule) _________
        F. Operating Expenses: (Expenses per General Ledger) 4,18,19 (continued) *Enter all amounts in whole dollars. Amount of Department or Account Expense Totals FTEs 18 ________(1)________ ___(2)____ __(3)___ __(4)__
        c. Other 18 _______________________ _________
        d. Total Add items a through c _______
        16. Psychological Services 21
        a. Salaries _________ ________
        b. Purchased services (Attach Itemized Schedule) _________
        c. Other 18 _______________________ _________
        d. Total Add items a through c _______
        17. Medical Records
        a. Salaries _________ ________
        b. Supplies _________
        c. Other 18 _______________________ _________
        d. Total Add items a through c _______
        18. Property Expense
        a. Real estate taxes on property used only for nursing home purposes _________
        b. Rent or lease fee on buildings or equipment used only for nursing home purposes _________
        c. Interest expense on buildings or equipment used only for nursing home purposes _________
        d. Insurance on property used only for nursing home purposes _________
        e. Total Add items a through d _______
        F. Operating Expenses: (Expenses per General Ledger) 4,18,19 (continued) *Enter all amounts in whole dollars. Amount of Department or Account Expense Totals FTEs 18 ________(1)________ ___(2)____ __(3)___ __(4)__
        19. Depreciation and Amortization 30 (Complete Schedule L)
        a. Land improvements _________
        b. Buildings _________
        c. Leasehold/building improvements _________
        d. Fixed equipment _________
        e. Movable equipment _________
        f. Automotive equipment $_________
        g. Other depreciation (Specify on Schedule L) _________
        h. Amortization of pre-opening costs _________
        i. Amortization of organization cost _________
        j. Other Amortization (Specify on Schedule L) _________
        k. Total Add items a through j $_________
        20. Other Expenses (Specify) (Attach schedule if additional space is needed)
        a. Salaries ________________________ ___________ ________
        b. Vending machines ___________
        c. Purchased barber and beauty services ___________
        d. Cable TV (not beneficial to all patients) ___________
        e. Other interest not included on line 18 (Include on Schedule M) ___________
        f. Annual nursing home privilege tax ___________
        g. Other 18 ___________________ ___________
        F. Operating Expenses: (Expenses per General Ledger) 4,18,19 (continued) *Enter all amounts in whole dollars. Amount of Department or Account Expense Totals FTEs 18 ________(1)________ ___(2)____ __(3)___ __(4)__
        h. Total Add items a through g _________
        21. Total Operating Expense Add totals in column 3, items 1 through 20 $______ _______ ____________________________________________________________________________________________
        G. Adjustments for Calculating Allowable Routine Operating Expense 22
        1. Total Amount of Expenses Per Books (Total should equal amount under Section F, Item 21) $_________
        2. Adjustments to be made (Deduct only items included in item 1 above) Description of Expense or Income Base 23 Amount
        a. Research and medical education ____________ $__________
        b. Vending machines, concessions, etc. ____________ __________
        c. Non-routine barber and beauty shop income ____________ __________
        d. Non-routine medical and surgical supply income ____________ __________
        e. Non-routine laundry income ____________ __________
        f. Applicable miscellaneous income ____________ __________
        g. Interest and investment income (limited to interest expense) ____________ __________
        h. Telephone charges paid for by patients, guests, employees, and others ____________ __________
        i. Guest, owner, and employee meals not considered as a part of compensation; and the cost of free meals to guests ____________ __________
        j. Drugs, supplies, or other services purchased by non-patients ____________ $__________
        k. Income from rental of facility furniture and equipment to patients and non-patients ____________ __________
        G. Adjustments for Calculating Allowable Routine Operating Expense 22 (continued) Description of Expense or Income Base 23 Amount
        l. Rental, maintenance, insurance, depreciation, taxes, and other expenses of non-nursing home facilities (attach supporting schedules) __________ __________
        m. Bad debts or provisions therefor, charity and courtesy allowances included in operating expenses __________ __________
        n. Expenses applicable to outpatients __________ __________
        o. Amounts collected for and paid to pharmacists, physicians, and other professional individuals __________ __________
        p. Non-allowable purchased services __________ __________
        q. Salaries or fees paid to physicians for treatment of individual patients and related expenses __________ __________
        r. Pharmacy (Amount shown in Section F, Item 9f as well as any other applicable amount) __________ __________
        s. Laboratory (Amount shown in Section F, Item 10e) __________ __________
        t. X-ray (Amount shown in Section F, Item 11e as well as any other applicable amount) __________ __________
        u. Cable TV (Other than those in lounge or lobby for general benefit of all patients). (Amount shown in Section F, Item 20d as well as any other applicable amount) __________ __________
        v. Facilities or accommodations furnished owners, administrators, and other non-patients not considered compensation. 24 (Attach computation sheets) __________ __________
        w. Indirect expenses apportioned to Ancillary Departments (Amount in Section H, Item 20) __________ __________
        G. Adjustments for Calculating Allowable Routine Operating Expense 22 (continued)
        x. Related organization:
        (1) Expense paid to a related organization $_________
        (2) Cost of services by the related organization $_________ ___________ (Difference between (1) and (2) is the amount to be adjusted) (Attach supporting cost data and schedules) Description of Expense or Income Base 23 Amount
        y. Excess owner’s compensation ___________ ___________
        z. Excise taxes (Amount shown in Section F, Item 1s) ___________ ___________ aa. Cost of items billed and collected from Medicare Part B on behalf of Medicaid NF1 recipients ___________ ___________ bb. All other items or services which are not covered by NF1 Medicaid services 25 ___________ ___________ cc. Other adjustments (Specify on an attached itemized schedule) ___________ ___________ dd. Total Add items a through cc $__________
        3. Total Allowable Routine Operating Costs Item G1 minus G2dd $___________
        H. Allocation of Cost to Routine, Ancillary, and Extra Charge Areas 26,27 Other Total Routine Pharmacy Laboratory Radiology Ancillary Cost Item (1) (2) (3) __(4) (5) (6)__
        1. Administration & General (F1) Allocation Statistics _______ _______ _______ _______ _______ _______ Cost $______ $______ $______ $______ $______ $______
        2. Employee Benefits (F2) Allocation Statistics Cost ______ ______ ______ ______ ______ ______ $_____ $ $ $ $ $
        H. Allocation of Cost to Routine, Ancillary, and Extra Charge Areas 26,27 Other Total Routine Pharmacy Laboratory Radiology Ancillary Cost Item (1) (2) (3) __(4) (5) (6)
        3. Dietary (F3) Allocation Statistics ______ _______ _______ _______ _______ _______ Cost $_____ $______ $______ $______ $______ $______
        4. Housekeeping (F4) Allocation Statistics _______ _______ _______ _______ _______ _______ Cost $______ $______ $______ $______ $______ $______
        5. Laundry and Linen (F5) Allocation Statistics _______ _______ _______ _______ _______ _______ Cost $______ $______ $______ $______ $______ $______
        6. Plant Operation and Maintenance (F6) Allocation Statistics _______ _______ _______ _______ _______ _______ Cost $______ $______ $______ $______ $______ $______
        7. Medical and Nursing (F7) Allocation Statistics Cost _______ _______ _______ _______ _______ _______ $______ $______ $______ $______ $______ $______
        8. Recreational Activities (F12) Allocation Statistics Cost _______ _______ _______ _______ _______ _______ $______ $______ $______ $______ $______ $______
        9. Social Services (F13) Allocation Statistics ______ ______ ______ ______ ______ ______ Cost $_____ $_____ $_____ $_____ $_____ $_____
        10. Physical Therapy (F14) Allocation Statistics ______ ______ ______ ______ ______ ______ Cost $_____ $_____ $_____ $_____ $_____ $_____
        11. Psychiatric Services (F15) Allocation Statistics ______ ______ _____ ______ ______ ______ $_____ $_____ $_____ $_____ $_____ $_____
        12. Psychological Services (F16) Allocation Statistics ______ ______ ______ ______ ______ ______ Cost $_____ $_____ $_____ $_____ $_____ $_____
        13. Medical Records (F17) Allocation Statistics ______ ______ ______ ______ ______ ______ Cost $_____ $_____ $_____ $_____ $_____ $_____
        14. Property Expense (F18) Allocation Statistics ______ ______ ______ ______ ______ ______ Cost $_____ $_____ $_____ $_____ $_____ $_____
        15. Building Depreciation (F19a-c) Allocation Statistics ______ ______ ______ ______ ______ ______ Cost $_____ $_____ $_____ $_____ $_____ $_____ Total Routine Pharmacy Laboratory Radiology Ancillary Cost Item (1) (2) (3) __(4) (5) (6)
        16. Equipment and Other Depreciation (F19d-g) Allocation Statistics ______ ______ ______ ______ ______ ______ Cost $_____ $_____ $_____ $_____ $_____ $_____
        17. Amortization (F19h-j) Allocation Statistics ______ ______ ______ ______ ______ ______ Cost $_____ $_____ $_____ $_____ $_____ $_____
        18. Any Other Shared Cost Allocation Statistics ______ ______ ______ ______ ______ ______ Cost $_____ $_____ $_____ $_____ $_____ $_____
        19. Totals $______ $______ $_____ $______ $______ $______
        20. Allocated Ancillary Costs (Columns 3, 4, 5, and 6) $________________
        I. Total Ancillary and Extra Charge Area Costs 26 Other Pharmacy Laboratory Radiology Ancillary
        1. Direct Costs (F8, F9, F10, etc.) $_______ $_______ $_______ $_______
        2. Indirect Costs (H19) _______ _______ _______ _______
        3. Total $_______ $_______ $________ $________ ________________________________________________________________________________________________
        J. Summary of Ancillary Charges 28
        (a) (b) (c) (d) Medicare Skilled Medicaid NF2 Private Total
        1. Pharmacy $___________ $__________ $__________ $__________
        2. Laboratory ___________ ___________ ___________ ___________
        3. X-ray ___________ ___________ ___________ ___________
        4. All therapies ___________ ___________ ___________ ___________
        5. Other ancillaries (Specify) ___________ ____________ ___________ __________ _______________ ___________ ____________ ___________ __________ _______________ ___________ ____________ ___________ __________ _______________ ___________ ____________ ___________ __________
        6. Totals - Add items 1 through 5 $____________ $____________ $___________ $___________ ________________________________________________________________________________________________
        K. Calculation of Expenses Applicable to NF1 Program (Reimbursable Cost) 29
        a. Facilities rendering one level of care (NF1 only)
        (1) (2) (3) (4) (5) Total Allowable Expenses Total Nursing Medicaid NF1 % Medicaid NF1 Routine Operating Applicable Facility Days Inpatient Days Days to Total Days Costs to NF1 Program (B.4.j.) (B.4.c.) (Col. 2 / Col. 1) (G.3.) (Col. 3 x Col. 4) ============ =========== ============ ============ =============
        b. Facilities rendering more than one level of care.
        (1) (2) (3) (4) (5) Routine Charges % Medicaid NF1 Total Allowable Expenses Total Routine to Medicaid NF1 Charges to Routine Operating Applicable NF Charges Patients Total Charges Costs to NF1 Program (D.1.a.10.) (D.1.a.3.) (Col. 2 / Col. 1) (G.3.) (Col. 3 x Col. 4) ___________ ____________ ______________% $____________ $____________
        L. Depreciation and Amortization Schedule 30 Date Estimated Salvage Current Period Asset Cost Acquired Useful Life Value Method Depreciation Land Improvements $______ ________ _________ $_______ S/L $__________ Building ______ ________ _________ ________ S/L__ ___________ Leasehold/Building _______ ________ _________ ________ __S/L__ ___________ Improvements Movable Equipment _______ ________ _________ ________ __S/L__ ___________ Other Depreciable _______ ________ _________ ________ __S/L__ ___________ Assets _______________ _______ ________ _________ ________ __S/L__ ___________ _______ ________ _________ ________ __S/L__ ___________ _______ ________ _________ ________ __S/L__ ___________ Totals $ $ Amortization Method of Current Period Amortization Original Amount Starting Date Period Amortization Amortization Pre-opening Cost $__________ __________ 5 years__ ____S/L____ $_________ Organization Cost $__________ __________ 5 years__ ____S/L____ $_________ Other (Specify) $__________ __________ ________ ____S/L____ $_________ _______________ $__________ __________ ________ ____S/L____ $_________ Totals $_____________ ___________ ____________________________________________________________________________________________
        M. Loans, Mortgages, and Notes 15
        1. List individually all loans, mortgages, and notes made in the name of the facility, operators, and/or owners of the facility, for which the related interest expense has been included as an allowable cost. If the amount of previously outstanding loans, mortgages, or notes was increased during the period, list amount and date of increase. State the name of the lender (optional, if not identified by name, enter some code which will be traceable to the provider’s records), date of loan, amount of principal, and the amount of interest for the accounting period. List new obligations incurred during this period in item 2. below. Beginning Ending Current Period Name of Lender Date of Loan Balance Balance Interest Expense _______________ ____________ $__________ $__________ $__________ _______________ ____________ ___________ ___________ ___________ _______________ ____________ ___________ ___________ ___________ _______________ ____________ ___________ ___________ ___________ _______________ ____________ ___________ ___________ ___________ _______________ ____________ ___________ ___________ ___________ _______________ ____________ ___________ ___________ ___________ _______________ ____________ ___________ ___________ ___________ _______________ ____________ ___________ ___________ ___________ Total Interest Expense for Item 1 ___________
        2. For each new obligation incurred during this reporting period state the name of lender (optional, if not identified by name, enter some code which will be traceable to the provider’s records), amount of the new obligation, interest expense included in Section F, the disposition of the proceeds of the loan, and the date the obligation was incurred. Do not duplicate items in 1 above. Date of Original Ending Current Period Name of Lender Purpose for Loan Loan Amount Amount Interest Expense _______________ ______________ ______ $______ $______ $____________ _______________ ______________ ______ _______ _______ _____________ _______________ ______________ ______ _______ _______ _____________ _______________ ______________ ______ _______ _______ _____________ _______________ ______________ ______ _______ _______ _____________ Total Interest Expense for Item 2 $____________ Total Interest Expense - Add items in 1 and 2 $____________
        N. Statement of Equity Capital 31 Date Amount
        1. Change in Equity Capital (Dates are required for c, d, and e)
        a. Equity Capital Beginning of Period $__________
        b. Net Income (Loss) for the Period (Item D.5.) ___________
        c. Capital Investments (Withdrawals) during the period (Attach schedule if more than one entry) __________________________________________ __________ ___________
        d. Gain (Loss) on Fixed Assets (Attach schedule if more than one entry) __________________________________________ __________ ___________
        e. Other Increases (Decreases) (Specify Attach schedule if more than one entry) __________________________________________ __________ ___________
        f. Equity Capital - End of Period $__________
        2. Reconciliation of Equity Capital with Total Capital
        a. Total Capital (Item C.3.b.) $__________
        b. Additions (Deductions) (Identify each entry) ____________________________________ $____________ ____________________________________ _____________ ____________________________________ _____________ ____________________________________ _____________ __________
        c. Equity Capital - End of Period $__________ ___________________________________________________________________________________________
        O. Certification by Owner, Officer, or Administrator of Facility I, ___________________________________________, ____________________________________ of the (Name) (Title) ____________________________________________, _________________________, ________________ (Name of Facility) (City) (State) do certify that I have examined the attached report for the fiscal period beginning _____________________, 19_____, and ending ___________________, 19_____, the accompanying Footnotes and Instructions and Accounting Principles, and that to the best of my knowledge and belief, this report is a true and correct statement of the information required, and that charges and expenses for services provided to Medicaid Program recipients were in accordance with applicable state and federal regulations. I understand that any false claims, statements, or documents, or the concealment of a material fact may lead to prosecution under applicable Federal or State Laws. Date __________________________, 19_____ ____________________________________________ Signature of Authorized Representative of Facility ____________________________________________ Typed Name of Authorized Representative ____________________________________________ Title

Authority: T.C.A. §§4-5-202, 12-4-301, 71-5-105, and 71-5-109. Administrative History: Original chapter filed January 12, 1988; effective February 26, 1988. Amendment filed December 1, 1988; effective January 15, 1989. Amendment filed August 17, 1995; effective October 30, 1995. Amendment filed January 21, 2000; effective April 5, 2000.