016-29-22 Ark. Code R. § 1
Medical Assistance Program Manual Of Cost Reimbursement Rules For Long Term Care Facilities
Introduction
This manual is for use by providers, their accountants and the Department of Human Services in determining the allowable and reasonable cost of Long Term Care services furnished to Medicaid recipients. The manual contains procedures to be used by each provider in accounting for its operations and in reporting the cost of care and services to the Department of Human Services.
The Long Term Care Program is administered by the Division of Medical Services. The program herein adopted is in accordance with Federal Statute in the Social Security Act § 1902 (a) (13) (A) and Public Law 105-33. The applicable Federal Regulations begin at 42 Code of Federal Regulations § 430. Each Long Term Care Facility which has contractually agreed to participate in the Title XIX Program will adopt the procedures set forth in this manual and must file the required cost reports.
As interpretations and changes of this program are made, appropriate revisions of the manual will be furnished to each provider and interested party. Care should be taken to insure that revisions to the manual are promptly inserted.
Questions relating to this program or relating to the interpretation of any of the provisions included in this manual should be addressed to:
Department of Human Services
Division of Medical Services
P. O. Box 1437, Slot S535
Little Rock, AR 72203-1437
All Long Term Care Facilities will be reimbursed according to the principles and procedures specified in these regulations. Allowable costs are those costs necessary and reasonable for performance of covered services required by Medicaid recipients.
A facility's direct and indirect allowable costs related to covered services will be considered in the findings and allocation of costs to the Medical Assistance Program for its eligible recipients. Total allowable, reasonable costs after removal of direct Medicare ancillary cost of a facility shall be apportioned on a per resident day basis between third-party payers and other residents so that the share borne by Medicaid under Title XIX is based upon actual services and costs related to Medical Assistance recipients.
Costs included in the per diem rate will be those necessary to be incurred by efficiently and economically operated facilities to comply with all requirements of participation in the Medicaid program.
Providers are required to maintain adequate financial records and statistical data for proper determination of costs payable under the program. The cost report is to be based on financial and statistical records maintained by the facility. Cost information must be current, accurate and in sufficient detail to support costs set forth in the report. This includes all ledgers, books, records, and original evidence of cost (purchase requisitions for supplies, invoices, paid checks, inventories, time cards, payrolls, bases for apportioning costs, etc.) which pertain to the determination of reasonable costs. A provider must make available (within the state) all financial and statistical records to the Department or its representatives for the purpose of determining compliance with the provisions of this program. Providers who find it difficult to provide home office records at the audit or review site can at their option, reimburse the Department for all costs associated with the travel of Department employees or their representatives in accordance with state laws and rules for the reimbursement of travel for state employees.
The Financial and Statistical Report/Cost Report and Schedules sets forth information to be reported. The report must be prepared on the accrual basis of accounting in accordance with instructions for completion of the Cost Report. Government facilities have the option to use the cash basis of accounting for reporting.
All financial and statistical records, including cost reports, must be retained for a period of five years after submission to the Department.
If the provider conducts activities not related to resident care, additional accounts must be added to accommodate those activities.
For non-governmental providers, the Financial and Statistical Report must be filed using information stated on the accrual method of accounting. The Chart of Accounts is designed to be used in a complete accrual accounting system.
Financial information stated on an accrual basis is essential to insure that the proper reimbursement is made to providers. The measurement of the cost of services performed must include all supplies, salaries, services and other expenses incurred, regardless of whether or not those items have been paid.
Many providers will find that the accounting for all transactions on a pure accrual basis may create undue workloads. Also, many providers account for their activities on a strict cash basis and they are satisfied with the management information produced from their existing system. Therefore, in lieu of accounting for all transactions on an accrual basis, the provider may maintain his records on a cash basis during the year and convert to an accrual basis at the beginning and end of the year for reporting purposes.
The applicable Chart of Accounts shall be used by all Long Term Care Facilities participating in the Title XIX Program. Each Chart of Accounts provides for the basic classifications of all assets, liabilities, income and expense necessary for the preparation of the Cost Report. Providers may take some latitude in assigning account numbers but must maintain the basic Chart of Accounts.
All providers in operation under a valid Medicaid agreement for long term care services must file a Financial and Statistical Report (commonly referred to as a Cost Report or FSR). In addition to the annual reporting requirement nursing facilities will be required to submit a limited cost report containing direct care cost information for the period January 12, 2001 to June 30, 2001, in order that the direct care per diem can be rebased after this initial period. Nursing facilities that have been newly constructed or a newly enrolled provider that did not previously participate in Medicaid, will be required to prepare and submit a cost report for the period beginning their first day of operation through the end of the month which includes their sixth month of operation. This report is essential in establishing rates for a new provider. If the facility was not certified for Medicaid participation at date of first opening or acquisition, then the reporting period shall begin at official certification date rather than the date of acquisition. Nursing Facilities that are newly purchased or leased shall submit a cost report for the period beginning with their first day of operation through the end the State Fiscal Year unless the cost reporting period would be less than three months of operation. Facilities that change ownership after April 1 of a State Fiscal Year would not submit a cost report from the date of initial operation to the end of the State Fiscal Year. Facilities changing ownership after April 1 of a State Fiscal Year will prepare and submit a cost report for the period beginning their first day of operation through the end of the month which includes their sixth month of operation.
Nursing facilities will report cost on a fiscal year ending June 30. Cost reports will be due within ninety (90) days after the end of the reporting period. Under sixteen (16) Bed ICF/IID providers will report cost on a calendar year basis. The cost report will be due within ninety (90) days of the end of the reporting period. The Arkansas Health Center Nursing Facility and the sixteen (16) bed and over ICF/IID providers will report cost semi-annually (January 1 - June 30) and (July 1 - December 31) with the cost reports being due within sixty (60) days of the end of the reporting period. Should the due date fall on a Saturday, Sunday, or State of Arkansas holiday or federal holiday, the due date shall be the following business day. Nursing Facility cost reports are to be electronically submitted through the LTC cost report web application on or before the applicable due date. ICF/IID reports are to be delivered, postmarked or electronically uploaded, to the web portal on or before the applicable due date.
Providers who fail to submit cost reports and other required schedules and information by the due date or extended due date have committed a Class D Violation of Arkansas Code 20-10-205. Civil penalties associated with failure to timely submit a cost report for Long Term Care Facilities are detailed in Section 1-11 of this Manual.
If a written request for an extension is received by the Division of Medical Services in advance of the report due date and a written extension is granted, a penalty will not be applied, provided the extended due date is met. Each request for extension will be considered on its merit. No extension will be granted unless the facility provides written evidence of extenuating circumstances beyond its control, which causes a late report. In no instance will an extension be granted for more than thirty (30) days.
In addition to the applicable cost report forms, providers must submit the following:
When it is determined, upon initial review for completeness by the Division of Medical Services, that a cost report has been submitted without all required information, providers will be allowed a specified amount of time to submit the requested information without incurring the penalty for a delinquent cost report. For cost reports which are submitted by the due date, ten (10) working days from the date of the provider's receipt of the request for additional information will be allowed for the provider to submit the additional information. For cost reports which are submitted by an extended due date, five (5) working days from the date of the provider's receipt of the request for additional information will be allowed for the provider to submit the additional information. If requested additional information has not been submitted by the specified date, the cost report will be subject to the penalty provisions for delinquent submission. An exception exists in the event that the due date (or extended due date when an extension has been granted) comes after the specified number of days for submission of the requested information. In these cases, the provider will be allowed to submit the additional requested information on or before the due date (or extended due date if an extension has been granted) of the cost report.
Nursing facility cost reports and additional information should be submitted through the LTC cost report web application. ICF/IID cost reports and additional information may be submitted to the address below or uploaded to the contractor's web portal.
Arkansas Department of Human Services Division of Medical Services
P. O. Box 1437 - Slot S535
Little Rock, AR 72203-1437
Providers can submit amended cost reports to the Department up to one hundred, eighty (180) days after the close of the cost reporting period.
The Department will review all cost reports to verify that all facilities have submitted reports properly and in compliance with this manual. Providers will be notified in writing of the results of the desk review.
A provider's cost report can be adjusted for any errors or unallowable costs identified on a provider's cost report after the initial desk review has been completed up to the last day of the rate year for which rates are based on the adjusted cost report.
Financial and Statistical Reports, financial records, statistical records, and any other pertinent documents will be analyzed to verify that:
The Department will provide for periodic audits of some or all cost reports and supporting records. The Department may also conduct limited reviews of cost data and/or client statistics reported in the cost reports.
The auditors will issue a report upon completion of each audit or review. The report will reflect cost and statistical information as submitted in the cost report and any adjustments the auditors recommend, such that the information complies with the criteria listed above. All audit reports will state the auditor's opinion as to whether, in all material respects, the cost information reported on the Schedule of Expenses (DHS 750, Form 5 or DOM 400, Form 6) and total actual resident days reported on the Statistical Data Schedule (DHS 750, Form 2 or DOM 400, Form 3), with audit adjustments, is presented fairly and in compliance with program policy and regulations.
If a facility is unable or unwilling to provide necessary documentation to support the financial or statistical records contained in their cost report, the auditors will issue a "disclaimer" report signifying that the audit could not be accomplished. The Office of Long Term Care will advise the facility of the disclaimer in writing. A period of 90 days from the date of the letter of notification will be allowed to permit the facility to accumulate necessary documentation. A follow-up audit will be attempted upon expiration of the 90 day period or sooner if requested by the facility. If the audit can not be completed on the second attempt, the facility will be advised, in writing, that their agreement to participate in the Medicaid program will be terminated effective immediately. A period of 30 days from the date of such notification will be allowed to permit the orderly relocation of Medicaid recipients. The appeals procedures specified in Section 1-10 of this Manual are available to providers.
Any objection requesting disqualification of the hearing officer upon allegations of personal interest or bias must be made in writing, supported by good faith affidavit, and submitted to the DHS Director at least fifteen days before the scheduled hearing. The DHS Director will consider the objection promptly and rule on it in a timely manner.
In addition to the above listing of causes for termination, State or Federal laws or rules may create requirements, the violation of which may cause adverse action.
Class C Violations: Providers who fail to comply with administrative and reporting requirements that do not directly threaten the health, safety, or welfare of a resident have committed a Class C Violation. Violations of this nature would include but are not limited to:
Class C Violations are subject to a civil money penalty to be set by the DHS Director or his designee, in an amount not to exceed five hundred dollars ($500.00) for a single violation. A single erroneous administrative or reporting practice will be considered a single violation regardless of the number of resident records affected by the practice.
Class D Violation: Failure to timely submit the Cost Report for Long Term Care Facilities. Cost Reports must be postmarked on or before the due date or the extended due date in order to avoid a penalty. The failure to timely submit a cost report shall be considered a separate Class D Violation during any month or part thereof of noncompliance.
Class D Violations are subject to a civil money penalty to be set by the Director, DHS, or his designee, in an amount not to exceed two hundred fifty dollars ($250.00) for each violation.
In addition to any civil money penalty which may be imposed, the Director of the OLTC is authorized after the first month of a Class D Violation to withhold any further reimbursement to the Long Term Care Facility until the Cost Report is received by the Office of Long Term Care.
Any violation repeated within six months subjects the facility to double civil money penalties up to a maximum of one thousand dollars ($1,000.00) per violation.
Assessment of civil money penalties does not limit the right of the OLTC to take such other action as may be authorized by law or regulation.
Providers violating this section may be referred to the Attorney General's office.
Administrative errors on the part of the Division or the Facilities may result in erroneous payments. These errors most commonly result from: failures to report a death, discharge, or transfer; system error in resident classification; and miscalculations of recipient incomes. Overpayments/Underpayments resulting from these errors will be corrected when discovered. Overpayments will be recouped by the Division and underpayments will be reimbursed to the Facility.
Federal law requires that states use published payment methodologies and justifications which specify comprehensively the methods and standards for making Medicaid provider payments to long term care facilities.
Certified Title XIX Long Term Care Facilities furnishing services in accordance with all state and federal Medicaid laws and rules will be paid in accordance with rates established under the state Medicaid plan.
Participation in the Title XIX Program is limited to those Facilities which agree to accept the Medicaid payment as payment in full for all care services provided to Medicaid recipients.
The purpose of this provision is to assure that the Medicaid program is not charged unfairly high rates as compared to other payers. To that end, Medicaid reimbursement is limited by the weighted average per diem rates charged to other payers. Specifically if a long-term care facility charges other long-term care payers less than 80% of the Medicaid rate for long-term care services, (except for those public facilities rendering long-term care services free of charge or at a nominal charge) then the weighted average Medicaid reimbursement will be reduced to no more than 125% of the facility's weighted average reimbursement. For purposes of applying this rule:
The Department has established the following specific payment methods:
Reimbursement rates for nursing facilities will be cost-based, facility-specific rates that will consist of four (4) major cost components and will be determined in the following way.
Reimbursement rates will be determined by adding calculated per diem amounts for four (4) separate components of cost: Direct Care, Indirect, Administrative and Operating, Fair Market Rental, and the Quality Assurance Fee. This cost data for calculating these per diems will be taken from desk reviewed cost reports submitted by providers in accordance with these regulations. Only full-year cost reports will be used in establishing cost ceilings and class rates. Cost reports that are submitted because of changes of ownership, whether via purchase or lease, will be used for calculating the facility's individual rate components but will not be used in calculating the direct care ceiling or the indirect, administrative, and operating class rate. The methodology for calculating the per diem amounts for each component of cost is provided below:
Direct care per diem cost shall be calculated from the facility's actual allowable Medicaid cost as reported on the facility's cost report. The direct care per diem cost is subject to a ceiling.
The ceiling shall be established at one hundred five percent (105%) of the allowable Medicaid direct care cost per diem incurred by the facility at the ninetieth (90th) percentile of arrayed Medicaid direct care facility cost.
The direct care component of the rate will rebase annually for the period July 1st to June 30th. An inflation index (see Section A. 6.) will be applied to the provider's direct care per diem cost to inflate cost from the cost reporting period to the rate period.
The per diem payment for this component will be set at one hundred ten percent (110%) of the median indirect, administrative, and operating per diem cost adjusted for inflation using the inflation index (see Section A. 6.) and paid as a class rate to all facilities. This per diem payment will be rebased annually.
A fair rental system will be used to reimburse property costs. The fair rental system reduces the wide disparity in the cost of property payments for basically the same service therefore making this payment fairer to all participants in the program. The fair market rental system will be used in lieu of actual cost and/or lease payments on land, buildings, fixed equipment, and major movable equipment used in providing resident care. The fair rental payment for facilities that are leased from a related party will be calculated from the costs associated with the related party in conformity with related party regulations.
The payment for provider property cost will be calculated annually by adding the return on equity, facility rental factor, and the cost of ownership, and dividing the sum of these three components by the greater of the actual resident days or resident days calculated at the following occupancy levels. The minimum occupancy percentage for the SFY 2022 cost reporting period and applicable to the CY 2023 rate year shall be sixty percent (60%). Thereafter, the minimum occupancy percentage shall increase as indicted in the following table, up to a maximum of seventy-five percent (75%).
Cost Report Period | Rate Period | % Occupancy |
SFY 2022 | SFY 2023 | 60% |
SFY 2023 | SFY 2024 | 65% |
SFY 2024 | SFY 2025 | 70% |
SFY 2025 | SFY 2026 | 70% |
SFY 2026 | SFY 2027 | 75% |
& after | & after |
Resident days at the minimum occupancy level are calculated as: Total Licensed Beds x Number of Days in the Period x Minimum Occupancy Percentage.
The return on equity portion of the fair market rental payment will be calculated by taking the Current Asset Value (CAV) of a facility less the ending loan balance on any loans used to finance fixed assets or major movable equipment, times the sum of the average Moody's Seasoned Baa Corporate Bond Yield for the month of June in the applicable cost reporting period plus one and a half percent (1.5%) as a risk premium. For purposes of calculating return on equity and determining allowable interest expense, allowable debt cannot exceed the facilities Current Asset Value. The maximum rate used for calculating return on equity will be ten percent (10%).
The Current Asset Value (CAV) of a facility is calculated by multiplying the number of beds in a facility by the Per Bed Valuation (PBV) less an aging index of one percent (1%) for each year of age, not to exceed a fifty percent (50%) reduction in PBV. A facility will be considered new the cost reporting period in which the facility is licensed. A facility will be considered one year old the following cost reporting period. The CAV of a facility will be recalculated and an appropriate adjustment to the per diem will be made when additional beds are placed in operation.
Beginning with the CY 2023 rate year and based on the Base PBV for the SFY cost reporting period, the PBV methodology shall differentially apply PBV amounts according to the class of resident room where a licensed bed is located.
Class A Resident Room | |
Criteria for Class A Room | PBV Applicable to Each Licensed Bed in a Class A Room |
A private, single occupancy resident bedroom. Maximum of one licensed bed per room. Each Class A private room shall have an attached private bathroom, or an attached private bathroom shared with one adjoining private resident room. A Class A room must meet minimum space and other standards for private rooms and attached private bathrooms as set in Department regulations for a licensed SNF. | Base PBV (full PBV) for the SFY 2022 cost reporting period and applicable to the CY 2023 rate year is $196,977. Updated annually as Base PBV is updated for increases in the construction index. |
Class B Resident Room | |
Criteria for Class B Room | PBV Applicable to Each Licensed Bed in a Class B Room |
A semi-private, double occupancy resident bedroom. Maximum of two licensed beds per Class B room. Each Class B room shall have an attached private bathroom, or an attached private bathroom shared with one adjoining private or semi-private resident room. A Class B room must meet minimum space and other standards for semiprivate rooms and attached private bathrooms as set in Department regulations for a licensed SNF. | Base PBV (full PBV) for the SFY 2022 cost reporting period and applicable to the CY 2023 rate year is $140,594. Updated annually as Base PBV is updated for increases in the construction index. |
Class C Resident Room | |
Criteria for Class C Room | PBV Applicable to Each Licensed Bed in a Class C Room |
A Class C room is any resident room that does not meet the criteria for a Class A room or Class B room. Maximum of two licensed beds per Class C room. For example, a Class C room includes any private or semi-private room lacking an attached private bathroom or where the occupants otherwise must rely on a communal bathroom(s) for toileting. | Fixed at the Per Bed Value in effect on June 30, 2022, with no annual update thereafter for the construction index. |
The PBV will be adjusted annually thereafter to reflect changes in construction costs as indicated per the Core Logic Marshall & Swift Valuation Service. A percentage increase will be calculated by dividing the difference between the Comparative Cost Multipliers construction index for Little Rock, Arkansas, for the quarter ending January of the cost reporting period and January of the previous year. The annual adjustment percentage will be the lessor of the percentage as calculated above for building classes:
Every five (5) years, the Division shall analyze and compare the annual updates made using the construction cost index and the actual total cost (including physical plant, fixed equipment, land acquisitions and land improvements) of new SNF construction in Arkansas during the same period. The Division shall rebase the base PBV if actual construction costs increased more than estimated by the construction index.
A facility rental factor will be paid for each facility. The rental factor is calculated by multiplying the CAV of the facility by two and a half percent (2.5%).
The cost of ownership component of the property payment will consist of interest, property taxes, and insurance premiums (including professional liability and property) as identified on the facility's cost report. The limitation on allowable interest expense is addressed in the return on equity calculation described above. The limitation on allowable professional liability insurance is addressed in Section 3-2 J. 9.
The cost of purchases of minor equipment is not covered in the Fair Market Rental Payment. Minor equipment for the purposes of reimbursement is any equipment that has a unit cost of less than two thousand five hundred dollars ($2,500). Minor equipment purchases are to be expensed in the cost area in which the equipment is normally used (i.e., direct care cost component or indirect, administrative, and operating component).
The current asset value of a facility will be adjusted as a result of major renovations made to an existing facility. A major renovation is defined as renovations made to a facility where the total per bed cost of the renovation equals or exceeds ten percent (10 %) of the facility's current per bed value for the beds renovated or five (5%) for renovations to common areas. The actual cost of all additions or fundamental alterations to a facility that are required by state or federal laws or rules that take effect during the cost reporting period will be treated as an adjustment to the provider's aging index regardless of the percentage of current per bed value. The cost of renovation will be treated as an adjustment to the provider's aging index. A facility's aging index will be reduced by one percent (1%) for each percent of the current per bed value expended for renovations on a per bed basis. For facilities that have beds that have been placed in operation at different times or when renovations include only a portion of the beds in a facility, the determination that the renovation meets the criteria of major renovation and the reduction of the aging index will relate to only those beds that were included in the renovation. For renovations to common areas, the determination that the renovation meets the criteria of major renovation and the reduction of the aging index will be applied proportionally to all beds.
Adjustments to the aging index will be rounded to a whole percentage. Percentages greater than or equal to.5 will be rounded up. Percentages less than.5 will be rounded down. A facility wishing to do major renovation to their facility must submit a plan for renovation to the Department of Human Services for review and approval to facilitate an adjustment to the provider's aging index. The duration of the renovation plan cannot exceed a three-year period. The plan shall include a detailed description of the renovation to be done along with the cost of the renovation. The Department will determine if the proposed renovation meets the requirements for major renovation.
The Department will approve or disapprove the renovation project within thirty days of receipt. The provider will then submit a detailed description of the actual work performed and a statement of the actual cost of the renovation upon completion of the project. Renovations that were not completed in compliance with the plan for renovation will not be considered. The Department will notify the provider of the adjustment to the facility aging index as a result of the major renovation. Under no circumstances will the aging index be reduced to less than zero.
Age of provider beds for purposes of calculating the aging index were taken from surveys provided by the Arkansas Health Care Association as prepared by providers. The provider is responsible for the accuracy of the information provided. The provider may at any time be required to provide records validating this information. The aging index is subject to adjustment based upon review or audit.
Act 635 of 2001 established the levy of a quality assurance fee on nursing facilities. The reimbursement rate paid nursing facilities will include a Quality Assurance Fee component. The Quality Assurance Fee component will be reimbursed at the amount established as the multiplier as defined in Act 635 for the date of service billed.
Act 1602 of 2001 requires nursing facilities to own and maintain emergency generators. This establishes an add-on payment for installing emergency generators applicable only to first time emergency generators installed in order to comply with act 1602 of 2001. Facilities that do not meet the requirement of existing facility as defined in Act 1602 will not receive any add-on payment in addition to the facility's fair market rental payment. Add-on payments shall be made only for the periods that depreciation or lease expense for the cost of first time generator installations is allowable.
Facilities will be required to submit copies of invoices indicating generator cost and a copy of the financing arrangement if any for the emergency generator installation or a copy of the generator operating lease if any. Facilities that fail to provide this information by December 1, 2002 will not be paid the add-on for thirty days past the date of submission. Should the financing arrangement on the emergency generator change during the add-on period; the facility must provide revised financing information that will be used to calculate the add-on for the following calendar year.
Facilities will be paid an add-on to their per diems for installing emergency generators. The add-on payment will begin January 1, 2003 and will be adjusted each January 1 for the period the add-on is applicable. Using cost information supplied by the facility, the add-on will be calculated by dividing the sum of projected yearly depreciation and projected yearly interest expense or projected yearly lease expense by the greater of the actual resident days from the previous cost reporting period or resident days calculated at the minimum occupancy levels identified in section 2-4 A. 1. C. Fair Market Rental.
Depreciation will be calculated using the straight-line method assuming a useful life of ten years. Interest expense will be allowable and included in the add-on for emergency generators for a maximum period of five years. Interest expense and the associated debt instrument reimbursed under this provision will not be included in the fair market rental payment or any other component of the rate. Lease expense on emergency generator systems will only be allowable for a maximum period of ten years.
Change of ownership does not affect add-on payments. Facilities that change ownership while receiving a generator add-on payment will continue to receive the add-on for the remainder of the allowable period identified above using the original owner's projected expense.
An interim rate will be established at the beginning of each state fiscal year for each facility. The interim rate will be established by applying the inflation index to the actual per diem rate from the previous rate period. (For the period January 12, 2001 to June 30, 2001, an actual rate will be calculated from cost reports submitted for the period July 1, 1999 to June 30, 2000. No initial interim rate is necessary because the methodology has been implemented the second half of the rate period and therefore actual rates have been calculated.) The interim rate is necessary to allow time for providers to complete cost reports and allow the Department adequate time to review the cost reports and calculate rates. After the actual per diem calculations occur providers will be paid a weighted per diem rate for the portion of the rate year remaining. The weighted per diem rate will provide for an average payment approximating providers actual per diem.
The following formula will be used to calculate the weighted per diem rate.
{(Actual Per Diem Rate x 12) - (Interim Rate x Months Used)}/ Months Remaining.
A provisional rate will be paid to a provider who:
The provisional rate will be established as follows.
Facilities who are placed on a provisional rate as detailed above must submit a six month cost report as required in section 1-6 of this manual. The provisional rate will be retroactively adjusted to the per diem calculated in the following manner.
If either the provisional rate or the actual rate calculated from the six month cost report extend from one rate period to another, appropriate adjustments will be made to the vendor payment. The inflation index will be applied to the direct care per diem. The administrative and operating per diem will be changed to the class rate for the latest rate period. The fair market rental per diem will be adjusted to reflect any change in the PBV for the latest rate period.
Facilities that have a change in licensure due to purchase or lease of an existing facility participating in the Medicaid program will be reimbursed the previous operator's rate as of the date of the change of ownership. When this rate extends from one rate period to another, an inflation index will be applied to the per diem rate to establish the rate for the new rate period. The inflation factor to be used is addressed in Section 2-4 A. 6.
Facilities that withdraw from the Medicaid program either voluntarily or involuntarily will not be required to submit a final cost report. All payments made to a facility as interim or provisional will be considered as final. This provision does not apply to any fines or penalties that have been imposed on a facility.
For all inflation adjustments (unless stated otherwise in the specific area of the plan) the Department will use the Skilled Nursing Facility Market Basket Index as published by the Centers for Medicare and Medicaid Services. The Department will use the Four Quarter Moving Average Percent Change identified for the final quarter of the rate period.
Adjustments to an individual provider's per diem may be necessary as a result of amended cost reports, desk review, or audit. Should a provider's per diem be adjusted for any reason a retroactive adjustment will be made for all resident days paid back to the beginning of the rate period. Adjustments to a provider's per diem resulting from any source other than an inquiry for additional information as a result of a desk review for which provided within required deadlines will only affect the per diem for that particular provider. Cost component ceilings for applicable cost components and the floor established for direct care will not be adjusted under these circumstances.
For rate setting, facility allowable costs from desk reviewed facility cost reports for an annual period ending June 30, will be identified and grouped as: Direct Care; Indirect, Administrative, & Operating; Property Costs (Identified for informational purposes, the reimbursement rate for property costs will be determined by the Fair Market Rental method as outlined above in Item A. 1. C.); and Quality Assurance Fee.
The following expenses are classified as Direct Care.
Salaries-Aides
Salaries-Medication Assistants
Salaries-LPN's
Salaries-RNs
Salaries-Occupational Therapists
Salaries-Physical Therapists
Salaries-Speech Therapists
Salaries-Other Therapists
Salaries-Rehabilitation Nurse Aide
Salaries-Assistant Director of Nursing
Salaries-Director of Nursing
FICA-Direct Care
Group Health-Direct Care
Pensions-Direct Care
Unemployment Taxes-Direct Care
Uniform Allowance-Direct Care
Worker's Compensation-Direct Care
Other Fringe Benefits-Direct Care
Contract-Aides
Contract-Medication Assistants
Contract-LPN's
Contract-RN's
Training-Direct Care
Drugs, Over-the-Counter
Oxygen
Medical Supplies-Direct Care
Contract-Occupational Therapists
Contract-Physical Therapists
Contract-Speech Therapists
Contract-Other Therapists
Therapy Supplies
Consultant Fees-Nursing
Raw Food
Food Supplements
Incontinence Supplies
The following expenses are classified as Indirect, Administrative & Operating.
Salaries-Administrator
Salaries-Assistant Administrator
Salaries-Dietary
Salaries-Housekeeping
Salaries-Laundry
Salaries-Maintenance
Salaries-Medical Records
Salaries-Other Administrative
Salaries-Owner or Owner/Administrator
Salaries-Activities
Salaries-Pharmacy
Salaries-Social Services
FICA- Indirect, Administrative, and Operating
Group Health- Indirect, Administrative, and Operating
Pensions- Indirect, Administrative, and Operating
Unemployment Taxes- Indirect, Administrative, and Operating
Uniform Allowance- Indirect, Administrative, and Operating Worker's Compensation- Indirect, Administrative, and Operating
Other Fringe Benefits- Indirect, Administrative, and Operating
Barber & Beauty Expense-Allowable
Consultant Fees-Activities
Consultant Fees-Medical Director
Consultant Fees-Pharmacy
Consultant Fees-Social Worker
Consultant Fees-Therapists
Medical Transportation
Patient Activities
Supplies-Care Related
Other Care Related Costs
Contract-Dietary
Contract-Housekeeping
Contract-Laundry
Contract-Maintenance
Consultant Fees-Dietician
Consultant Fees-Medical Records
Accounting Fees
Advertising for Labor/Supplies
Amortization Expense-Non-Capital
Bank Service Charges
Board of Directors Fees
Data Processing Fees
Dietary Supplies
Depreciation Expense
Dues
Educational Seminars & Training
Housekeeping Supplies
Interest Expense-Non-Capital
Laundry Supplies
Legal Fees
Linen & Laundry Alternatives
Miscellaneous
Management Fees& Home Office Costs
Office Supplies & Subscriptions
Postage
Repairs & Maintenance
Taxes-Other
Telephone & Communications
Travel
Utilities
Criminal Backgrounds Check
Vehicle Depreciation
Vehicle Interest
The following expenses are classified as property.
Insurance-Professional Liability
Amortization Expense-Capital
Depreciation
Interest Expense-Capital
Property Insurance
Property Taxes
Rent-Building
Rent Furniture & Equipment
Effective January 1, 2004, the Non-State Public Nursing Facility Adjustment is eliminated.
Minimum occupancy rules (as defined in Section 2-4 A.1. C.) for calculating the facility fair market rental payment will be calculated and applied separately for beds certified as Home Style. All other policy described in this Cost Manual regarding the calculation of a facility's fair market rental payment is applicable to Home Style Facility beds.
All costs associated with renovating or constructing beds for initial certification as Home Style shall not be considered a renovation as detailed in section 2-4, A.1. C. 5. of this Cost Manual. Thereafter, Home Style beds are eligible for renovation adjustment as detailed in the Cost Manual.
A nursing facility participating in this program may certify less than one hundred percent (100%) of its beds as Home Style Facility beds. A facility may have a combination of traditional style nursing facility beds and Home Style Facility beds within a single licensed facility.
A facility or any part thereof, certified by the Office of Long Term Care as Home Style shall prepare and submit a Financial and Statistical Report/Cost Report. The cost report for Home Style beds will be identified as such by including the words Home Style at the end of the facility name wherever used. The cost report must be prepared in accordance with all reimbursement rules and reporting requirements detailed in the "Manual of Cost Reimbursement Rules." Combination facilities will be required to complete a separate cost report for both the traditional beds and beds certified as Home Style Facility beds. Whenever possible, costs that can be directly identified to either the traditional or Home Style beds must be included on the appropriate cost report. The department recognizes that certain costs cannot be directly identified and benefit both reporting entities. These shared costs must be allocated between each of the benefiting entities. Any shared cost included in the calculation of the facility's fair market rental payment must be allocated based on the Current Asset Value (CAV). All other shared cost must be allocated based on resident days. The cost report for the Home Style portion of a combination facility will include forms 1, 2, 3, 4, 6, 7, 8, 9, 10, and 16.
The cost report for the traditional beds in a combination facility must include all forms. The cost report for traditional beds in a combination facility will include aggregate information (includes both traditional and Home Style) on forms 5, 11, 12, 13, 14, and 15. These forms relate to the overall operation of the facility and cannot be allocated between traditional and Home Style.
The Cost Report for Home Style Beds will be used for the purpose of establishing a per diem rate for the facility's Home Style beds.
Full year cost reports for facilities certified entirely as Home Style Facilities will be included when calculating the direct care ceiling and the median for the indirect, administrative and operating component of the rate during the overall rate setting process. Full year cost reports for combination facilities will be combined into an aggregate per diem cost for both direct care and indirect, administrative and operating, and will be included in the overall rate setting process as well.
Certified Nurse Assistant's (CNA) utilized in staffing Home Style beds are designated as universal workers within the Home Style concept. The universal worker performs CNA duties, and performs dietary, laundry, housekeeping and other services to meet the needs of residents. CNA duties are considered primary to other duties performed by the CNA, therefore the cost of salaries and fringe benefits for CNA's are considered direct care costs and are appropriately reported in Section 1 of Form 6 on the facility cost report.
With the exceptions detailed above, the per diem rate for beds certified as Home Style beds will be established in the same manner as traditional beds.
Act 433 of 2009 established the levy of a provider fee on Intermediate Care Facilities for Individuals with Developmental Disabilities. The reimbursement rate paid 16 Bed & Over - State-Operated Facilities will include a Provider Fee component. The Provider Fee component will be reimbursed at the amount established as the multiplier for the date of service billed.
Effective with dates of service on or after January 1, 1999, ICF/IID 16 bed and over facilities will be paid a prospective rate based on a combination of actual allowable cost for Direct Care & Care Related costs and a class rate up to a ceiling for Administrative and Operating costs. Effective the beginning of each state fiscal year, rates will be rebased or adjusted for inflation. The Department will in its sole discretion determine whether to rebase the rate or apply an inflationary adjustment.
For rate setting, facility allowable costs from desk reviewed facility cost reports for an annual period determined by the Department, will be identified and grouped as Direct Care & Care Related or Administrative and Operating. Direct Care & Care Related include those expenses the facility incurs in providing care directly to the resident. Because these costs most directly affect the quality of care given a resident, the methodology includes as a component the actual allowable cost incurred for Direct Care & Care Related costs.
Administrative and Operating constitute the remainder of facility costs. Costs associated with Administrative and Operating are more directly controllable by the facility. The methodology includes as a component a class rate up to a ceiling to cover the costs for Administrative and Operating.
For rates effective January 1, 1999, desk reviewed facility cost reports for the period 1/1/97 through 6/30/97 and 71/97 through 12/31/97 were combined to establish the base year rates. Rebasing and cost reporting period for rebasing will be at the discretion of the Department. Should the Department decide to rebase, the most currently available desk reviewed cost reports will be used.
Rates will be established in the following manner: An average per diem cost for Administrative and Operating will be calculated for the facility class. This will be accomplished by determining per diem cost for Administration & Operating for each facility by dividing the actual allowable cost for each facility by their total resident days, adding the individual facility per diem costs and dividing by the number of facilities within the facility class. A ceiling for Administrative and Operating will be set at 105% of the average. A facility will be paid at the lesser of the ceiling or their actual per diem cost plus 10% of the amount calculated as 105% of the average. A per diem cost will be calculated for each facility for Direct Care and Care Related costs. The per diem cost will be calculated by dividing the actual allowable cost for each facility by their total resident days. A facility's per diem cost for Direct Care and Care Related cost and Administrative & Operating cost will be combined to get a facility's total per diem. Once the total per diem by facility has been established, these rates will be adjusted for inflation from the base year to the rate year. In years that the rates are not rebased, existing rates will be adjusted for projected inflation. The Department will use the HCFA Input Price Index (market basket) - Nursing Facilities published quarterly for determining appropriate inflation rates. Facility rates will be rebased periodically at the Department's discretion.
Act 433 of 2009 established the levy of a provider fee on Intermediate Care Facilities for Individuals with Developmental Disabilities. The reimbursement rate paid 16 Bed & Over - Private facilities will include a Provider Fee component. The Provider Fee component will be reimbursed at the amount established as the multiplier for the date of service billed.
The Department recognizes that the current rate structure limits the providers' ability to invest additional monies for the purpose of improving the quality of care. Additionally the recent increase in the minimum wage (an unfunded federal mandate) will make it difficult for providers to maintain current standards much less improve the quality of care. Therefore the Department will implement an enhanced care add-on in the amount of $10.54 per day. This enhanced payment will provide additional funds for wage adjustments in the base salaries for new hires and incumbent salaries to address the increase of the federal minimum wage in July 2009. This will also directly increase benefits related to these salary increases such as FICA, LTD, Life insurance, retirement, etc. This add-on will also provide funding for additional initiatives to improve the quality of care. The following list of items identifies these additional initiatives.
The Enhanced Care Add-on is paid in addition to the rate components identified in paragraph a. and b. above.
Modeling of this methodology produced estimates that each facility identified as efficient and economic (providers operating at or below the median of arrayed non-direct care costs) would receive payment equaling 100% (plus or minus 5%) of that facility's actual allowable cost. Cost coverage in the aggregate is equal to or less than 100% for ICF/IID facilities.
Act 433 of 2009 established the levy of a provider fee on Intermediate Care Facilities for Individuals with Developmental Disabilities. The reimbursement rate paid Under 16 Beds facilities will include a Provider Fee component. The Provider Fee component will be reimbursed at the amount established as the multiplier for the date of service billed.
The Provider Fee component is paid in addition to the rate identified in paragraph a. above.
The Department recognizes that the current class rate structure limits the providers' ability to invest additional monies for the purpose of improving the quality of care. Additionally the recent increase in the minimum wage (an unfunded federal mandate) will make it difficult for providers to maintain current standards much less improve the quality of care. Therefore the Department will implement an enhanced care add-on in the amount of $7.02 per day. This enhanced payment will provide additional funds for wage adjustments in the base salaries for new hires and incumbent salaries to address the increase of the federal minimum wage in July 2009. This will also directly increase benefits related to these salary increases such as FICA, LTD, Life insurance, retirement, etc. This add-on will also provide funding for additional initiatives to improve the quality of care. The following list of items identifies these additional initiatives.
The Enhanced Care Add-on is paid in addition to the rate components identified in paragraph a. and b. above.
Overpayment/underpayments resulting from Section 1-12 administrative errors shall be handled through the vendor payment by recouping overpayments and reimbursing underpayments.
The Arkansas Health Center Nursing Facility will be reimbursed on an actual cost reimbursement system with provisions for retrospective adjustments to ensure reimbursement of actual allowable and reasonable costs. The facility will have an interim per diem rate established based on the most recent semi-annual cost report. This interim per diem rate will be adjusted retrospectively as a result of actual costs for that semi-annual cost reporting period. The per diem will be calculated by dividing actual allowable cost by resident days for the cost reporting period. The per diem rate shall be changed as a result of adjustments to the semi-annual cost reports resulting from provider corrections, desk reviews, or audits, and will be retrospectively adjusted to the first day of the applicable cost report period.
Overpayments/underpayments resulting from Section 1-12 administrative errors shall be handled through the vendor payment by recouping overpayments and reimbursing underpayments.
The Department of Human Services acknowledges that State laws passed by the Arkansas General Assembly and administrative rules promulgated by the Division of Medical Services occasionally require the state's long term care facilities to incur costs which were not incurred prior to the adoption of the law or rule. DHS will assess the impact of newly required costs and, when warranted, seek additional reimbursement through the state and federal executive and legislative agencies. The Division of Medical Services will implement any available additional reimbursement, including appropriate retroactive payments, within the quarter following all necessary approvals, appropriation, and funding.
DHS will inform state and federal agencies proposing new nursing facility mandates of the projected costs, if any, of such mandates. If a proposed mandate would substantially increase costs without attendant state and federal funding, DHS will object to implementing the mandate without corresponding state and federal funding.
The following list of allowable costs is not all inclusive but serves as a general guide and clarifies certain key expense areas. The absence of a particular cost does not necessarily mean that it is not an allowable cost. As discussed further in Section 3-4, certain income items will reduce allowable costs and be offset against the appropriate line items for salaries and wages or other service expenses. Except where specific exceptions are noted, the allowability of all costs is subject to the amounts being reasonable and to the other general principles specified in section 3-1 of this chapter.
To be included as allowable cost, the compensation shall not exceed 150% of the median wage (excluding non-wage compensation) for comparable positions in facilities that do not have owner operators. Cost Reports from the previous reporting period will be used for setting the ceiling. The HCFA Market Basket projection of inflation will be used to adjust ceilings calculated from the cost reporting period to the rate setting period. Three peer groups will be established for this purpose:
If at the time of the request, records are in active use or are located in a place which makes immediate access impossible or impractical, the facility must certify that fact in writing and deliver the records within 72 hours of the request.
Depreciation on capital assets, including assets for normal standby or emergency use in which the facility is the record title holder and which assets are used to provide covered services to Medical Assistance Recipients, will be allowable subject to the following conditions:
Depreciation expense for the year of acquisition and the year of disposal can be computed by using:
The depreciation method, a description; the date acquired; cost; depreciable cost; estimated useful life; depreciation for the year and accumulated depreciation. Salvage value is not required to be maintained.
Amounts paid in excess of allowable salaries will be considered a withdrawal of equity. Net income must be adjusted for salaries in excess of allowable.
No working capital interest will be allowed when the facility has cash on hand equal to or greater than two months' operating expenses.
The following list of unallowable costs is not all inclusive, but rather serves as a general guide and clarifies certain key expense areas. The absence of a particular item does not necessarily mean that it is an allowable cost. Except where specific exceptions are noted, the allowability of all costs is subject to the general principle specified in section 3-1 of this chapter.
The cost of advertising related to classified advertisements for labor and supplies are allowable costs and should be included in the Administrative and Operating Expenses section;
The direct costs of prescription drugs, physician, dental, dentures, podiatry, eye glasses, appliances, x-rays, laboratory, and any other materials or services for which benefits are offered by direct provider payment plans under Medical Assistance or Medicare Part B, CHAMPUS, Blue Cross-Blue Shield, various other insurers or third-party resources are not allowed.
Facilities must not charge recipients, relatives, or recipient representatives for any item included in this manual as an allowable cost item. No provider participating in this program can solicit contributions, donations, or gifts directly from Medicaid recipients or family members. See 42 U.S.C. 1302a-7b(D), 42 U.S.C. 1396 (a) (g), 42 U.S.C. 447.15, 42 U.S.C. Part 1001, and 42 U.S.C. 1003.102(b).
Effective November 1, 2007 software applications for medication management employing point of care technology is afforded special treatment for cost reporting periods beginning July 1, 2007. Characteristics of point of care technology include software applications installed on medication carts allowing point of care based medication management. The allowable cost of software and associated hardware (used exclusively for this application) required to operate a point of care software application will be treated as direct care cost for cost reporting purposes. All costs associated with the point of care application must continue to meet all allowable cost principles as defined in Chapter 3 including capitalization requirements. Chapter 4-A and Chapter 4-B of the state Manual of Cost Reimbursement Rules for Long Term Care Facilities dated July 1, 1999 include specific instructions on how these costs will be reported on provider cost reports.
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 XVII I) 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.
Detailed schedules, calculations and descriptions for all cost report adjustments must be attached to the submitted 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.
The true name of the long term care facility as licensed by the Department of Human Services, Division of Medical Services.
The facility's Medicaid provider number in effect for the dates of the cost report. This is the nine (9) digit number used to bill for Medicaid services.
The name by which the long term care facility operates (complete only if different from facility name above).
The facility's four (4) digit State Vendor Number.
Facility's physical location address.
The county in which the facility is located.
The county's two (2) digit identification number.
The facility's administrator at the close of the cost reporting period and their Arkansas license number.
Facility telephone number.
The person employed by the facility who should be contacted regarding the cost report and their telephone number.
Identify the reporting period and the number of months covered by the cost report.
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).
Column (B) plus Column (C) plus Column (D) plus Column (E).
All Medicaid reimbursed days will be identified here. This category will also include Medicaid reimbursed reserved bed days due to hospitalization and therapeutic home leave.
All Medicare reimbursed days will be identified here.
All private pay reimbursed days by the resident, resident's family, etc. will be identified here. This category will also include private pay reimbursed reserved bed days due to hospitalization and home therapeutic leave.
All third party (VA, other insurance), hospice, respite care, etc. reimbursed days will be identified here. This category will also include other reimbursed reserved bed days due to hospitalization and home therapeutic leave.
Complete the number of actual resident days by resident level of care -Column (A) Total resident days, Column (B) Skilled resident days, Column (C) Intermediate I resident days, Column (D) Intermediate II resident days, and Column (E) Intermediate III resident days. Line 4.2, Column A must agree with Line 4.1, Column A.
Complete the number of Medicaid resident days by resident level of care -Column (A) Total Medicaid resident days, Column (B) Skilled resident days, Column (C) I ntermediate I resident days, Column (D) Intermediate II resident days, and Column (E) Intermediate III resident days. Line 4.3, Column A must agree with Line 4.1, Column B.
Identify the number of beds licensed at the beginning and end of the period. Temporary changes because of alterations, repairs, etc. do not affect bed capacity.
Complete if Lines 5 and 6 are different.
Compute the total licensed bed days available during the period by multiplying the number of beds available for the period by the number of 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.
Total of Columns 2, 3, 4, and 5. The total of this column must agree with Form 3, Line 4.1, Column A.
List the total number of bed days available for each month. The total of this column must agree with Form 3, Line 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%.
List the facility's third party daily rates for both private rooms and semiprivate 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.
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 34, 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.
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.
Physical Therapy, Occupational Therapy, Speech Therapy, medical supplies and other ancillary services/supplies billed separately to Medicare Part A.
Physical Therapy, Occupational Therapy, Speech Therapy and medical supplies amounts received and receivable for Medicare Part B reimbursed services.
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.
Amounts received and receivable for drugs and pharmaceuticals from residents, employees or other non-residents.
Amounts received and receivable for beauty and barber services.
Amounts received from contributions, gifts, grants, etc.
Amounts received and receivable for guest and employee meals.
Interest Income earned per savings accounts, bonds, etc.
Amounts received and receivable for laundry services.
Amounts received and receivable from the sale of personal items.
Amounts received and receivable for nurse aide training and testing.
Amounts received and receivable for rental.
Amounts received and receivable for television services.
Amounts received and receivable for telephone services.
Amounts received and receivable from vending machine sales.
Amounts received and receivable for criminal records checks.
Amounts received and receivable for other. Attach a detail schedule of other income items.
Any other necessary adjustments including excess direct compensation as described in Sections 3-2.B. and 3-2.O.
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 nonallowable items. Columns 2 and 5 must be used to reclassify or adjust out any nonallowable 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.
Line 1-01, Salaries - Aides
Salaries of certified nurse aides and nurse aides in training.
Line 1-02, Salaries - Medication Assistants
Salaries of Medication Assistants-Certified
Line 1-03, Salaries - LPN's
Salaries of licensed practical nurses and graduate practical nurses.
Line 1-04, Salaries - RN's (exclude DON and Assistant DON)
Salaries of registered nurses and graduate nurses (excluding the DON and Assistant DON).
Line 1-05, Salaries - Assistant Director of Nursing
Salaries of the Assistant Director of Nursing.
Line 1-06, Salaries - Director of Nursing Salaries of Director of Nursing.
Line 1-07, Salaries - Occupational Therapists
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.
Line 1-08, Salaries - Physical Therapists
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.
Line 1-09, Salaries - Speech Therapists
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.
Line 1-010, Salaries - Other Therapists
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.
Line 1-23, Contract - Occupational Therapists
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.
Line 1-24, Contract - Physical Therapists
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.
Line 1-25, Contract - Speech Therapists
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.
Line 1-26, Contract - Other Therapists
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.
Line 1-27, Consultant Fees - Nursing
Fees paid to nursing personnel, not on the facility payroll, for providing advisory and educational services to the facility.
Line 1-28, Training - Direct Care (Schedule)
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:
* 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.
* Pressure relieving devices that cannot be used by more than a single resident or that would be classified as minor equipment.
* Minor medical equipment used in providing direct medical care such as thermometers, sphygmomanometers, stethoscopes, etc.
* Costs of supplies for which Medicare Part B revenue is received must be reclassified to Line 5-11 in Column 2 or removed in Column 5 per Form 5 revenue adjustments.
Cost associated with point of care software applications.
* Cost of operating a point of care software application that does not require capitalization.
* Depreciation of capitalized cost associated with a point of care software application reclassified from Section 3.
* Interest expense associated with a point of care software application reclassified from Section 3.
* Rent expense associated with a point of care software application reclassified from Section 3.
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.
Line 1-34, Food - Supplements
Cost of food products given in addition to normal meals and snacks under doctor's orders.
Line 1-35, Incontinence Supplies
Cost of incontinence supplies to include both disposable and linen diapers, and disposable underpads.
Line 1-36, Dental (Schedule)
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.
Line 1-37, Drugs Legend
Cost of prescription drugs are allowable only for AHC. Other nursing facilities must reclassify these costs to Line 5-11 in Column 2.
Line 1-38, Lab and X-Ray
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.
Line 2-22, Contract - Laundry
Cost of laundry services and personnel hired through contract that are not facility employees.
Line 2-23, Contract - Maintenance
Cost of maintenance services and personnel hired through contract that are not facility employees.
Line 2-24, Consultant Fees - Dietitian
Fees paid to consulting registered dietitians.
Line 2-25, Consultant Fees - Medical Records
Fees paid to consulting Accredited Records Technicians or Medical Records Administrators.
Line 2-26, Consultant Fees - Activities
Fees paid to activities personnel, not on the facility payroll, for providing advisory services to the facility.
Line 2-27, Consultant Fees - Medical Director
Fees paid to a medical doctor, not on the facility payroll, for providing advisory, educational and emergency medical services to the facility.
Line 2-28, Consultant Fees - Pharmacy
Fees paid to a registered pharmacist, not on the facility payroll, for providing advisory and educational services to the facility.
Line 2-29, Consultant Fees - Social Worker
Fees paid to a social worker, not on the facility payroll, for providing advisory and educational services to the facility.
Line 2-30, Consultant Fees - Therapists
Fees paid to licensed therapists, not on the facility payroll, for providing advisory and educational services to the facility.
Line 2-31, Barber and Beauty Expense - Allowable
The cost of barber and beauty services provided to residents by facility staff.
Line 2-32, Transportation
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.
Line 2-33, Resident Activities
Cost of resident activities should include pastoral services, recreational activities and supplies.
Line 2-34, Care Related 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.
Line 2-35, Accounting Fees
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.
Line 2-36, Advertising for Labor/Supplies Allowable advertising expense.
Line 2-37, Amortization Expense - Non-Capital (Schedule)
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.
Line 2-38, Bank Service Charges
Fees paid to banks for service charges, excluding penalties and insufficient funds charges.
Line 2-39, Criminal Records Checks
Cost of Criminal Records Checks for employees and job applicants.
Line 2-40, Data Processing Fees
Cost of purchased services for data processing systems and services.
Line 2-41, Dietary Supplies
Costs of consumable items such as soap, detergent, napkins, paper cups, straws, etc. used in the dietary department.
Line 2-42, Dues (Schedule)
A detailed schedule of dues must be included. The schedule should include the dates and purpose covered by the charge.
Line 2-43, Educational Seminars and Training
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.
Line 2-44, Governing Body (Schedule)
Costs incurred by members of the facility governing body to attend meetings. Attach a detail schedule of the members' names and costs incurred.
Line 2-45, Housekeeping Supplies
Cost of consumable housekeeping items including waxes, cleaners, soap, brooms and lavatory supplies.
Line 2-46, Laundry Supplies
Cost of consumable goods used in the laundry including soap, detergent, starch and bleach.
Line 2-47, Legal Fees (Schedule)
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.
Line 2-48, Linen and Laundry Alternatives
Cost of mattress covers, sheets, blankets, pillows, and gowns.
Line 2-49, Miscellaneous (Schedule)
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.
Line 2-50, Management Fees and Home Office Costs
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.
Line 2-51, Office Supplies and Subscriptions
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.
Line 2-52, Postage
Cost of postage, including stamps, metered postage, freight charges and courier services.
Line 2-53, Repairs and Maintenance
Supplies and services, including electricians, plumbers, extended service agreements, etc., used to repair the facility building, furniture, equipment, vehicles and vehicle insurance.
Line 2-54, Taxes - Other (Schedule)
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.
Line 2-55, Telephone and Communications
Cost of telephone services, WATS lines and FAX services.
Line 2-56, Travel (Schedule)
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.
Line 2-57, Utilities
Cost of water, sewer, gas, electric, and garbage collection services. Cost of television and cable services for common use areas in the facility.
Line 2-58, Depreciation - Vehicles and Software
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.
Line 2-59, Interest - Working Capital, Vehicles and Software
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, Total Indirect, Administrative and Operating Costs
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.
Line 3-01, Amortization Expense - Capital (Schedule)
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.
Line 3-02, Depreciation - Fair Market Rental
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.
Line 3-03, Depreciation - Generator
Depreciation on generators approved by the Office of Long Term Care under Act 1602 of 2001.
Line 3-04, Interest Expense - Fair Market Rental
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.
Line 3-05, Interest Expense - Generator
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.
Line 3-06, Property Insurance
Cost of fire and casualty insurance on facility buildings and equipment.
Line 3-07, Professional Liability Insurance
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.
Line 3-08, Property Taxes
Taxes levied on the facility's land, buildings, furniture and equipment.
Line 3-09, Rent - Building
Cost of leasing the facility's real property.
Line 3-10, Rent - Furniture and Equipment
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, Total Property
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.
Line 5-01, Advertising
Costs of unallowable advertising.
Line 5-02, Bad Debts
Accounts receivable written off as uncollectable.
Line 5-03, Barber and Beauty Expense
The cost of barber and beauty services provided by non-facility personnel.
Line 5-04, Contributions
Amounts donated to charitable or other organizations.
Line 5-05, Depreciation Over Straight Line
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.
Line 5-06, Income Taxes - State and Federal
Taxes on net income levied or expected to be levied by the Federal or
State government.
Line 5-07, Insurance - Officers
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.
Line 5-11, Other Non-Allowable Costs
Other costs that are considered non-allowable in accordance with other provisions of the State Plan (products sold to residents, etc.).
Line 5-12, Penalties & Sanctions
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).
Line 5-13, Television & Cable (Resident Rooms)
Cost of television sets used in the residents' rooms or for providing cable TV to the residents' rooms.
Line 5-14, Vending Machines
Cost of items sold to employees, residents and the general public including candy bars and soft drinks.
Line 5-15, Goodwill
Amortization of Goodwill costs. These costs are not to be included on the Form 7 depreciation schedule.
Line 5-16, Total Non-Allowable Costs
Line 5-16 is the sum of Line 5-01 through Line 5-15.
Line 6, Total Costs
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.
Line 7, Total Resident Days
Enter the number of total resident days from Form 3, Line 4.1, Column A.
Line 8, Direct Care Costs
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.
Line 9, Indirect, Administrative and Operating Costs
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.
Line 10, Property Costs
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.
Line 11, Quality Assurance Fee
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, Total Costs
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.
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.
The total accumulated depreciation calculated using the straight-line method will be reported in this column.
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 302, Column 1 and Line 3-03, Column 1.
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.
Column 3 plus or minus Column 4 adjustments.
All providers must complete this section. If yes, complete Sections II. and III.
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, 304, 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.
List the name of each owner of the facility and their relationship with organizations described in Section II.
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.
Report the lender's name.
Report the total amount financed at the loan's origination.
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.
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.
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.
The non-current portion of long-term notes payable should be reported in this column. The Page 1 total must agree with Form 11, Line 33.
Describe the terms of the debt.
Describe the asset financed or purpose of the loan. For example, mortgage of building, purchase of equipment, working capital, vehicle, software, etc.
List the interest rate.
Report the allowable interest expense for Fair Market Rental payment for the cost reporting period.
Report the allowable interest expense for generator for the cost reporting period.
Report the allowable working capital interest expense for the cost reporting period. Also report the allowable interest expense on other items such as vehicles and software.
Report the non-allowable interest expense for the cost reporting period.
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.
Cash on Hand & in Banks includes all funds actually on hand or in bank accounts subject to immediate withdrawal.
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.
Allowance for Uncollectable Accounts includes the estimated loss for accounts receivable that will not be collected.
Notes Receivable includes the current portion of notes other than those 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.
Other Receivables include all current receivables which are not appropriately included on another line such as amounts due from a previous owner.
Inter-Company Receivables represent amounts owed the facility by a home office or other nursing home facility in a multi-facility operation.
Inventory includes those goods awaiting sale or use, and excludes those longterm 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.
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.
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.
Other Current Assets include all current assets which are not appropriately included on any other line of the balance sheet.
Total Current Assets is the sum of Line 1 through Line 11.
Property, Plant and Equipment must agree with the total of all assets recorded on Form 7, Page 1, Column 1.
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.
Total Fixed Assets is the difference between Line 13 and Line 14.
Notes Receivable - Noncurrent includes the non-current portion of notes other than those due from officers, owners, and 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.
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.
Other Noncurrent Assets represent those non-current assets which are not appropriately reported on any other line (ex. organization costs).
Total Other Assets is the sum of amounts recorded on Lines 16 through 19.
Total Assets represents the sum of amounts recorded on Lines 12, 15, and 20 of the balance sheet.
Accounts Payable represent liabilities of daily transactions normally kept on open account for goods and services purchased. Exclude accounts payable owed to related parties.
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.
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.
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.
Accrued Income Taxes include any liability the facility has for federal and state income taxes.
Inter-company Payables represent amounts owed by the facility to a home office or other nursing home facility in a multi-facility operation.
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.
Total Current Liabilities represents the sum of amounts reported on Lines 22 through 28 of this form.
Mortgage Payable represents the mortgage obligation that is scheduled to mature after one year from the balance sheet date.
Notes Payable - Long-Term include obligations that are scheduled to mature after one year from the balance sheet date.
Notes Payable to Officers, Owners or Related Organizations represent liabilities to officers, owners or related organizations.
Total Long-Term Liabilities represents the sum of Lines 30 through 32.
Total Liabilities is the sum of current liabilities (Line 29) and long-term liabilities (Line 33).
Capital has sections, which apply to proprietorships, partnerships, governmental facilities, and corporations. Only the applicable lines should be completed.
Total Capital is the sum of amounts reported on Lines 35 through 41.
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.
Net Income (Loss) for Period is obtained from Form 5, Line 22.
Contributions to capital must be listed together with the date the contribution was made.
List any other additions to capital.
Dividends include those dividends declared during the cost reporting period.
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.
List any other reductions to capital.
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.
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.
Expenses, which are directly related to the management of all other facilities, must be reported in Column 4.
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.
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.
The total of expenses directly related to this facility from Line 2-31, Column 3 are reported here.
The total amount of this facility's allocated portion of the indirectly related expenses from Line 2-31, Column 6 are reported here.
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.
Total of Lines 3-01, 3-02, and 3-03.
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.
Form 16 must be completed for each facility.
This column must equal the amount on Form 6, Column 1 for the line recorded in column 1.
This column is used to record the actual hours paid during the report period for each staff classification.
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.
CASH | ACCOUNT NAME | ACCOUNT DESCRIPTION |
110.00 | Cash in Bank - General | Cash on deposit in a checking account at a bank. |
111.00 | Cash in Bank - Payroll | 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. |
114.00 | Cash in Bank - Savings | Cash on deposit in bank or Savings and Loan earning interest income. |
116.00 | Resident Trust | Funds left with the facility by residents for safekeeping, which is either as cash on hand or in a checking/savings account on deposit. |
118.00 | Petty Cash | Amount of cash retained on the premises to meet the daily requirements for small purchases or to make change for residents and visitors. |
ACCOUNTS RECEIVABLE | ||
120.00 | Private | Amounts due from self-pay residents and other Third Parties. |
121.00 | Medicare - Part A | Amounts billed to the Medicare Title XVIII fiscal intermediary for SNF services. |
122.00 | Medicare - Part B | Amounts billed to the Medicare Title XVIII fiscal intermediary for Part B services. |
122.10 | Medicare Coinsurance/Deductible | Amounts billed to the resident or third party for coinsurance or deductible for Medicare services. |
123.00 | Medicaid | Amounts due from the Department of Human Services (DHS) for services provided to Medicaid residents. |
123.10 | Medicaid Resident Liability | Amounts due from the Medicaid resident or third party for his care as established by the local DHS county office. |
124.00 | Nurse Aide Training & Testing | Amounts due from Medicaid/Medicare/ Private Pay/etc. for Nurse Aide Training and/or Testing. |
130.00 | Allowance for Doubtful Accounts | Estimate of accounts receivable which will not be collected. |
INVENTORY | ||
135.00 | Nursing Supplies | The value of supplies on hand used for the professional care of the resident (i.e., medical and nursing supplies). |
136.00 | Food | The value of food and food items on hand. |
137.00 | Food Supplements | The value of food supplements such as Ensure, etc. on hand. |
138.00 | Linen | 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. |
PREPAID EXPENSES | ||
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. |
FIXED ASSETS | ||
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. |
ACCUMULATED DEPRECIATION | ||
170.00 | Accumulated Depreciation | Depreciation expense taken during the current period as well as prior years on the above assets. |
OTHER 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. |
CURRENT LIABILITIES | ||
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. |
PAYROLL TAX WITHHELD | ||
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. |
ACCRUED PAYROLL TAXES | ||
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. |
OTHER TAXES | ||
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. |
CONTRACTUAL OBLIGATIONS | 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. |
LONG TERM LIABILITIES | ||
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. |
EQUITY | ||
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. |
PROPRIETOR DRAW | ||
395.00 | Proprietor Draw | Amount withdrawn from the business by the owner(s) in cases where the facility is not a corporation. |
ROUTINE REVENUE | 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. |
MISCELLANEOUS REVENUE | ||
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. |
ALLOWANCES | Year end adjustments to reduce billed amounts to estimated collectible amounts as recorded per general ledger revenue accounts. | |
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. |
DIRECT CARE EXPENSES | ||
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. |
ADMINISTRATIVE AND OPERATING COSTS | ||
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. |
735.10 736.00 | Payroll Processing Advertising for Labor/Supplies | Fees paid to banks, data processing companies, or accounting firms for preparing the facility payroll. 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, excludingpenalties 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. |
PROPERTY | ||
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 Improvements | Depreciation on major additions or 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. |
QUALITY ASSURANCE FEE | ||
820.00 | Quality Assurance Fee | Cost of the quality assurance fee paid monthly to the Department of Human Services. |
NON-ALLOWABLE COSTS | ||
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 employees of the facility. |
839.00 | Non-Working Officer's Salaries | Salaries and other compensation paid to nonworking 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. |
The DHS-750 cost reporting forms described below must be used by all ICF/IID long term care 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.
These instructions are for use in the preparation and submission of the cost report to the Division of Medical Services by all ICF's/MR providing care and services under the Medical Assistance Program. Nursing Facilities will use the Nursing Facility Financial and Statistical Report, DOM-400 and applicable instructions.
All dollar amounts must be rounded to the nearest dollar (no cents) upon transfer to the cost report. For ICF's/MR, only per diem cost amounts calculated on Form 2, Line 11 and Form 8, Lines 4 and 5 will be reported/calculated in cents.
Detailed schedules, calculations and descriptions for all cost report adjustments must be attached to the submitted cost report.
Cost report forms which are not applicable to a facility must be submitted with the other forms and identified as "Not Applicable" or "NA" on the unused form.
The "Certification By Officer or Administrator of Provider(s)" section 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. No signature under the "Opinion of Accounting Firm" section is required unless the period covered by the cost report was audited by a Certified Public Accountant, Public Practicing Accountant, or accounting firm engaged to audit and prepare the financial statements and/or report. Outside accountants preparing the cost report without audit must instead submit a signed "Disclaimer of Opinion" or "Compilation of Report." If an accountant employee/officer/other employee of the facility prepared the cost report, the name, address, and telephone number of the preparer must be reported even though that person's signature is not required.
Please check the appropriate block which applies to your facility.
Please check the appropriate accounting basis used to complete the cost report. Non-governmental facilities must use and check the accrual block. Governmental facilities can use either the cash or accrual basis.
Identify the number of beds available during the year. Temporary changes because of alterations, repairs, etc., do not affect the bed capacity.
Calculate by multiplying the number of beds available for the period by the number of days in the period. Any increase or decrease in the number of beds must be taken into consideration as well as the days elapsed during such an increase or decrease.
Identify the actual total resident days for the reporting period.
The percent occupancy is calculated by dividing Line 4 by Line 3.
The decimal place should be carried to four places. Example -95.31%
Complete Line 6 only if Line 5 is less than 85%. Resident days at 85% occupancy is calculated by multiplying Line 3 by 85%.
These lines are self-explanatory. This information is requested for statistical purposes.
Upon completion of Form 5, enter on Line 10 the total allowable costs from Form 5, Column 9.
Calculate the per diem cost by dividing the allowable cost on Line 10 by the actual resident days for the period on Line 4 if the total occupancy per Line 5 is 85% or greater. If the occupancy percentage per Line 5 is less than 85%, complete Form 8 and bring the per diem amount calculated on Form 8, Line 5 forward to Form 2, Line 11.
All revenue is to be entered in Column 1 on this schedule and should agree with the revenue recorded in the general ledger. Revenue adjustments to expenses should be identified in Column 2. These adjustments are made to reduce the applicable expense by any revenues received for that expense. For example, any revenues received from the sale of medical supplies (Line 3) should be used to reduce medical supplies expense (Form 5, Line 10) because the expenses related to these sales are included in total expenses. Suggested line numbers for the adjustments to be made on Form 5 are listed. However, if a different line number must be used to make an adjustment to the proper expense line, cross out the suggested line number and identify the actual line number adjusted.
Line 31 will be used to record net adjustments due to related party transactions and excess owners', partners' and stockholders' compensation. These adjustments are recorded in Column 6 of Form 5.
Adjustments to expenses are separated into two categories:
Complete all lines applicable to your facility that require adjustment. Not all possible adjustments may apply to your particular facility. Additional lines are also provided on this form for other adjustments your facility may need to make which are not included in the listing.
Enter the amounts in the adjustment column next to the applicable line item description. These amounts will then be entered on Form 5, Column 6, as adjustments to the expenses per the general ledger descriptions. Suggested line numbers for the adjustments to be made on Form 5 are listed. However, if a different line number must be used to make an adjustment to the proper expense line, cross out the suggested line number and identify the actual line number adjusted.
The cost centers on Form 5 are broken down into the following:
Line item expense descriptions are listed under each cost center. Enter the general ledger expense balances in the first three columns. Do not net general ledger expense balances by omitting from the first three columns any nonallowable activities. These adjustments are to be made in Columns 5 and 6 and reported on Forms 3 and 4, respectively.
If the facility's general ledger includes expense accounts which are not listed on Form 5, fill them in on the extra lines provided. It is not necessary to list every expense account on a separate line. If several expense accounts need to be added and their total amount is not large in relation to other amounts in that cost center, a line item for "miscellaneous" or "other" may be added to indicate the total of these amounts. A schedule should be attached identifying the breakdown of the individual expense account names and amounts. Any large expense account to be added should be shown as a separate line item, If the general ledger does not contain a breakdown for some of the line item expenses listed on Form 5, it is acceptable to combine some of the amounts. Clearly mark which items have been included as on line item total.
Column 1 will contain the amount of the gross salaries applicable to each line item.
Column 2 is the employer's fringe benefits paid on behalf of the employees. This would include such items as the employer's share of FICA, health insurance, life insurance, etc. Apportion the fringe benefits to various expense centers based on the percentage of salaries and wages in each expense center. If a more accurate method is determined, it will be acceptable as long as it is documented.
Column 3 is all other expenses. In addition to other expenses, this column should include the cost of contractual services, in-service education costs, and related equipment and supplies expenses.
Column 4 is the total of Columns 1 through 3. The total of Column 4 must agree with the total expenses per the general ledger.
Column 5 and 6 are the adjustments to revenue and expense brought forward from Forms 3 and 4.
Column 7 is the total expenses shown in Column 4 plus or minus the adjustments to revenue (Column 5) and expense (Columns 6).
Column 8 represents allocation of overhead costs supporting direct costs disallowed. All unallowable cost activities must also bear a proportionate share of indirect costs (overhead) supporting these activities. For example, the Manual establishes the cost center line item "Gift, flower, coffee shop" as an unallowable cost, therefore, the allocable share of overhead supporting these activities must be deducted in arriving at allowable costs. Adjustments to allowable overhead must be made for all direct costs disallowed as result of provider adjustment, desk review, or audit.
Instructions for Column 8 follow:
Computation of Allocation Factor | |
1. Total Direct Care Costs (Form 5, Column 4, Line 5 + Line 23) | $________________ |
2. Unallowable Direct Costs (Form 5, Column 6, Line 5 + Line 23) | $________________ |
3. Unallowable Direct Costs divided by Total Direct Costs (Item 2 divided by Item 1; carry to four decimal places) | _______________% |
Allocation of M&O and G&A
Lines 24 through 29 and 31 through 37 Column 7, Form 5, are to be reduced by the computation made by multiplying the percentage from Item 3 above by each of the lines on Form 5, with the resulting figure placed on the corresponding line on Form 5, Column 8.
Example: Line 31, Column 7, on Form 5 = $10,000
Percentage determined in the calculation above = 3%
Form 5 would reflect:
Column 7 | Column 8 | Column 9 | |
Line 31 | $10,000 | $ 300 | $ 9,700 |
Column 9 is the net adjusted allowable costs calculated by subtracting Column 8 amounts from Column 7 balances.
Line 1, Dietary
Dietitian's salary, kitchen and dining room wages, kitchen and dining supplies, services.
Line 2, Food
Cost of unprocessed food. Cost of preparation and serving are to be recorded on Line 1.
Line 3, Laundry and Linen
Wages of laundry, ironing and sewing help, laundry soaps and supplies, outside laundry service.
Line 4, Unassigned
(ICF/IID 16 Bed Private; Expense included in this line should meet the criteria for the Administrative and Operating Cost Category)
Line 5, Total Room and Board
Line 6, Nursing
Salaries of nurses, wages of aides and orderlies, supplies, dressings, thermometers, etc.
Line 7, Physician
Salaries, services, supplies. This would include the Medical Director.
Line 8, Unassigned
(ICF/IID 16 Bed Private; Expense included on this line should meet the criteria for the Direct Care & Care Related Cost Category)
Line 9, Pharmacy
Salaries of pharmacists, (or cost for pharmacy consultant). Nonallowable drugs and medications reported in the general ledger columns must be adjusted out using Columns 5 and/or 6. Allowable non-prescriptions medications should be listed on Line 10.
Line 10, Medical Supplies
Medical supplies furnished by the facility as part of required medical or nursing care, as ordered by a physician.
Cost associated with point of care software applications.
* Cost of operating a point of care software application that does not require capitalization.
* Depreciation of capitalized cost associated with a point of care software application reclassified from Line 26.
* Interest expense associated with a point of care software application reclassified from Line 35.
* Equipment rental associated with a point of care software application reclassified from Line 21.
Line 11, Laboratory
Salaries and supplies, or purchased services.
Line 12, X-Rays
Salaries of technicians and supplies or purchased services.
Line 13, Physical Therapy and Rehabilitation
Salaries and therapeutic supplies for physical therapy, occupation therapy and purchased services.
Line 14, Social Service
Salary or agreement cost of social workers and support staff used on a full or part-time basis to provide social services required and performed by the facility.
Line 15, Resident Activities
Cost of resident activities should include recreational activities and pastoral activities.
Line 16, Volunteer Services
Cost of supporting services and staff functions related to the use of volunteers which are resident related and are for improving resident care.
Line 17, Gift, Flower, Coffee Shop
Costs of non-resident related services. Include beauty and barber shop, etc., on this line. These are non-allowable expenses and no profit or loss should affect the allowable cost; therefore, it is necessary to completely eliminate these items. Expenses listed in Columns 1, 2, and 3 for this line will be adjusted to zero by an entry of the same amount in Column 6. A zero is already shown in Columns 7 and 9 for this item.
Line 18, Personal Purchases for Residents
Same as policy for Line 17, applies for personal purchases for residents.
Line 19, Oxygen
Cost of Oxygen, its administration, and related medications.
Line 20, Incontinence
Cost of supplies.
Line 21, Equipment Rental
Cost of renting any equipment necessary for resident care.
Rent expense associated with point of care software applications must be reclassified to Line 10.
Line 22, Unassigned.
(ICF/IID 16 Bed Private; Expense included on this line should meet the criteria for the Administrative and Operating Cost Category)
Line 23, Total Health Care.
Line 24, Housekeeping
Wages of housekeepers and maids, housecleaning supplies.
Line 25, Plant Operations, Maintenance, and Utilities
Utilities, repairs, engineers' salaries, handyman wages, contractual repairs, maintenance supplies. Utilities include water, sewer, garbage and waste disposal, electricity, heating fuel, and cable TV.
Line 26, Depreciation and Amortization
Total straight-line depreciation and amortization. The detail of depreciation and amortization is shown on Form 6. The total of the detailed schedule should agree with the depreciation shown on this line.
Depreciation expense associated with point of care software applications must be reclassified to Line 10.
Line 27, Rent
Rentals paid for buildings, equipment and land used in the operation of the facility.
Line 28, Real Estate Taxes and Insurance
School taxes, other taxes on land and buildings, capital stock tax, insurance, etc.
Line 29, Unassigned
(ICF/IID 16 Bed Private; Expense included on this line should meet the criteria for the Administrative and Operating Cost Category)
Line 30, Total Maintenance and Operation
Line 31, Salaries
Administrator's salaries, officers' salaries, and wages of general administrative personnel.
Line 32, Professional Services
Legal fees, outside accounting, data processing, management services, etc.
Line 33, Insurance
Officers' life insurance.
Line 34, Travel and Education
Seminars and educational programs. Any cost related to a particular cost center should be apportioned to that cost center. For example, the travel expense of a nurse should be included in the health care cost center and not with this line.
Line 35, Interest
Interest expense incurred on short-term and long-term loans and mortgages.
Interest expense associated with point of care software applications must be reclassified to Line 10.
Line 36, Other General Administrative Expenses
This line is provided to cover costs for such various general administrative expenses as office supplies, telephone, postage, bank service charges, dues, licenses, subscriptions, advertising, etc. Attach a schedule listing the account names and amounts used for this total.
Line 37, Unassigned
(ICF/IID 16 Bed Private; Expense included on this line should meet the criteria for the Administrative and Operating Cost Category)
Line 38, Total General Administration
Line 39, Provider Fee
Cost of the provider fee paid monthly to the Department of Human Services.
Line 40, Federal and State Income Taxes
Federal and State Income Taxes (not personal taxes). These are non-allowable expenses and should be adjusted to zero by an entry of the same amount in Column 6. A zero is already shown in Columns 7 and 9 for this item.
Line 41, Utilization Review (UR) and Medical Review
Reimbursement to physicians on the UR committee and other staff functions related to implementing the facility's UR plan.
Line 42, Total Other Costs
Line 43, Total All Costs
Line 44, Total Compensation-Administrator
This section on the bottom of Form 5 is for Administrator's salary, fringe benefits, and other reimbursed costs.
This listing is to be used only as a guideline and is not all inclusive for all expenses that are to be included in an expense account.
Identify the month/year in which the equipment was acquired. Use "various" if the assets were acquired in many different years.
Enter the actual cost of the assets.
Identify salvage value if used.
Cost or other basis less salvage value.
Enter the totals of depreciation claimed this period plus the total accumulated depreciation from the prior year. The total of this column will agree with the amount of Accumulated Depreciation reported on Form 10, Current Year Column, Line 12.
Enter the number of years or the equivalent rate over which the asset is being depreciated. In the case of many different lives in any classification of assets, enter "various".
Calculate by dividing the depreciable base by the useful life. The total of this column should agree with the amount reported on Form 5, Line 26, Column 7.
The purpose of this schedule is to identify costs for which reimbursement is claimed for services or supplies furnished to the facility by related organizations as described in Section 3-1.F.2.
The line number column is used to identify which Form 5 line number includes the related party expense. Balance sheet items should be referenced to the proper line on Form 10. Provide the amount, the name of the related business, the percentage ownership the related business has in the facility, or the percentage of ownership the facility has in the related business as indicated by the column headings.
List any leases pertaining to the property, plant and equipment. Identify the leased item, the amount of rent applicable to the current reporting year and the terms of the lease including the amount of the monthly payment, the interest rate, the life of the lease, and the effective date of the lease.
If rental/lease costs claimed on Form 5 are different from the facility's actual costs due to allowable reimbursement limits, state the difference and specify the reason. Identify rentals/leases for which the costs to the related organization are claimed instead of the lease payments.
This form is to be used only if the total occupancy rate was below 85%. If the occupancy level was below 85%, the lower level of occupancy will apply to variable cost. The fixed cost will have to be adjusted to an 85% occupancy level.
Separate allowable costs between fixed and variable costs. To calculate a per diem, divide total variable costs by actual resident days and divide total fixed costs by the resident days at 85%. Total the per diem for variable costs and the per diem for fixed costs to obtain the total per diem. Enter the total per diem on Form 2, Line 11.
This form should be completed by listing the facility's private pay rates during the reporting period. If a change of rates occurred during the period, list each rate structure and the dates the rates were in effect. The rates may be shown either as per diem or monthly charges.
Includes all funds actually on hand or in bank accounts subject to immediate withdrawal. Savings deposits, certificates of deposit, etc., are to be classified under investments.
Represent monies due the facility for services rendered to residents or amounts due from creditors, (i.e. notes receivable, advances, etc.) as of the balance sheet date. The dollar amount recorded on the schedule will represent gross accounts and notes receivable less accounts and notes receivable from related parties and less, if so recorded, an allowance for uncollectable accounts and notes receivable.
Represent amounts owed the Facility by related parties as of the balance sheet date.
Designate those goods awaiting sale or use, and exclude those long-term assets subject to depreciation. Inventories are normally conservatively priced at the lower of "cost or market" values. List the method at which the inventory is priced in space provided. Inventories may include dietary supplies, housekeeping and linen, other, etc. in accordance with the practice in each individual facility.
Investments are normally permanent or long-term securities with value, but are normally not available for immediate withdrawal. Investments include stocks and bonds, savings accounts, certificates of deposit, etc.
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. Utility deposits are examples of deposits.
Total of Lines 1 through 6.
Includes the following classifications: Land, Buildings, Leasehold Improvements, and Equipment. The total accumulated depreciation for all classifications should be entered on Line 12. Lines 8 through 12 must agree with the amounts entered on the depreciation schedule on Form 6. Equipment should be divided into departmental equipment, office furniture and fixtures, and transportation equipment on the detailed depreciation schedule on Form 6.
Total Property, Plant and Equipment is the net book value of the property, plant and equipment listed on Lines 8 through 11 less the allowance for depreciation on Line 12.
Total assets is the Total Current Assets plus the Total of the Property, Plant and Equipment (Line 13).
Represents liabilities on daily transactions normally kept on open account for goods and services purchased. This amount should exclude accounts payable to related parties.
Represent liabilities kept on open account and owing related parties.
Represents amounts due creditors other than related parties and normally evidenced by written instruments and due within one year from the end of the reporting period.
Represents amounts such as loans due to related parties and evidenced by written instruments. Amount shown should be due within one year from the end of the reporting period.
Represent the salaries and wages earned by employees but not paid during the accounting period. To be recognized as an allowable expense, accrued salaries must be paid within 30 days after the close of the cost reporting period.
Deferred Income is a liability if revenue is received before it has been earned. Services which will be rendered in a future accounting period for which monies have been collected is an example of deferred income.
Total of Lines 11 through 16.
Mortgage Payable is the amount of any mortgages due over one year from the end of the current reporting year. The current portion of a mortgage due within one year should be included in Current Liabilities.
Includes all notes owed creditors other than related parties and due over one year from the end of the current reporting year.
Includes the portion of notes owed to related parties and due over one year from the end of the reporting period.
Includes any long-term liabilities that do not fall into the categories of mortgages or notes. The type and amount of these liabilities should be specified and if necessary for clarity detailed on a separately attached schedule.
Total of Lines 22 through 25.
Total Liabilities is the Total Current Liabilities (Line 21) plus the Total Long-Term Liabilities (Line 26).
Owner's Equity is for the investment made in the facility by the owner or owners. Use this line for proprietorships and partnerships.
Represents the investment by the stockholders in the corporation. The amount outstanding on the balance sheet date will be the amount shown.
Either Line 28 or 29 will be filled out as applicable to the facility. Both lines will not be used.
Includes retained earnings and represents accumulated earnings after all expense and distributions have been paid. The surplus portion of the balance sheet reflects the surplus at the beginning of the year, the addition of the profit for the year or deduction of the loss for the year, other surplus transactions and the new surplus balance at the end of the year on the balance sheet date.
Total Liabilities and Capital is the total of Lines 27 and 34. This total amount should equal the amount reported on Line 14 Total Assets.
CASH | ACCOUNT NAME | ACCOUNT DESCRIPTION |
110.00 | Cash in Bank - General | Cash on deposit in a checking account at a local bank. |
111.00 | Cash in Bank - Payroll | 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. |
114.00 | Cash in Bank - Savings | Cash on deposit in bank or Savings and Loan earning interest income. |
116.00 | Resident Trust | Funds left with the facility by residents for safekeeping which is either cash on hand or in a checking account on deposit. |
118.00 | Petty Cash | Amount of cash retained on the premises to meet the daily requirements for small purchases or to make change for residents and visitors. |
ACCOUNTS RECEIVABLE | ||
120.00 | Private | Amounts due from Private or self-pay residents. |
121.00 | Medicare | Amounts billed to the Medicare Title XVIII fiscal intermediary. |
122.00 | Medicaid | Amounts due from Department of Human Services (DHS). |
130.00 | Allowance for Doubtful Accounts | Estimate of accounts receivable which will not be collected. |
INVENTORY | ||
135.00 | Nursing Supplies | The value of supplies on hand used for the professional care of the resident (i.e., medical and nursing supplies). |
136.00 | Food | The value of food and food supplies on hand. |
137.00 | Linen | The cash value of sheets, blankets, pillow cases and gowns on hand. |
PREPAID EXPENSES | ||
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. |
FIXED ASSETS | ||
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 improvement not attached to the building, but associated with facility's providing resident care. |
155.00 | Buildings | The cost of buildings used in providing resident care. |
156.00 | Building Improvements | The cost of any remodeling done to buildings used in providing resident care. |
160.00 | Equipment | Cost of equipment which has sufficient individuality and size to make feasible control by identification tag or number, (e.g., beds, x-rays apparatus, filing cabinets, typewriters, desks, ovens, freezers). |
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. |
ACCUMULATED DEPRECIATION | ||
170.00 | Accumulated Depreciation | Depreciation expense taken during the current as well as prior years on the above assets. |
OTHER 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 purchaser, between the purchase price and 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.. |
CURRENT LIABILITIES | ||
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. |
207.00 | Resident's Deposits | Amounts owed to residents for funds left with the facility for safekeeping. |
PAYROLL WITHHELD | ||
221.00 | Federal Income Tax | Amounts 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. |
ACCRUAL TAXES | ||
230.00 | FICA (Social Security) | Social Security taxes owed by employer in addition to those withheld from employees. |
231.00 | SUI (State Unemployment) | State Unemployment Insurance payroll tax owed by the employer. |
232.00 | FUI (Federal Unemployment) | Federal Unemployment Insurance payroll tax owed by the employer. |
235.00 | Disability | Disability or Workmen's Compensation premiums owed by the employer. |
OTHER ACCRUAL TAXES | ||
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 customers or residents, levied on the retail sales of the facility, which are owed by the facility to state or local governments. |
CONTRACTUAL OBLIGATIONS | 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 the Title XVIII fiscal intermediary based on Cost Settlements. |
255.00 | Medicaid | Amount due to the Department of Human Services. |
LONG TERM LIABILITIES | ||
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 | Note 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. |
EQUITY | ||
301.00 | Capital | Owner's capital 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 of (Loss) | Net profit or (loss) from operations for current year to date before provisions for income taxes have been made. |
PROPRIETOR DRAW | ||
395.00 | Proprietor Draw | Amount withdrawn from the business by the owner(s) in cases where the facility is not a corporation. |
ROUTINE REVENUE | The gross charges made to residents for room and board services, including general nursing, dietary, housekeeping, and all other commonly used services available to all residents and normally expressed as a daily or monthly rate. | |
402.00 | Private | All routine revenue for self-pay residents and other third party covered residents. |
403.00 | Medicare | All routine revenue for Title XVIII coverage including amounts paid by the Intermediary as well as coinsurance payments. |
404.00 | Medicaid | All routine revenue for Title XIX coverage including amounts paid by the state as well as resident liability payments. |
ANCILLARY REVENUE | ||
410.00 | Physical Therapy | Revenue associated with the following types of services performed by a registered physical therapist or under his supervision. Including (1) evaluating residents by applying tests of functional ability, nerves, muscles, etc., and (2) treating residents to relieve pain, restore functions and maintain performance, using physical means such as exercise, heat, water and electricity. |
412.00 | Pharmacy | Revenue associated with drugs and pharmaceuticals prescribed by the attending physician. |
414.00 | Speech Therapy | Revenue associated with the provision by a registered speech therapist of services which include providing assistance to the physician in evaluating residents to determine the type of speech disorder; recommending appropriate therapy and providing rehabilitative services. |
416.00 | Oxygen (Inhalation Therapy) | Revenue associated with the provision of that service providing inhalation of medications with the aid of special appliances and compressed gases for the purpose of correcting respiratory disease or alleviating respiratory symptoms. |
418.00 | Nursing Supplies | Revenue for medical and surgical supplies which are chargeable to residents (e.g., catheters, colostomy bags, dressings, syringes). |
OTHER REVENUE | ||
430.00 | Television | Revenue earned from rental of televisions to residents. |
432.00 | Beauty and Barber | Revenue derived from the provision of beauty and barber services to residents. |
434.00 | Personal Items | Revenue derived from the sale of personal items such as toothpaste, razor blades, shaving cream, etc. |
436.00 | Vending Machines | Revenue derived from the sale of products in vending machines, such as candy bars and soda pop. |
438.00 | Rental | Revenue derived from rental of space or equipment. |
440.00 | Interest | Interest earned on cash deposits, investments or notes and accounts receivable. |
441.00 | Meal Income | Revenue from meals sold to guests and employees. |
442.00 | Laundry Income | Revenue derived from doing personal laundry for residents. |
DEDUCTIONS | ||
501.00 | Contractual Adjustments | Adjustments made to resident care revenue to reflect estimated cost settlements with a third party. These adjustments are usually made as a result of an agreement to accept cost as payment from a contracting agent. |
503.00 | Medicare | Adjustments to Title XVIII covered charges. |
505.00 | Medicaid | Adjustments to Title XIX covered charges. |
ALLOWANCES | Offsets to gross billed charges to reduce them to actual collectible amounts. | |
522.00 | Private | Offsets to gross charges for self-pay residents and other third party covered residents. |
524.00 | Medicare | Offsets to gross charges for Title XVIII residents. |
526.00 | Medicaid | Offsets to gross charges for Title XIX charges. |
NURSING | ||
601.00 | Salary - Director | Gross salary (includes sick pay, holiday pay and vacation pay) of Director of Nursing who is in a supervisory position. |
602.00 | Salaries - RN's | Gross salaries of Registered Nurses. |
603.00 | Salaries - LPN's | Gross salaries of Licensed Practical Nurses. |
604.00 | Salaries - Aides & Orderlies | Gross salaries of unlicensed personnel. |
606.00 | Supplies | Cost of items for which a separate identifiable charge is not usually made such as swabs, tongue depressors, cotton balls. |
606.10 | Supplies - Point of Care | Cost of Point of Care Software Applications that does not require capitalization. |
607.00 | Oxygen | Cost of oxygen for which a separate charge is not usually made. |
608.00 | Non-Prescription Drugs | Costs of items for which a separate charge is not usually made such as Milk of Magnesia, Rubbing Alcohol. |
609.00 | Inservice | Costs of training and education of all Nursing personnel. |
RESTORATIVE | ||
621.00 | Salaries | Gross salaries of personnel providing restorative services to the facility, for which a separate charge is not usually made to the residents. |
622.00 | Consultants | Fees paid to personnel not on the facility payroll for which a separate charge is not usually made to the residents. |
623.00 | Physical Therapy | |
624.00 | Speech Therapy | |
625.00 | Inhalation Therapy | |
626.00 | Occupation Therapy | |
ALLOWANCES | ||
631.00 | Supplies | Cost of supplies and other restorative services. |
ACTIVITIES | ||
641.00 | Salaries | Gross salaries of personnel providing recreational programs to residents such as arts & crafts, church services and other social activities. |
642.00 | Supplies | Cost of consumable items used in the activities program (e.g., games, puzzles, art supplies). |
649.00 | Income | Revenue derived from the sale of arts & crafts items. |
SOCIAL SERVICES | ||
661.00 | Salaries | Gross salaries of personnel providing Social Services. |
662.00 | Supplies | Cost of consumable items used in providing Social Services (e.g., office supplies). |
MEDICAL RECORDS AND SERVICES | ||
663.00 | Salary - Medical Director | Gross salaries of doctors providing advisory, educational and emergency medical services to the facility. |
664.00 | Salaries - Medical Records | Gross salary of licensed medical librarian. |
665.00 | Consultants - Medical Directors | Fees paid to a physician to act as a medical director. |
667.00 | Medical Records | Fees paid to a licensed medical records librarian. |
668.00 | Utilization Review | Fees paid to physicians attending utilization review committee meetings. |
671.00 | Supplies | Cost of supplies including nursing and charting forms, admission forms, medication and treatment records, Physician order forms, etc.. |
DIETARY | ||
681.00 | Salaries | Gross salaries of kitchen personnel including dietary supervisor, cooks, helpers and dishwashers. |
682.00 | Supplies | Cost of consumable items such as soap and detergent, napkins, paper cups, straws, etc.. |
683.00 | Dishes and Utensils | Cost of knives, forks, spoons, plates, cups, saucers, bowls and glasses. |
684.00 | Consultants | Fees paid to consulting dietitians. |
685.00 | Purchased Services | Cost of other services. |
686.00 | Food | Cost of raw food. |
LAUNDRY | ||
701.00 | Salaries | Gross salary of laundry personnel. |
702.00 | Linen | Cost of sheets, blankets, pillows and gowns. |
703.00 | Supplies | Cost of consumables used in the laundry including soap, detergent, starch and bleach. |
704.00 | Purchased Services | Cost of other services including commercial laundry services. |
HOUSEKEEPING | ||
721.00 | Salaries | Gross salary of housekeeping personnel including housekeepers, maids and janitors. |
722.00 | Supplies | Cost of consumable housekeeping items including waxes, cleaners, soap, brooms and lavatory supplies. |
723.00 | Purchased Services | Cost of other services. |
MAINTENANCE | ||
741.00 | Salaries | Gross salary of personnel involved in operating and maintaining the physical plant, including maintenance men or plant engineer. |
742.00 | Supplies | Cost of supplies used in maintaining the physical plant including light bulbs, nails, lumber, glass, etc.. |
743.00 | Painting | Supplies and services. |
744.00 | Gardening | Supplies and services. |
745.00 | Purchased Services | Cost of other services including electricians, plumbers, locksmiths, etc.. |
746.00 | Repairs and Maintenance | Supplies and services involved with repairing the building and equipment. |
ADMINISTRATION SALARIES | ||
761.00 | Administrator | Gross salary of individual responsible for administering the activities of the facility. |
762.00 | Assistant Administrator | Gross salary of person directly assisting the Administrator. |
763.00 | Bookkeeping | Gross salaries of personnel responsible for accumulating and maintaining financial and statistical records. |
764.00 | Receptionist | Gross salaries of personnel answering telephones, greeting visitors, answering questions and performing secretarial functions. |
GENERAL | ||
765.00 | Management Fees | Cost of fees paid to a related organization such as a home office or another division of the same company, for providing overall management and direction. |
766.00 | Advertising - Other | The cost of advertisements in magazines, newspapers, trade publications, radio, TV and yellow pages. |
767.00 | Advertising - Want Ads | Cost of advertising to recruit new employees. |
768.00 | Telephone | Cost of telephone service. |
769.00 | Dues and Subscriptions | Cost of subscribing to newspapers, magazines and periodicals, and of dues paid for membership in industry associations. |
770.00 | Insurance - Liability | Cost of insuring the facility against injury and malpractice claims. |
771.00 | Photo Copy | Cost of copying equipment and supplies. |
772.00 | License | Fees for licenses including state, county and local business licenses as well as nursing home and administrator licensing fees. |
773.00 | Equipment Rental | Cost of rented equipment used in the business office, (e.g., postage meter, adding machine). |
774.00 | Office Supplies | Cost of consumable items used in the business office, (e.g., pencils, erasers, paper, staples). |
775.00 | Printing | Cost of printing up forms and stationary including accounting and census forms, charge tickets, facility letterhead and billing forms. |
776.00 | Postage | Cost of postage including stamps, metered postage and freight charges. |
777.00 | Bank Charges | Cost of processing checks and other related charges. |
778.00 | Professional - Accounting | Fees paid to auditors and accountants. |
779.00 | Professional - Legal | Fees paid to attorneys. |
780.00 | Professional - Other | Fees, other than legal or accounting paid for professional services, for example personnel or labor relations consultation. |
781.00 | Payroll Processing | Fees paid to banks, data processing companies, or accounting firms for preparing the facility payroll. |
782.00 | Financials | Fees paid to data processing organizations, or accounting firms for producing the facility's general ledger, financial statements and other computer reports. |
783.00 | Purchased Services | Cost of other services. |
784.00 | Travel | Cost of travel (airfare, lodging, meals, etc.) by administrator and other authorized personnel. |
785.00 | Auto | All costs of maintaining autos or other vehicles including depreciation interest, rental payments, gas, oil, tires and maintenance, taxes and licenses as well as auto insurance. |
786.00 | Seminars and Training | Cost of and fees for attending seminars or training sessions for non-nursing personnel. |
787.00 | Public Relations | Cost of promotional expenses including brochures and other informational documents regarding the facility. Do not include advertising costs. |
788.00 | Governing Body | Cost of Governing Body. |
789.00 | Provider Fee | Cost of the provider fee paid monthly to the Department of Human Services. |
PAYROLL TAXES AND BENEFITS | ||
801.00 | FICA (Social Security) | Cost of Employer's portion of Social Security tax. |
802.00 | SUI (State Unemployment) | State Unemployment Insurance costs. |
803.00 | FUI (Federal Unemployment) | Federal Unemployment Insurance costs. |
806.00 | Workmen's Compensation | Cost of Workmen's Compensation Insurance. |
807.00 | Health Insurance | Cost of Employer's contribution to employee Health Insurance. |
808.00 | Group Life Insurance | Cost of Employer's contribution to employee Group Life Insurance Plan. |
UTILITIES | ||
821.00 | Heating (Fuel) | Cost of heating oil, natural gas or coal. |
822.00 | Electricity | Self-Explanatory. |
823.00 | Water, Sewer and Garbage | Self-Explanatory. |
831.00 | Real Property Taxes | Amount of taxes levied on the facility's land and buildings. |
832.00 | Personal Property Taxes | Amounts of taxes levied on the facility's property and equipment. |
833.00 | Insurance - (Property) | Cost of fire and casualty insurance on facility buildings and equipment. |
COST OF CAPITAL DEPRECIATION | ||
841.00 | Land Improvements | Depreciation on improvements having a limited life made to the land of the facility, (e.g., paving, landscaping). |
842.00 | Building | Depreciation on the facility's buildings. |
843.00 | Building Improvements | Depreciation on major additions or improvements to the facility. For example, new laundry or dining room. |
844.00 | Equipment | Depreciation on items of equipment. For example beds, chairs, floor polishers, office machines, stoves and washing machines. |
844.10 | Point of Care Equipment | Depreciation expense associated with point of care software applications. |
845.00 | Leasehold Improvements | Depreciation on major additions or improvements to building or plant where the facility is leased and the costs of the changes are incurred by the lessee (tenant). |
RENT | ||
851.00 | Building | Rental amounts paid by the facility on all rented or leased real property (land and building). |
852.00 | Equipment | Rental amounts paid by the facility for leased or rental furniture and equipment. |
852.10 | Point of Care Equipment | Rent expense associated with point of care software applications. |
INTEREST | ||
856.00 | Building | Interest paid or accrued on notes, mortgages and other loans, the proceeds of which were used to purchase the facility's real property. (Land and building). |
857.00 | Equipment | Interest paid or accrued on notes, chattel mortgages and other loans, the proceeds of which were used to purchase the facility's equipment. |
857.10 | Point of Care Equipment | Interest expense associated with point of care software applications. |
AMORTIZATION | ||
861.00 | Deferred Financial Costs | Amortization of legal and other costs incurred when financing or refinancing the facility. They should be spread over the life of the new mortgage. |
862.00 | Deferred Org. Cost | Amortization of the legal and other costs of bringing a business into existence. They should be spread over a 60 month period. |
ANCILLARY EXPENSE | Cost or services for which a separate identifiable charge is or should be made, in addition to the routine charges. | |
871.00 | Physical Therapy Salaries | Gross salaries of those employees engaged in providing physical therapy services. |
872.00 | Physical Therapy - Purchased Services | Cost of physical therapy services performed on a contract basis by other than employees. |
873.00 | Supplies | Cost of consumable items used by the physical therapy department. |
875.00 | Occupational Therapy - Purchased Services | Cost of occupational therapy services performed on a contract basis. |
876.00 | Speech Therapy - Purchased Services | Cost of speech therapy services performed on a contract basis. |
878.00 | Oxygen - Purchased Services | Cost of inhalation therapy services performed on a contract basis. |
879.00 | Supplies | Cost of consumable items used in the provision of inhalation therapy services. |
880.00 | Occupational Therapy Salaries | Gross salaries of those employees engaged in occupational therapy services. |
881.00 | Supplies | Cost of consumable items used by the occupational therapy department. |
OTHER ANCILLARY | ||
882.00 | Supplies | Cost of medical and surgical supplies which are chargeable to residents (e.g., catheters, colostomy bags, dressings and syringes). |
885.00 | Laboratory - Purchased Services | Cost of laboratory procedures performed on a contract basis. |
886.00 | X-Ray - Purchased Services | Cost of X-Ray services performed on a contract basis. |
887.00 Pharmacy | Cost of drugs and pharmaceuticals prescribed by the attending physician. | |
NON-ALLOWABLE | ||
888.00 | Barber and Beautician | Costs directly related to the provision of beauty and barber services to residents. |
889.00 | Personal Items | Cost of the personal items such as cigarettes, tooth paste, shaving cream, etc. sold to residents. |
890.00 | Vending Machines | Cost of items sold to employees and residents including candy bars and soft drinks. |
891.00 | Television | Cost of television sets used in the resident rooms |
892.00 | Gift Shop | Cost of products sold in the gift shop and other costs that are directly associated with the sale of these products. |
893.00 | Insurance - Officers | Cost of life insurance on officers and key employees of the facility, other than group life insurance. |
894.00 | Income Taxes | Taxes on net income levied or expected to be levied by the Federal or State Government. |
895.00 | Contributions | Amounts donated to charitable or other organizations. |
896.00 | Bad Debts | Accounts receivable written off as uncollectable. |
897.00 | Goodwill | Amortization of amounts paid for a facility in excess of the book value of its tangible assets. |
898.00 | Advertising | Cost of advertising not related to recruiting new employees. |
899.00 | Other Nonallowable | Cost of other nonallowable services and purchases. Attach a schedule. |
The resident has the right to manage his or her financial affairs, and the facility may not require residents to deposit their personal funds with the facility. But many residents are unable or unwilling to manage their own financial affairs and do not have a responsible party that will manage their funds. In this case the facility must hold, safeguard, manage and account for the personal funds deposited with the facility. The facility will manage the personal allowance funds for residents when a responsible third party does not exist to handle these funds and the following circumstances exist. Each of these situations must be documented in writing.
When the facility assumes the responsibility for managing a resident's personal funds, withdrawals by family members should not be allowed. If the family makes purchases on behalf of the resident, the family can be reimbursed from the resident trust fund by presenting a receipt to the trust fund custodian. This transaction should be properly recorded in the Participant Ledger file. Families who object to following these procedures should be advised that they will have to assume responsibility for managing the resident's money. This provision should be fully explained to the appropriate family members when the participation in the resident trust fund begins. The forms referenced in Section 5 of this manual can be found in Section V of the Arkansas Medicaid Provider Manuals by clicking the hyperlink within this sentence.
The facility must account for each resident's money in such a fashion as to safeguard the money and avoid theft and loss. The system outlined below is designed to maximize security and maintain records sufficient to properly account for personal funds. Although the facility's system does not have to be identical to the system outlined below, it must contain the major components and ensure the integrity and accountability of personal funds.
In the event of the death of a resident, the facility administrator shall within 30 days of the resident's death provide an accounting and shall return all refunds and funds held in trust as detailed below. The administrator must determine if a personal representative has been appointed for the resident. If one has been appointed, then the personal trust funds shall be disbursed to that personal representative. If no such personal representative exists, then the facility administrator should disburse the funds to the named beneficiary designated by the resident on the form provided by the long term care facility or surviving spouse. If a personal representative, surviving spouse, or named beneficiary does not exist or cannot be located at the time of disbursement, the facility administrator shall deposit the funds into an interest bearing account in a bank, savings and loan association, trust company, or credit union located in this state and if possible, located within the same county in which the facility is located. The long term care facility needs to maintain only one account in which the trust funds amounting to less than one hundred dollars ($100) of deceased residents are placed. However, it shall be the obligation of the long term care facility to maintain adequate records to permit compilation of interest due each individual resident's account. Separate accounts shall be maintained with respect to trust funds of deceased residents equal to or in excess of $100. The facility shall maintain such account until such time as the trust funds are disbursed pursuant to the provisions of Arkansas' Probate Code.
At the time the funds are disbursed the nursing facility should notify DHS of the account on the DECEASED RESIDENT PERSONAL TRUST FUND FORM. If the resident trust fund is disbursed to a personal representative, a surviving spouse or a named beneficiary a BENEFICIARY RECEIPT FORM should be completed and a copy submitted along with the DECEASED RESIDENT PERSONAL TRUST FUND FORM.
These forms should be completed and submitted to:
Arkansas Department of Human Services
Third Party Liability
Estate Recovery
P.O. Box 1437 Slot 296
Little Rock, AR 72203-1437
Long Term Care Facilities are required to maintain a daily midnight census of residents in their facility. Resident day information must be accumulated in a clear, accurate and auditable format. Resident day information is an important component of the cost reporting process. The daily midnight census documents resident day information stated on the facility's cost report. This information must be retained by the facility for no less than five years following the date cost reports are submitted to the Division of Medical Services. Facilities that do not maintain accurate and auditable census information are in violation of their provider agreement and may be subject to civil penalty.
The codes and form located in Section V of the Arkansas Medicaid Provider Manuals, provide an easily understood method for accumulating daily census information. The provider may utilize the codes and form or may construct their own form which contains all elements of the referenced form. The codes and form can be found by clicking the hyperlink, "Section V".
An actual physical census of a facility's residents should be conducted each midnight and recorded on the daily census form. This ensures that the day of admission is included as a resident day while the day of discharge is not.
Facilities that certify that occupancy levels are eighty-five percent (85%) or greater will be paid up to five (5) consecutive days for a leave of absence (LOA) to the hospital. The date on which the provider must meet occupancy requirements depends on their billing method. Providers billing on a TAD must certify eighty-five percent (85%) occupancy on the last day of the month the LOA occurred. Providers billing on an electronic billing system must certify eighty-five percent (85%) occupancy for the last day of the month previous to the LOA.
Facilities may bill for up to fourteen consecutive days for therapeutic home visits regardless of the occupancy rate.
LOA days paid for both hospital and therapeutic home visits must be properly identified on the daily census. These days are included in resident day totals for cost reporting purposes.
CODES FOR COMPLETING DAILY MIDNIGHT CENSUS
Resident Name: | Enter Resident Roll |
Pay Status: | M = Medicaid |
E = Medicare | |
V = Veteran's Administration | |
P = Private Pay | |
O = Other Third Party | |
Census Codes: | LEVEL OF CARE |
S = Skilled | |
A = Intermediate I | |
B = Intermediate II | |
C = Intermediate III | |
D = ICF/IID | |
Present = | Identify the RESIDENT as being present by placing the appropriate level of care designation for each day on the census roll sheet. |
H = | Paid Hospital Leave, Bed Reserved. Place an H for each day on the census roll sheet in addition to the level of care when a resident is in the hospital and the day is a paid day. |
T = | Paid Therapeutic Home Leave, Bed Reserved. Place a T for each day on the census roll sheet in addition to the level of care when a resident is on Therapeutic Home Leave and the day is a paid day. |
________ | Deceased ________ |
________ | Transferred ________ |
________ | Discharged ________ |
X = | Non-Paid Leave |
016.29.22 Ark. Code R. § 001