1984-14 Hospice Facility Cost Report

Hospice Facility Cost Report (CMS-1984-14)

2024 PRA-Hospice - r6P243f (1) (2).xlsx

Hospice Cost Report and Supporting Regulations in 42 CFR 413.20 and 413.24

OMB: 0938-0758

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Overview

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Sheet 1: S

02-22					FORM CMS-1984-14										4390 (Cont.)
THIS REPORT IS REQUIRED BY LAW (42 USC 1395g; 42 CFR.200(B)). COMPLETION OF THIS REPORT															FORM APPROVED
IS VIEWED AS A CONDITION OF YOUR PROVIDER AGREEMENT.															OMB NO. 0938-0758
															EXPIRES XX/XX/XXXX
HOSPICE COST AND DATA REPORT						PROVIDER CCN:			PERIOD:				WORKSHEET S
												FROM _______________	PARTS I & II
						____________________						TO _______________


PART I - COST REPORT STATUS
										ECR DATE				ECR TIME
								1		2				3
Provider		1	Electronically prepared cost report												1
use only		2	Manually prepared cost report												2
		3	Number of times cost report has been amended												3
		4	Medicare utilization												4
Contractor		5	Cost report status												5
use only:				[ 1 ] As Submitted
				[ 2 ] Reserved
				[ 3 ] Reserved
				[ 4 ] Reserved
				[ 5 ] Amended
		6	Date received												6
		7	Contractor number												7
		8	First cost report for this provider CCN												8
		9	Last cost report for this provider CCN												9
		10	Reserved												10
		11	Contractor vendor code												11
		12	Reserved												12

PART II - CERTIFICATION







	SIGNATURE OF CHIEF FINANCIAL OFFICER OR ADMINISTRATOR						CHECKBOX				ELECTRONIC
	1						2				SIGNATURE STATEMENT
1															1



2	Signatory Printed Name														2
3	Signatory Title														3
4	Signature date														4


















FORM CMS-1984-14 (02/2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4306)

Rev. 5															43-101

Sheet 2: S-1

4390 (Cont.)							FORM CMS-1984-14													02-22
HOSPICE IDENTIFICATION DATA										PROVIDER CCN:				PERIOD:			WORKSHEET S-1
																FROM _______________	PART I
										____________________						TO _______________


PART I - IDENTIFICATION DATA
1	Name																			1

		1									2				3
2	Street address								P.O. Box:											2
3	City								State:			ZIP Code:								3
4	County																			4

			1		2
5	CCN																			5
6	Date hospice began operation																			6

			TITLE XVIII - MEDICARE		TITLE XIX - MEDICAID
7	Certification date																			7
			FROM		TO
8	Cost reporting period																			8

	Malpractice Insurance Information										1				2				3
9	Is this facility legally required to carry malpractice insurance? Enter "Y" for yes or "N" for no.																			9
10	Enter 1 if the malpractice insurance is a claims-made policy. Enter 2 if the malpractice insurance is an occurrence policy.																			10
											PREMIUMS				PAID LOSSES				SELF-INSURANCE
11	Amounts of malpractice premiums, paid losses, and self-insurance																			11
12	Are malpractice premiums and paid losses reported in a cost center other than A&G?																			12
	If yes, submit supporting schedule listing cost centers and amounts contained therein.

															1				2
	Home Office/Chain Organization Information														Y/N				HO NUMBER
13	Are HO/CO costs (as defined in CMS Pub. 15-1, §2150ff) claimed? Enter "Y" for yes or "N" for no in col. 1.																			13
	If yes, enter the home office number in col. 2. (See instructions.)

14	HO/CO name																			14

		1									2				3
15	HO/CO street address								HO/CO P.O. Box:											15
16	HO/CO city								HO/CO State:			HO/CO ZIP Code:								16

17	HO/CO contractor name																			17
18	HO/CO contractor number																			18

															1				2
	Other Information
19	Type of control (see instructions)																			19
20	Number of CBSAs where Medicare covered services were provided during the cost reporting period																			20
21	List each CBSA code where Medicare covered hospices services were provided during the cost reporting period (line 21 contains the first code)																			21




FORM CMS-1984-14 (02/2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4307 - 4307.1)

43-102																				Rev. 5
08-14							FORM CMS-1984-14													4390 (Cont.)
HOSPICE IDENTIFICATION DATA										PROVIDER CCN:				PERIOD:			WORKSHEET S-1
																FROM _______________	PART II
										____________________						TO _______________


PART II - STATISTICAL DATA
				U N D U P L I C A T E D D A Y S
						TITLE XVIII - MEDICARE		TITLE XIX - MEDICAID					OTHER					TOTAL
						1		2					3					4
30	Continuous Home Care																			30
31	Routine Home Care																			31
32	Inpatient Respite Care																			32
33	General Inpatient Care																			33
34	Total Hospice Days																			34

PART III - CONTRACTED STATISTICAL DATA
				U N D U P L I C A T E D D A Y S
						TITLE XVIII - MEDICARE		TITLE XIX - MEDICAID					OTHER					TOTAL
						1		2					3					4
40	Inpatient Respite Care																			40
41	General Inpatient Care																			41
































FORM CMS-1984-14 (08/2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4307.2 - 4307.3)

Rev. 1																				43-103

Sheet 3: S-2

4390 (Cont.)				FORM CMS-1984-14									08-14
HOSPICE REIMBURSEMENT QUESTIONNAIRE						PROVIDER CCN:		PERIOD:			WORKSHEET S-2
										FROM _______________
						____________________				TO _______________


PROVIDER ORGANIZATION AND OPERATION
									Y / N	DATE		V/I
									1	2		3
1	Has the provider changed ownership immediately prior to the beginning of the cost reporting period? Enter "Y" for yes or "N" for no in column 1.												1
	If yes, enter the date of the change in column 2. (see instructions)
2	Has the provider terminated participation in the Medicare program? Enter "Y" for yes or "N" for no in column 1.												2
	If yes, enter in column 2 the termination date.
	If yes, enter in column 3, "V" for voluntary or "I" for involuntary.
3	Is the provider involved in business transactions, including management contracts, with individuals or entities that were related to the provider or its officers, medical staff,												3
	management personnel, or members of the board of directors through ownership, control, or family and other similar relationships? Enter "Y" for yes or "N" for no in column 1.
	(see instructions)

FINANCIAL DATA AND REPORTS
									Y / N	A / C / R		DATE
									1	2		3
4	Column 1: Were the financial statements prepared by a certified public accountant? Enter "Y" for yes or "N" for no.												4
	Column 2: If yes, enter in column 2: "A" for audited, "C" for compiled, or "R" for reviewed. Submit complete copy of financial
	statements or enter date available in column 3. (See instructions.) If no, see instructions.
5	Are the cost report total expenses and total revenues different from those on the filed financial statements? Enter "Y" for yes or "N" for no in column 1. If yes, submit reconciliation.												5





























FORM CMS-1984-14 (08/2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4308)

43-104													Rev. 1
02-21				FORM CMS-1984-14									4390 (Cont.)
HOSPICE REIMBURSEMENT QUESTIONNAIRE						PROVIDER CCN:		PERIOD:			WORKSHEET S-2
										FROM _______________
						____________________				TO _______________


P S & R REPORT DATA
										Y / N		DATE
										1		2
6	Was the cost report prepared using the PS&R report only? Enter "Y" for yes or "N" for no in column 1.												6
	If yes, enter in column 2 the paid-through date of the PS&R report used to prepare the cost report. (See instructions.)
7	Was the cost report prepared using the PS&R report for totals and the provider's records for allocation? Enter "Y" for yes or "N" for no in col.1.												7
	If yes, enter in col. 2 the paid-through date of the PS&R report. (See instructions.)
8	If line 6 or 7 is yes, were adjustments made to PS&R report data for additional claims that have been billed but are not included on the PS&R report used to file the cost report?												8
	Enter "Y" for yes or "N" for no. If yes, see instructions.
9	If line 6 or 7 is yes, were adjustments made to PS&R report data for corrections of other PS&R report information? Enter "Y" for yes or "N" for no.												9
	If yes, see instructions.
10	If line 6 or 7 is yes, were adjustments made to PS&R report data for Other? Enter "Y" for yes or "N" for no.												10
	If yes, describe the other adjustments: __________________________________________
11	Was the cost report prepared only using the provider's records? Enter "Y" for yes or "N" for no.												11
	If yes, see instructions.

COST REPORT PREPARER CONTACT INFORMATION
		1			2				3
12	First name		Last name				Title						12
13	Employer												13
14	Telephone number		Email address										14



























FORM CMS-1984-14 (08/2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4308)

Rev. 4													43-105

Sheet 4: A

4390 (Cont.)					FORM CMS-1984-14									02-21
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES							PROVIDER CCN:		PERIOD:			WORKSHEET A
											FROM _______________
							____________________				TO _______________


						TOTAL
						( SUM OF COL. 1	RECLASS-						TOTAL
			SALARIES	OTHER		PLUS COL. 2 )	IFICATIONS	SUBTOTAL		ADJUSTMENTS			( COL. 5 ± COL. 6 )
			1	2		3	4	5		6			7
GENERAL SERVICE COST CENTERS
1	0100	Cap Rel Costs - Bldg & Fixt*												1
2	0200	Cap Rel Costs - Mvble Equip*												2
3	0300	Employee Benefits Department*												3
4	0400	Administrative & General*												4
5	0500	Plant Operation & Maintenance*												5
6	0600	Laundry & Linen Service*												6
7	0700	Housekeeping*												7
8	0800	Dietary*												8
9	0900	Nursing Administration*												9
10	1000	Routine Medical Supplies*												10
11	1100	Medical Records*												11
12	1200	Staff Transportation*												12
13	1300	Volunteer Service Coordination*												13
14	1400	Pharmacy*												14
15	1500	Physician Administrative Services*												15
16		Other General Service (specify)*												16
17	1700	Patient/Residential Care Services												17
DIRECT PATIENT CARE SERVICE COST CENTERS
25	2500	Inpatient Care - Contracted**												25
26	2600	Physician Services**												26
27	2700	Nurse Practitioner**												27
28	2800	Registered Nurse**												28
29	2900	LPN/LVN**												29
30	3000	Physical Therapy**												30
31	3100	Occupational Therapy**												31
32	3200	Speech/Language Pathology**												32
33	3300	Medical Social Services**												33
34	3400	Spiritual Counseling**												34
35	3500	Dietary Counseling**												35
36	3600	Counseling - Other**												36
37	3700	Hospice Aide and Homemaker Services**												37
38	3800	Durable Medical Equipment/Oxygen**												38
39	3900	Patient Transportation**												39

*	Transfer the amounts in column 7 to Wkst. B, col. 0, line as appropriate.
**	See instructions. Do not transfer the amounts in col. 7 to Wkst. B.







FORM CMS-1984-14 (02/2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4310)

43-106														Rev. 4
02-22					FORM CMS-1984-14									4390 (Cont.)
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES							PROVIDER CCN:		PERIOD:			WORKSHEET A
											FROM _______________
							____________________				TO _______________


						TOTAL
						( SUM OF COL. 1	RECLASS-						TOTAL
			SALARIES	OTHER		PLUS COL. 2 )	IFICATIONS	SUBTOTAL		ADJUSTMENTS			( COL. 5 ± COL. 6 )
			1	2		3	4	5		6			7
DIRECT PATIENT CARE SERVICE COST CENTERS (Cont.)
40	4000	Imaging Services**												40
41	4100	Labs and Diagnostics**												41
42	4200	Medical Supplies - Non-routine**												42
42.50	4250	Drugs Charged to Patients**												42.50
43	4300	Outpatient Services**												43
44	4400	Palliative Radiation Therapy**												44
45	4500	Palliative Chemotherapy**												45
46		Other Patient Care Services (specify)**												46
NONREIMBURSABLE COST CENTERS
60	6000	Bereavement Program*												60
61	6100	Volunteer Program*												61
62	6200	Fundraising*												62
63	6300	Hospice/Palliative Medicine Fellows*												63
64	6400	Palliative Care Program*												64
65	6500	Other Physician Services*												65
66	6600	Residential Care *												66
67	6700	Advertising*												67
68	6800	Telehealth/Telemonitoring*												68
69	6900	Thrift Store*												69
70	7000	Nursing Facility Room & Board*												70
71		Other Nonreimbursable (specify)*												71
72	7200	Items and services under ASFRA 1997												72
100		Total												100

*	Transfer the amounts in column 7 to Wkst. B, col. 0, line as appropriate.
**	See instructions. Do not transfer the amounts in col. 7 to Wkst. B.

















FORM CMS-1984-14 (02/2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4310)

Rev. 5														43-107

Sheet 5: A-1

4390 (Cont.)				FORM CMS-1984-14									02-22
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES						PROVIDER CCN:		PERIOD:			WORKSHEET A-1
CONTINUOUS HOME CARE										FROM _______________
						____________________				TO _______________


					TOTAL
					( SUM OF COL. 1	RECLASS-						TOTAL
		SALARIES	OTHER		PLUS COL. 2 )	IFICATIONS	SUBTOTAL		ADJUSTMENTS			( COL. 5 ± COL. 6 )
		1	2		3	4	5		6			7
DIRECT PATIENT CARE SERVICE COST CENTERS
25	Inpatient Care - Contracted												25
26	Physician Services												26
27	Nurse Practitioner												27
28	Registered Nurse												28
29	LPN/LVN												29
30	Physical Therapy												30
31	Occupational Therapy												31
32	Speech/Language Pathology												32
33	Medical Social Services												33
34	Spiritual Counseling												34
35	Dietary Counseling												35
36	Counseling - Other												36
37	Hospice Aide and Homemaker Services												37
38	Durable Medical Equipment/Oxygen												38
39	Patient Transportation												39
40	Imaging Services												40
41	Labs and Diagnostics												41
42	Medical Supplies - Non-routine												42
42.50	Drugs Charged to Patients												42.50
43	Outpatient Services												43
44	Palliative Radiation Therapy												44
45	Palliative Chemotherapy												45
46	Other Patient Care Svc (specify)												46
100	Total *												100

*	Transfer the amount in column 7 to Wkst. B, col. 0, line 50.

















FORM CMS-1984-14 (04/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4311)

43-108													Rev. 5

Sheet 6: A-2

02-21				FORM CMS-1984-14									4390 (Cont.)
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES						PROVIDER CCN:		PERIOD:			WORKSHEET A-2
ROUTINE HOME CARE										FROM _______________
						____________________				TO _______________


					TOTAL
					( SUM OF COL. 1	RECLASS-						TOTAL
		SALARIES	OTHER		PLUS COL. 2 )	IFICATIONS	SUBTOTAL		ADJUSTMENTS			( COL. 5 ± COL. 6 )
		1	2		3	4	5		6			7
DIRECT PATIENT CARE SERVICE COST CENTERS
25	Inpatient Care - Contracted												25
26	Physician Services												26
27	Nurse Practitioner												27
28	Registered Nurse												28
29	LPN/LVN												29
30	Physical Therapy												30
31	Occupational Therapy												31
32	Speech/Language Pathology												32
33	Medical Social Services												33
34	Spiritual Counseling												34
35	Dietary Counseling												35
36	Counseling - Other												36
37	Hospice Aide and Homemaker Services												37
38	Durable Medical Equipment/Oxygen												38
39	Patient Transportation												39
40	Imaging Services												40
41	Labs and Diagnostics												41
42	Medical Supplies - Non-routine												42
42.50	Drugs Charged to Patients												42.50
43	Outpatient Services												43
44	Palliative Radiation Therapy												44
45	Palliative Chemotherapy												45
46	Other Patient Care Svc (specify)												46
100	Total *												100

*	Transfer the amount in column 7 to Wkst. B, col. 0, line 51.

















FORM CMS-1984-14 (04/2018) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4311)

Rev. 4													43-109

Sheet 7: A-3

4390 (Cont.)				FORM CMS-1984-14									02-21
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES						PROVIDER CCN:		PERIOD:			WORKSHEET A-3
INPATIENT RESPITE CARE										FROM _______________
						____________________				TO _______________


					TOTAL
					( SUM OF COL. 1	RECLASS-						TOTAL
		SALARIES	OTHER		PLUS COL. 2 )	IFICATIONS	SUBTOTAL		ADJUSTMENTS			( COL. 5 ± COL. 6 )
		1	2		3	4	5		6			7
DIRECT PATIENT CARE SERVICE COST CENTERS
25	Inpatient Care - Contracted												25
26	Physician Services												26
27	Nurse Practitioner												27
28	Registered Nurse												28
29	LPN/LVN												29
30	Physical Therapy												30
31	Occupational Therapy												31
32	Speech/Language Pathology												32
33	Medical Social Services												33
34	Spiritual Counseling												34
35	Dietary Counseling												35
36	Counseling - Other												36
37	Hospice Aide and Homemaker Services												37
38	Durable Medical Equipment/Oxygen												38
39	Patient Transportation												39
40	Imaging Services												40
41	Labs and Diagnostics												41
42	Medical Supplies - Non-routine												42
42.50	Drugs Charged to Patients												42.50
43	Outpatient Services												43
44	Palliative Radiation Therapy												44
45	Palliative Chemotherapy												45
46	Other Patient Care Svc (specify)												46
100	Total *												100

*	Transfer the amount in column 7 to Wkst. B, col. 0, line 52.

















FORM CMS-1984-14 (02/2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4311)

43-110													Rev. 4

Sheet 8: A-4

02-21				FORM CMS-1984-14									4390 (Cont.)
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES						PROVIDER CCN:		PERIOD:			WORKSHEET A-4
GENERAL INPATIENT CARE										FROM _______________
						____________________				TO _______________


					TOTAL
					( SUM OF COL. 1	RECLASS-						TOTAL
		SALARIES	OTHER		PLUS COL. 2 )	IFICATIONS	SUBTOTAL		ADJUSTMENTS			( COL. 5 ± COL. 6 )
		1	2		3	4	5		6			7
DIRECT PATIENT CARE SERVICE COST CENTERS
25	Inpatient Care - Contracted												25
26	Physician Services												26
27	Nurse Practitioner												27
28	Registered Nurse												28
29	LPN/LVN												29
30	Physical Therapy												30
31	Occupational Therapy												31
32	Speech/Language Pathology												32
33	Medical Social Services												33
34	Spiritual Counseling												34
35	Dietary Counseling												35
36	Counseling - Other												36
37	Hospice Aide and Homemaker Services												37
38	Durable Medical Equipment/Oxygen												38
39	Patient Transportation												39
40	Imaging Services												40
41	Labs and Diagnostics												41
42	Medical Supplies - Non-routine												42
42.50	Drugs Charged to Patients												42.50
43	Outpatient Services												43
44	Palliative Radiation Therapy												44
45	Palliative Chemotherapy												45
46	Other Patient Care Svc (specify)												46
100	Total *												100

*	Transfer the amount in column 7 to Wkst. B, col. 0, line 53.

















FORM CMS-1984-14 (02/2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4311)

Rev. 4													43-111

Sheet 9: A-6

4390 (Cont.)							FORM CMS-1984-14											02-21
RECLASSIFICATIONS										PROVIDER CCN:			PERIOD:			WORKSHEET A-6
															FROM _______________
										____________________					TO _______________


				INCREASES					DECREASES								LOC
					WKST A		AMOUNT				WKST A		AMOUNT				WKST IN-
		EXPLANATION OF	CODE(1)	COST CENTER	LINE NO.		SALARY	OTHER	COST CENTER		LINE NO.		SALARY	OTHER			DICATOR
		OF RECLASSIFICATION(S)	1	2		3	4	4.01	5			6	7	7.01			8
1																		1
2																		2
3																		3
4																		4
5																		5
6																		6
7																		7
8																		8
9																		9
10																		10
11																		11
12																		12
13																		13
14																		14
15																		15
16																		16
17																		17
18																		18
19																		19
20																		20
21																		21
22																		22
23																		23
24																		24
25																		25
26																		26
27																		27
28																		28
29																		29
30																		30
31																		31
32																		32
33																		33
34																		34
35																		35
100	Total reclassifications																	100

	(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.
	Transfer the amounts in columns 4, 4.01, 7, and 7.01 to Wkst. A, col. 4, lines as appropriate.





FORM CMS-1984-14 (02/2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4316)

43-112																		Rev. 4

Sheet 10: A-8

07-15			FORM CMS-1984-14								4390 (Cont.)
ADJUSTMENTS TO EXPENSES				PROVIDER CCN:			PERIOD:		WORKSHEET A-8
								FROM _______________
				____________________				TO _______________


						EXPENSE CLASSIFICATION
			BASIS			ON WKST. A TO / FROM WHICH
			FOR			THE AMOUNT IS TO BE ADJUSTED				LOC
			ADJUST-					WKST A.		WKST IN-
	DESCRIPTION (1)		MENT(2)		AMOUNT	COST CENTER		LINE NO.		DICATOR
			1		2	3		4		5
1	Investment income on restricted funds										1
	(chapter 2)
2	Telephone services (pay stations excluded)										2
	(chapter 21)
3	Adjustment resulting from transactions with related organ-		Wkst.								3
	izations (chapter 10) and home office costs (chapter 21)		A-8-1
4	Revenue - employee and guest meals		B			Dietary		8			4

5	Income from imposition of interest, finance or penalty		B			Administrative and General		4			5
	charges (chapter 21)
6	Bad debts included on trial balance		A								6

7	Patient personal purchases										7

8	Depreciation - buildings and fixtures					Buildings & Fixtures		1			8

9	Depreciation - movable equipment					Movable Equipment		2			9

10	Revenue - State-redirected room and board		B			Nursing Facility Room & Board		70			10

11	Other adjustments (specify) (3)										11

12											12

13											13

14											14

15											15



















50	TOTAL (sum of lines 1 through 49)										50
	(transfer to Wkst. A, col. 6, line 100)

	(1)	Description - all chapter references in this column pertain to CMS Pub. 15-1
	(2)	Basis for adjustment (see instructions)
		A. Costs - if cost, including applicable overhead, can be determined
		B. Amount Received - if cost cannot be determined
	(3)	Additional adjustments may be made on lines 11 thru 49 and subscripts thereof.





FORM CMS-1984-14 (07/2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4318)

Rev. 2											43-113

Sheet 11: A-8-1

4390 (Cont.)						FORM CMS-1984-14										07-15
STATEMENT OF COSTS OF SERVICES FROM								PROVIDER CCN:		PERIOD:				WORKSHEET A-8-1
RELATED ORGANIZATIONS AND HOME OFFICE COSTS													FROM _______________
								____________________					TO _______________


PART I - COSTS INCURRED AND ADJUSTMENTS REQUIRED AS A RESULT OF TRANSACTIONS WITH RELATED ORGANIZATIONS OR
CLAIMED HOME OFFICE COSTS
												NET
	WKST. A								AMOUNT	AMOUNT		ADJUSTMENTS			LOC WS
	LINE								ALLOWABLE	INCLUDED		(COL. 4 MINUS			INDIC-
	NUMBER			COST CENTER		EXPENSE ITEMS			IN COST	IN WKST. A		COL. 5) *			ATOR
	1			2		3			4	5		6			7
1																1
2																2
3																3
4																4
5																5
6																6
7																7
8																8
9																9
10	TOTALS (sum of lines 1 through 9)															10
	(transfer col. 6, line 10 to Wkst. A-8, col. 2, line 3)






PART II - INTERRELATIONSHIP TO RELATED ORGANIZATION(S) AND / OR HOME OFFICE








							RELATED ORGANIZATION(S) AND/OR HOME OFFICE
					PERCENTAGE						PERCENTAGE
					OF						OF		TYPE OF
	SYMBOL(1)		NAME		OWNERSHIP		NAME				OWNERSHIP		BUSINESS
	1		2		3		4				5		6
1																1
2																2
3																3
4																4
5																5
6																6
7																7
8																8
9																9
10																10

	(1) Use the followings symbols to indicate interrelationship to related organizations:
		A. Individual has financial interest (stockholder, partner, etc.) in both related organization and in provider.
		B. Corporation, partnership or other organization has financial interest in provider.
		C. Provider has financial interest in corporation, partnership, or other organization.
		D. Director, officer, administrator or key person of provider or organization.
		E. Individual is director, officer, administrator or key person of provider and related organization.
		F. Director, officer, administrator or key person of related organization or relative of such person has financial interest in provider.
		G. Other (financial or non-financial) specify ______________________________________________________________










FORM CMS-1984-14 (07/2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4319)

43-114																Rev. 2

Sheet 12: B

02-22					FORM CMS-1984-14											4390 (Cont.)
COST ALLOCATION								PROVIDER CCN:		PERIOD:				WORKSHEET B
													FROM _______________
								____________________					TO _______________


		NET	CAP REL	CAP REL		EMPLOYEE	SUBTOTAL	ADMINIS-	PLANT		LAUNDRY	HOUSE-			DIETARY
		EXPENSES	BLDG	MVBLE		BENEFITS	(SUM COLS 0	TRATIVE &	OP &		& LINEN	KEEPING
		FOR ALLOC.	& FIX	EQUIP		DEPARTMENT	THROUGH 3)	GENERAL	MAINT
	Cost Center Descriptions	0	1	2		3	3A	4	5		6	7			8
GENERAL SERVICE COST CENTERS
1	Cap Rel Costs - Bldg & Fixt															1
2	Cap Rel Costs - Mvble Equip															2
3	Employee Benefits Department															3
4	Administrative & General															4
5	Plant Operation & Maintenance															5
6	Laundry & Linen Service															6
7	Housekeeping															7
8	Dietary															8
9	Nursing Administration															9
10	Routine Medical Supplies															10
11	Medical Records															11
12	Staff Transportation															12
13	Volunteer Service Coordination															13
14	Pharmacy															14
15	Physician Administrative Services															15
16	Other General Service (specify)															16
17	Patient/Residential Care Services															17
LEVEL OF CARE
50	Continuous Home Care															50
51	Routine Home Care															51
52	Inpatient Respite Care															52
53	General Inpatient Care															53





















FORM CMS-1984-14 (07/2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4320)

Rev. 5																43-115
4390 (Cont.)					FORM CMS-1984-14											02-22
COST ALLOCATION								PROVIDER CCN:		PERIOD:				WORKSHEET B
													FROM _______________
								____________________					TO _______________


		NET	CAP REL	CAP REL		EMPLOYEE	SUBTOTAL	ADMINIS-	PLANT		LAUNDRY	HOUSE-			DIETARY
		EXPENSES	BLDG	MVBLE		BENEFITS	(SUM COLS 0	TRATIVE &	OP &		& LINEN	KEEPING
		FOR ALLOC.	& FIX	EQUIP		DEPARTMENT	THROUGH 3)	GENERAL	MAINT
	Cost Center Descriptions	0	1	2		3	3A	4	5		6	7			8
NONREIMBURSABLE COST CENTERS
60	Bereavement Program															60
61	Volunteer Program															61
62	Fundraising															62
63	Hospice/Palliative Medicine Fellows															63
64	Palliative Care Program															64
65	Other Physician Services															65
66	Residential Care															66
67	Advertising															67
68	Telehealth/Telemonitoring															68
69	Thrift Store															69
70	Nursing Facility Room & Board															70
71	Other Nonreimbursable (specify)															71
72	Items and services under ASFRA 1997															72
100	Negative Cost Center															100
101	Total															101




























FORM CMS-1984-14 (02/2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4320)

43-116																Rev. 5
02-22					FORM CMS-1984-14											4390 (Cont.)
COST ALLOCATION								PROVIDER CCN:		PERIOD:				WORKSHEET B
													FROM _______________
								____________________					TO _______________


		NURSING	ROUTINE	MEDICAL		STAFF	VOLUNTEER	PHARMACY	PHYSICIAN		OTHER	PATIENT /
		ADMINIS-	MEDICAL	RECORDS		TRANS-	SVC COOR-		ADMINISTRA-		GENERAL	RESIDENTIAL
		TRATION	SUPPLIES			PORTATION	DINATION		TIVE SVCS		SERVICE	CARE SVCS			TOTAL
	Cost Center Descriptions	9	10	11		12	13	14	15		16	17			18
GENERAL SERVICE COST CENTERS
1	Cap Rel Costs - Bldg & Fixt															1
2	Cap Rel Costs - Mvble Equip															2
3	Employee Benefits Department															3
4	Administrative & General															4
5	Plant Operation & Maintenance															5
6	Laundry & Linen Service															6
7	Housekeeping															7
8	Dietary															8
9	Nursing Administration															9
10	Routine Medical Supplies															10
11	Medical Records															11
12	Staff Transportation															12
13	Volunteer Service Coordination															13
14	Pharmacy															14
15	Physician Administrative Services															15
16	Other General Service (specify)															16
17	Patient/Residential Care Services															17
LEVEL OF CARE
50	Continuous Home Care															50
51	Routine Home Care															51
52	Inpatient Respite Care															52
53	General Inpatient Care															53





















FORM CMS-1984-14 (08/2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4320)

Rev. 5																43-117
4390 (Cont.)					FORM CMS-1984-14											02-22
COST ALLOCATION								PROVIDER CCN:		PERIOD:				WORKSHEET B
													FROM _______________
								____________________					TO _______________


		NURSING	ROUTINE	MEDICAL		STAFF	VOLUNTEER	PHARMACY	PHYSICIAN		OTHER	PATIENT /
		ADMINIS-	MEDICAL	RECORDS		TRANS-	SVC COOR-		ADMINISTRA-		GENERAL	RESIDENTIAL
		TRATION	SUPPLIES			PORTATION	DINATION		TIVE SVCS		SERVICE	CARE SVCS			TOTAL
	Cost Center Descriptions	9	10	11		12	13	14	15		16	17			18
NONREIMBURSABLE COST CENTERS
60	Bereavement Program															60
61	Volunteer Program															61
62	Fundraising															62
63	Hospice/Palliative Medicine Fellows															63
64	Palliative Care Program															64
65	Other Physician Services															65
66	Residential Care															66
67	Advertising															67
68	Telehealth/Telemonitoring															68
69	Thrift Store															69
70	Nursing Facility Room & Board															70
71	Other Nonreimbursable (specify)															71
72	Items and services under ASFRA 1997															72
100	Negative Cost Center															100
101	Total															101




























FORM CMS-1984-14 (02/2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4320)

43-118																Rev. 5

Sheet 13: B-1

02-22					FORM CMS-1984-14											4390 (Cont.)
COST ALLOCATION - STATISTICAL BASIS								PROVIDER CCN:		PERIOD:				WORKSHEET B-1
													FROM _______________
								____________________					TO _______________


			CAP REL	CAP REL		EMPLOYEE		ADMINIS-	PLANT		LAUNDRY	HOUSE-			DIETARY
			BLDG	MVBLE		BENEFITS		TRATIVE &	OP &		& LINEN	KEEPING
			& FIX	EQUIP		DEPARTMENT		GENERAL	MAINT
			SQUARE	DOLLAR		GROSS	RECONCIL-	ACCUM.	SQUARE		IN-FACIL-	SQUARE			IN-FACIL-
			FEET	VALUE		SALARIES	IATION	COST	FEET		ITY DAYS	FEET			ITY DAYS
	Cost Center Descriptions		1	2		3	4A	4	5		6	7			8
GENERAL SERVICE COST CENTERS
1	Cap Rel Costs - Bldg & Fixt															1
2	Cap Rel Costs - Mvble Equip															2
3	Employee Benefits Department															3
4	Administrative & General															4
5	Plant Operation & Maintenance															5
6	Laundry & Linen Service															6
7	Housekeeping															7
8	Dietary															8
9	Nursing Administration															9
10	Routine Medical Supplies															10
11	Medical Records															11
12	Staff Transportation															12
13	Volunteer Service Coordination															13
14	Pharmacy															14
15	Physician Administrative Services															15
16	Other General Service (specify)															16
17	Patient/Residential Care Services															17
LEVEL OF CARE
50	Continuous Home Care															50
51	Routine Home Care															51
52	Inpatient Respite Care															52
53	General Inpatient Care															53



















FORM CMS-1984-14 (07/2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4320)

Rev. 5																43-119
4390 (Cont.)					FORM CMS-1984-14											02-22
COST ALLOCATION - STATISTICAL BASIS								PROVIDER CCN:		PERIOD:				WORKSHEET B-1
													FROM _______________
								____________________					TO _______________


			CAP REL	CAP REL		EMPLOYEE		ADMINIS-	PLANT		LAUNDRY	HOUSE-			DIETARY
			BLDG	MVBLE		BENEFITS		TRATIVE &	OP &		& LINEN	KEEPING
			& FIX	EQUIP		DEPARTMENT		GENERAL	MAINT
			SQUARE	DOLLAR		GROSS	RECONCIL-	ACCUM.	SQUARE		IN-FACIL	SQUARE			IN-FACIL
			FEET	VALUE		SALARIES	IATION	COST	FEET		ITY DAYS	FEET			ITY DAYS
	Cost Center Descriptions		1	2		3	4A	4	5		6	7			8
NONREIMBURSABLE COST CENTERS
60	Bereavement Program															60
61	Volunteer Program															61
62	Fundraising															62
63	Hospice/Palliative Medicine Fellows															63
64	Palliative Care Program															64
65	Other Physician Services															65
66	Residential Care															66
67	Advertising															67
68	Telehealth/Telemonitoring															68
69	Thrift Store															69
70	Nursing Facility Room & Board															70
71	Other Nonreimbursable (specify)															71
72	Items and services under ASFRA 1997															72
100	Negative Cost Center															100
101	Cost to be allocated (per Wkst. B)															101
102	Unit cost multiplier															102

























FORM CMS-1984-14 (02/2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4320)

43-120																Rev. 5
02-22					FORM CMS-1984-14											4390 (Cont.)
COST ALLOCATION - STATISTICAL BASIS								PROVIDER CCN:		PERIOD:				WORKSHEET B-1
													FROM _______________
								____________________					TO _______________


		NURSING	ROUTINE	MEDICAL		STAFF	VOLUNTEER	PHARMACY	PHYSICIAN		OTHER	PATIENT /
		ADMINIS-	MEDICAL	RECORDS		TRANS-	SVC COOR-		ADMINISTRA-		GENERAL	RESIDENTIAL
		TRATION	SUPPLIES			PORTATION	DINATION		TIVE SVCS		SERVICE	CARE SVCS
		DIRECT	PATIENT	PATIENT			HOURS OF		PATIENT		SPECIFY	IN-FACIL
		NURS. HRS.	DAYS	DAYS		MILEAGE	SERVICE	CHARGES	DAYS		BASIS	ITY DAYS			TOTAL
	Cost Center Descriptions	9	10	11		12	13	14	15		16	17			18
GENERAL SERVICE COST CENTERS
1	Cap Rel Costs - Bldg & Fixt															1
2	Cap Rel Costs - Mvble Equip															2
3	Employee Benefits Department															3
4	Administrative & General															4
5	Plant Operation & Maintenance															5
6	Laundry & Linen Service															6
7	Housekeeping															7
8	Dietary															8
9	Nursing Administration															9
10	Routine Medical Supplies															10
11	Medical Records															11
12	Staff Transportation															12
13	Volunteer Service Coordination															13
14	Pharmacy															14
15	Physician Administrative Services															15
16	Other General Service (specify)															16
17	Patient/Residential Care Services															17
LEVEL OF CARE
50	Continuous Home Care															50
51	Routine Home Care															51
52	Inpatient Respite Care															52
53	General Inpatient Care															53



















FORM CMS-1984-14 (07/2015) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4320)

Rev. 5																43-121
4390 (Cont.)					FORM CMS-1984-14											02-22
COST ALLOCATION - STATISTICAL BASIS								PROVIDER CCN:		PERIOD:				WORKSHEET B-1
													FROM _______________
								____________________					TO _______________


		NURSING	ROUTINE	MEDICAL		STAFF	VOLUNTEER	PHARMACY	PHYSICIAN		OTHER	PATIENT /
		ADMINIS-	MEDICAL	RECORDS		TRANS-	SVC COOR-		ADMINISTRA-		GENERAL	RESIDENTIAL
		TRATION	SUPPLIES			PORTATION	DINATION		TIVE SVCS		SERVICE	CARE SVCS
		DIRECT	PATIENT	PATIENT			HOURS OF		PATIENT		SPECIFY	IN-FACIL
		NURS. HRS.	DAYS	DAYS		MILEAGE	SERVICE	CHARGES	DAYS		BASIS	ITY DAYS			TOTAL
	Cost Center Descriptions	9	10	11		12	13	14	15		16	17			18
NONREIMBURSABLE COST CENTERS
60	Bereavement Program															60
61	Volunteer Program															61
62	Fundraising															62
63	Hospice/Palliative Medicine Fellows															63
64	Palliative Care Program															64
65	Other Physician Services															65
66	Residential Care															66
67	Advertising															67
68	Telehealth/Telemonitoring															68
69	Thrift Store															69
70	Nursing Facility Room & Board															70
71	Other Nonreimbursable (specify)															71
72	Items and services under ASFRA 1997															72
100	Negative Cost Center															100
101	Cost to be allocated (per Wkst. B)															101
102	Unit cost multiplier															102

























FORM CMS-1984-14 (02/2022) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4320)

43-122																Rev. 5

Sheet 14: C

08-14		FORM CMS-1984-14								4390 (Cont.)
CALCULATION OF PER DIEM COST			PROVIDER CCN:		PERIOD:			WORKSHEET C
							FROM _______________
			____________________				TO _______________


				TITLE XVIII		TITLE XIX
				MEDICARE		MEDICAID			TOTAL
				1		2			3
CONTINUOUS HOME CARE
1	Total cost (Wkst. B, col 18, line 50)									1
2	Total unduplicated days (Wkst. S-1, col. 4, line 30)									2
3	Total average cost per diem (line 1 divided by line 2)									3
4	Unduplicated program days (Wkst. S-1, col. as appropriate, line 30)									4
5	Program cost (line 3 times line 4)									5
ROUTINE HOME CARE
6	Total cost (Wkst. B, col. 18, line 51)									6
7	Total unduplicated days (Wkst. S-1, col. 4, line 31)									7
8	Total average cost per diem (line 6 divided by line 7)									8
9	Unduplicated program days (Wkst. S-1, col. as appropriate, line 31)									9
10	Program cost (line 8 times line 9)									10
INPATIENT RESPITE CARE
11	Total cost (Wkst. B, col. 18, line 52)									11
12	Total unduplicated days (Wkst. S-1, col. 4, line 32)									12
13	Total average cost per diem (line 11 divided by line 12)									13
14	Unduplicated program days (Wkst. S-1, col. as appropriate, line 32)									14
15	Program cost (line 13 times line 14)									15
GENERAL INPATIENT CARE
16	Total cost (Wkst. B, col. 18, line 53)									16
17	Total unduplicated days (Wkst. S-1, col. 4, line 33)									17
18	Total average cost per diem (line 16 divided by line 17)									18
19	Unduplicated program days (Wkst. S-1, col. as appropriate, line 33)									19
20	Program cost (line 18 times line 19)									20
TOTAL HOSPICE CARE
21	Total cost (sum of line 1 + line 6 + line 11 + line 16)									21
22	Total unduplicated days (Wkst. S-1, col. 4, line 34)									22
23	Average cost per diem (line 21 divided by line 22)									23




































FORM CMS-1984-14 (08/2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4330)

Rev. 1										43-123

Sheet 15: F

4390 (Cont.)		FORM CMS-1984-14						08-14
BALANCE SHEET			PROVIDER CCN:	PERIOD:		WORKSHEET F
					FROM _______________
			____________________		TO _______________


	Assets						AMOUNT
CURRENT ASSETS
1	Cash on hand and in banks							1
2	Temporary investments							2
3	Notes receivable							3
4	Accounts receivable							4
5	Other receivables							5
6	Less: allowances for uncollectible notes and accounts receivable							6
7	Inventory							7
8	Prepaid expenses							8
9	Other current assets							9
10	TOTAL CURRENT ASSETS (sum of lines 1 through 9)							10
FIXED ASSETS
11	Land							11
12	Land improvements							12
13	Less: Accumulated depreciation							13
14	Buildings							14
15	Less Accumulated depreciation							15
16	Leasehold improvements							16
17	Less: Accumulated Amortization							17
18	Fixed equipment							18
19	Less: Accumulated depreciation							19
20	Automobiles and trucks							20
21	Less: Accumulated depreciation							21
22	Major movable equipment							22
23	Less: Accumulated depreciation							23
24	Minor equipment - Depreciable							24
25	Less: Accumulated depreciation							25
26	TOTAL FIXED ASSETS (sum of lines 11 through 25)							26
OTHER ASSETS
27	Investments							27
28	Deposits on leases							28
29	Due from owners/officers							29
30	Other assets							30
31	TOTAL OTHER ASSETS (sum of lines 27 through 30)							31
32	TOTAL ASSETS (sum of lines 10, 26, and 31)							32


	Liabilities and Fund Balances						AMOUNT
CURRENT LIABILITIES
33	Accounts payable							33
34	Salaries, wages, & fees payable							34
35	Payroll taxes payable							35
36	Notes & loans payable (short term)							36
37	Deferred income							37
38	Accelerated payments							38
39	Other current liabilities							39
40	TOTAL CURRENT LIABILITIES (sum of lines 33 through 39)							40
LONG TERM LIABILITIES
41	Mortgage payable							41
42	Notes payable							42
43	Unsecured loans							43
44	Loans from owners:							44
45	Other long term liabilities							45
46	TOTAL LONG TERM LIABILITIES (sum of lines 41 through 45)							46
47	TOTAL LIABILITIES (sum of lines 40 and 46)							47
CAPITAL ACCOUNT
48	Fund balance							48
49	TOTAL LIABILITIES AND FUND BALANCE (sum of lines 47 and 48)							49

( ) = contra amount






FORM CMS-1984-14 (08/2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4350 and 4350.1)

43-124								Rev. 1

Sheet 16: F-1

02-21		FORM CMS-1984-14								4390 (Cont.)
STATEMENT OF CHANGES			PROVIDER CCN:		PERIOD:			WORKSHEET F-1
IN FUND BALANCES							FROM _______________
			____________________				TO _______________


			GENERAL	SPECIFIC		ENDOWMENT			PLANT
			FUND	PURPOSE FUND		FUND			FUND
			1	2		3			4
1	Fund balances at beginning									1
	of period
2	Net income / (loss)									2
	(from Wkst. F-2, line 42)
3	Total									3
	(sum of line 1 and line 2)
4	Additions (credit adjustments)									4
	(specify)
5										5

6										6

7										7

8										8

9										9

10	Total additions									10
	(sum of lines 4 through 9)
11	Subtotal									11
	(line 3 plus line 10)
12	Deductions (debit adjustments)									12
	(specify)
13										13

14										14

15										15

16										16

17										17

18	Total deductions									18
	(sum of lines 12 through 17)
19	Fund balance at end of period per balance									19
	sheet (line 11 minus line 18)


























FORM CMS-1984-14 (08/2014) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4350 and 4350.2)

Rev. 4										43-125

Sheet 17: F-2

4390 (Cont.)		FORM CMS-1984-14									02-21
STATEMENT OF REVENUES			PROVIDER CCN:		PERIOD:				WORKSHEET F-2
AND OPERATING EXPENSES								FROM _______________
			____________________					TO _______________


PART I - REVENUES
			TITLE XVIII	TITLE XIX
			MEDICARE	MEDICAID			OTHER			TOTAL
			1	2			3			4
GROSS PATIENT REVENUE
1	Continuous Home Care										1
2	Routine Home Care										2
3	Inpatient Respite Care										3
4	General Inpatient Care										4
5	Drug copay / coinsurance										5
6	Total gross patient revenue (sum of lines 1 through 5)										6
7	Less: Contractual allowances and discounts										7
8	Net patient revenue (line 6 minus line 7)										8
OTHER REVENUE
9	Hospice physician services										9
10	Room and board										10
11	Palliative consults / Other phys. services										11
12	Donations / Charitable contributions										12
13	Rebates / refunds of expenses										13
14	Income from investments										14
15	Governmental appropriations										15
16	Other (specify)										16
16.50	COVID-19 PHE Funding					`					16.50
17											17
18											18
19											19
20											20
21											21
22											22
23											23
24											24
25											25
26	Total revenues (sum of lines 8 through 25)										26

PART II - OPERATING EXPENSES
			1	2			3			4
27	Operating expenses (per Wkst A, col. 3, line 100)										27
28	Add (specify)										28
29											29
30											30
31											31
32											32
33											33
34	Total additions (sum of lines 28 through 33)										34
35	Deduct (specify)										35
36											36
37											37
38											38
39											39
40	Total deductions (sum of lines 35 through 39)										40
41	Total operating expenses (sum of lines 27 and 34, minus line 40)										41
42	Net income / (loss) for the period (line 26 minus line 41)										42















FORM CMS-1984-14 (02/2021) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4350 and 4350.3)

43-126											Rev. 4

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File Modified	0000-00-00
File Created	0000-00-00